Quotes of the Day

"Matt Thomas" (a pseudonym) had only recently begun experimenting with marijuana when he got caught selling a few joints in the bathroom at his junior high school. It was no big deal, Thomas thought, especially considering that his parents — an investment banker and a homemaker — smoked pot too.

But Thomas' grades had already begun to slip, perhaps because of his increasing alcohol and marijuana use; that, coupled with his drug-dealing offense, was enough for the school to recommend that his parents place him in an inpatient drug-treatment program. Thomas, then 13, was sent to Parkview West, a residential rehab center located a few miles from his suburban Minneapolis home.

But rather than encouraging sobriety, Thomas says, his seven-week stint at Parkview West helped trigger a decades-long descent into severe addiction — from regular marijuana user to daily drinker to cocaine and methamphetamine addict. "It was [in rehab] that they told me that I was a drug addict and an alcoholic," says Thomas. "There was no turning back. The whole event solidified and created this notion in my own mind and in my social status. Who I was, was an alcoholic and drug addict."

In treatment, Thomas met other addicts. He attended daily group therapy with older teens, who regaled him with glamorized war stories about drugs he'd never tried. In rehab, says Thomas, one's first question upon meeting a new person is, "What's your drug of choice?" And that's often followed by, "What's that like?" Thomas recalls hearing a description of an LSD high so seductive that he pledged he would try it if he got the chance. He did, not long after getting out of rehab.

Increasingly, substance-abuse experts are finding that teen drug treatment may indeed be doing more harm than good. Many programs throw casual dabblers together with hard-core addicts and foster continuous group interaction. It tends to strengthen dysfunctional behavior by concentrating it, researchers say. "Just putting kids in group therapy actually promotes greater drug use," says Dr. Nora Volkow, director of the National Institute on Drug Abuse (NIDA).

The exposure can be especially dangerous for impressionable youngsters. "I've known kids who have gone into inpatient treatment and met other users. After treatment, they meet up with them and explore new drugs and become more seriously involved in drug use," says Tom Dishion, director of research at the Child and Family Center at the University of Oregon, who has documented such peer influence in scientific studies.

In academic terms, the problem is known as deviancy training, or the negative impact of friends on teen behavior — what parents would simply call a bad influence. In one 2000 study, in which researchers measured how much time teens spent together and how much they encouraged their peers' misbehavior, Dishion found that social exposure to delinquent peers at age 14 accounted for 53% of adolescents' life problems five years later — including criminal convictions, sexual promiscuity, relationship issues and drug use.

In another study looking specifically at the impact of group interventions, teenagers who had been identified as being at high risk for drug use and delinquency at ages 11 through 14 were more likely to smoke cigarettes and have disciplinary problems at school three years later if they had been enrolled in a teen focus group about drugs, compared with those who underwent private counseling sessions with their immediate families. "Any condition that promotes kids talking about or endorsing drug use [with one another] would increase the likelihood that the treatment would have a negative effect," says Dishion.

In addition, researchers find, the harm of many teen drug-treatment programs may come not only from the negative influence of new relationships but also from the degradation of positive bonds with family. In a 2003 paper, Jose Szapocznik, chair of the epidemiology and public-health department at the University of Miami, found that teens who used marijuana but still had healthy relationships with their families saw those relationships deteriorate — and their drug habits increase — when they were assigned to peer-therapy groups. Among these teens, who were in treatment for a minimum of four weeks, 17% reduced their marijuana habit, but 50% ended up smoking more. "In group, the risk of getting worse was much greater than the opportunity for getting better," Szapocznik says, adding that in contrast, 57% of teens who were assigned to family therapy showed a significant decrease in drug use, while 19% used more.

Although teens with fewer problems may be adversely affected by their more dysfunctional peers, the reverse can also be true: teens with severe behavioral problems actually improve when placed in groups with better-adjusted youth. The 2004 Cannabis Youth Treatment (CYT) trial, which included 600 teens, found that over the course of a year, marijuana use dropped 25% in teens in both group therapy and family therapy, no matter how severe their behavioral problems were.

CYT's success may be due to the fact that while its participants had varying degrees of behavioral difficulties, they did not differ significantly in terms of substance use — the trial excluded anyone who had used any drug other than marijuana for 13 or more days in the previous three months. That factor alone may account for the across-the-board benefits, but in most teen rehab centers outside of research settings, patients continue to be lumped together with little regard for the severity of their drug problems.

It doesn't help either that the philosophy behind many drug-treatment programs can be easily misinterpreted by teenagers. Most programs in the U.S., including the one Thomas attended, are modeled after the 12-step recovery plan used by Alcoholics Anonymous. The first step encourages participants to accept that they are "powerless" over their addiction and to surrender their will to a higher force. For some people, it inspires mutual support and abstinence, but for others — especially teenagers — it can foster a feeling of defeat. "You get these 12-step teachings telling you that you're doomed, that you have this disease and this is the only way out," Thomas says.

Indeed, surrender is not a word that comes easily to teens, and teaching them to believe they are powerless may create a fatalism that leads to relapse, according to Andrew Morral, a senior behavioral scientist at the Rand Corp. In his studies of teens treated at Phoenix House, one of the largest treatment providers in the U.S., he found that participants who subscribed to the tenet of powerlessness were more likely to return to drugs after treatment, compared with teenagers who did not take the message to heart.

Still, for an estimated 10% of teen drug users whose addictions are severe enough that they already feel helpless to control them, the 12-step method can help. For example, a study published in July in the journal Drug and Alcohol Dependence found that teens who had severe addictions to alcohol, marijuana, heroin or painkillers and chose voluntarily to attend 12-step meetings once a week for three months had nearly double the number of sober days as those who did not attend. "People who go to Alcoholics Anonymous or Narcotics Anonymous and stick with it are the most severe cases," says study author John Kelly, associate director of the Massachusetts General Hospital – Harvard Center for Addiction Medicine, while people with milder problems typically don't feel they "fit" and quit attending.

The problem is that most treatment programs do not give teens a choice about 12-step attendance; it is usually a mandatory part of rehab or is in some cases legally mandated by a court.

Although individual and family therapy have shown more success with teen drug users than group treatment, most programs continue to use problematic approaches. One reason is cost. Group treatment allows a therapist to see many more patients in a day than individual sessions would. "If you can have four groups a day, you're going to do a lot better [financially] than if you have seven or eight individuals," says Szapocznik, noting that if insurers would pay for individualized treatment according to patient instead of by the hour, treatment for single patients or families could be made affordable.

The 12-step model also remains popular in part because such meetings are free and widely available. What's more, given that about half of addiction counselors are recovering addicts themselves, they tend to stay true to the treatment that worked for them — usually a 12-step program — and are not often well trained in other approaches like family therapy.

Some experts worry that unfavorable treatment strategies may only increase with forthcoming revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the bible of psychiatry. In the current edition of the DSM, substance problems are divided into two diagnoses: "substance dependence," which signifies severe, chronic addiction, and "substance abuse," which applies to the kind of short-term risky behavior that many teens engage in but tend to outgrow.

In the proposed fifth edition of the DSM, however, diagnoses will be divided by drug, then by severity, all under the umbrella category of "addiction." That would mean the label of "addict" may be applied equally to a college binge drinker and a long-term heroin addict, which would not only reinforce the negative labeling effect on teens but also encourage mixing patients with varying substance problems in group therapy. "Failing to make the distinction at diagnosis will contribute to failing to make distinction in treatment," says Dr. Allen Frances, emeritus professor of psychiatry at Duke University and chair of the DSM task force that was in charge of the fourth edition.

What impact the new diagnostic categories may have remains to be seen. For now, researchers say the evidence shows the most effective teen drug treatment involves nongroup settings, especially for young people whose drug habits have not evolved to include harder substances. Anders Hoff, 23, says he was able to overcome his alcohol problem through individual therapy and by avoiding groups that required him to bear the label "alcoholic." At 18, Hoff left his home in Minnesota to attend college in Vermont. By the end of his first semester, he had developed a drinking habit so severe that he was frequently falling down drunk and suffering concussions. He had powerful headaches, and his senses of taste and smell were damaged by brain injury, but he didn't stop binge drinking. Panicked three days before the end of the term, he says, "with a knot in my stomach, I called my parents, said I had a problem and told them I had to go home."

He began individual counseling for alcoholism with Bob Muscala, a nurse in private practice in Edina, Minn., who has worked in the addictions field for 40 years. Hoff had two slips during his three years of therapy, but unlike with the standard 12-step program, his stumbles didn't force him to go back to zero and start counting his sober days all over again. "It didn't make me shut down and say, 'I'm done, let's start again with my old behavior,' " says Hoff, who is now back in school. "When I admitted the incidents, no one said, 'Well, you're an addict. You're never going to stop.' "

NIDA is funding collaborations with drug-treatment programs throughout the U.S. that are aimed at bringing both youth and adult treatments in line with practices that are known to work — for teens, that means family therapy, selective groups or individual therapy that prevents prolonged teen interaction in waiting rooms or other common areas. "There has been an incredible acceptance of evidence-based treatment" in programs that have joined NIDA's initiatives, Volkow says; however, many more community-based programs are still using interventions that have not proved to work.

Meanwhile, some individual treatment providers, like Muscala, continue to do their part, reducing drug use in the U.S. patient by patient. Matt Thomas, who has been in counseling with Muscala for about a year, just celebrated 10 months of sobriety at age 41.

• Maia Szalavitz