Module 3: Treatment Strategies

5E. Critical Treatment Issues

It is critical to develop continuity between treatment programs and treatment components. This includes treatment services that are provided sequentially over time and those provided concurrently. In practice, many youth participate in mental health and substance abuse treatment at different locations and for different purposes. Even in programs where the substance abuse and the mental health treatments are delivered together, youth may require different treatment services at different times.

Youth in the juvenile justice system are often moving within the system (e.g., detention to probation, detention to institution, institution to parole or group home). In each of these cases, continuity of treatment or the lack of continuity can have a significant effect on positive outcomes.

When developing treatment plans, juvenile justice, mental health, and substance abuse treatment providers should discuss sequence of interventions, length of treatment, voluntary versus mandatory treatment, and pretreatment services appropriate for youth with co-occurring disorders. With an increasing number of females involved in the juvenile justice system, gender differences must be discussed and taken into account when planning treatment strategies.

Sequence of Interventions

A question that commonly comes up when working with youth with co-occurring disorders is "Which disorder should I treat first?" There are three models related to the timing of treatment for individuals with co-occurring disorders (Ries, 1994):

1. Sequential: Treatment is provided sequentially; the youth receives treatment from one system (mental health or substance abuse) and then receives treatment from the other one. This is a common way that treatment has been provided to youth with co-occurring disorders. The system the youth enters initially may be determined by symptom severity or by whomever the youth happened to come into contact with first. Then that system refers the youth to the other system. In this model, the youth and their family typically are responsible for coordinating services and for sharing information. This type of treatment works best for youth involved with the juvenile justice system who have episodic experiences with their mental health and psychiatric disorder (e.g., episodic depression and occasional drinking binges).
   
   
2. Parallel: Treatment is provided in a parallel manner; the youth receives treatment from the mental health system and the substance abuse system at the same time. This type of treatment works best with youth who have mild to moderate disorders. The youth may be receiving quality treatment in both systems, but unfortunately there is often minimal coordination and integration between the two settings. The youth and their family are often responsible for the coordination of services and the sharing of information. The youth may receive conflicting messages from treatment providers (e.g., substance abuse agency does not support use of psychiatric medication prescribed by mental health provider).
   
   
3. Integrated: When treatment is provided according to the integrated model, the youth receive treatment for both their mental health and substance abuse disorders at the same time and in the same setting or by the same clinicians. Comprehensive treatment is provided by staff who have been cross-trained, and the program combines elements of both mental health and substance abuse. Treatment is individualized and flexible to tailor intervention strategies to the needs of each youth. Because both disorders are being addressed at the same time, a multidisciplinary approach is taken and decision making is shared. A strong case management component ensures that the interactive nature of the disorders is addressed, that the youth receives consistent messages, that there is a continuity of treatment services, and that clinical information is shared among all individuals involved in the treatment. It also makes it possible to monitor the youth and promptly provide treatment if a psychiatric or substance abuse crisis arises. This is likely the best treatment format when working with youth involved in the juvenile justice system who have severe or persistent co-occurring disorders.

Length of Treatment

Because most mental health and substance abuse disorders are persistent disorders with a high likelihood of relapse, it is important to provide long-term treatment to youth with co-occurring disorders. This does not necessarily mean that the youth must remain in a formal treatment program for years, but they should have some continuous involvement with the treatment system to utilize services when necessary. Studies have reported conflicting findings regarding length of treatment. For example, in residential treatment programs/therapeutic communities, length of time in substance abuse treatment is strongly related to how well a youth does after treatment ends. With regard to outpatient substance abuse treatment, a lengthy period of treatment sometimes has positive benefits and sometimes does not (Catalano et al., 1991).

Voluntary Versus Mandatory Treatment

Children and adolescents, particularly those involved in the juvenile justice system, like to feel they have some power and are able to make their own choices. These youth often become defensive and oppositional when told what to do. It is important for youth with co-occurring disorders to feel they are making choices about their treatment. Perceived choice is associated with treatment progress and posttreatment success among adolescents in substance abuse programs (Hawkins et al., 1991).

Many youth who have come into contact with the juvenile justice system have received court orders to attend treatment, or it may be part of their probation or sentence. Dropping out of treatment can have serious legal ramifications for these youth. Using motivational enhancement approaches can increase the youth’s perception that they are participating in treatment (and changing their behavior). By the treatment provider expressing empathy, pointing out discrepancies about what the youth wants for their life versus how they are currently living, highlighting negative consequences of their behavior, and taking a nonjudgmental and nonconfrontational approach, youth tend to feel they are making a personal choice to change their behavior, rather than changing because an authority figure has told them they have to. This increases the youth’s motivation, commitment to change, and sense of self-efficacy, which are likely to lead to more successful outcomes.

Pretreatment Services

Youth who come into contact with the juvenile justice system may be involved with the system only for a short time. If this is the case, it is best to focus on pretreatment services such as assessment, engagement, and getting the youth to commit to change their behavior. Time can also be spent educating them about the interaction of mental health symptoms and the use of drugs and alcohol. Emphasis should be on linking the youth with community treatment programs. More comprehensive treatment services should be offered to the youth with co-occurring disorders who will be involved with the juvenile justice system for a longer time.

If community treatment programs are full or there are long waiting lists for treatment programs at juvenile correctional facilities due to overcrowding or resource shortages, it is important to provide pretreatment services to keep the youth engaged and motivated for treatment. It is critical to continue contact with the youth at this stage and to reinforce their desire to seek treatment. It can be helpful to give them writing assignments focusing on questions such as:

• Why are they are seeking treatment now?
• What do they hope to receive from a treatment program?
• What makes them a good candidate for treatment?
• How do they want their life to be different?
• What problems has not seeking treatment caused for them?

If there are several youth awaiting treatment services, it may be appropriate to form a group to receive basic information about mental illness and substance abuse and discuss their individual responses to writing assignments. The goal is to continue the youth’s engagement and motivation toward treatment until the youth can be connected to a treatment program.

Gender Differences

An increasing number of females are entering and remaining in the juvenile justice system, and many of them have co-occurring mental health and substance abuse disorders. Gender differences include maturational development, socialization, health issues, stressful life events, and behaviors leading to juvenile justice involvement. To provide the most appropriate and most effective treatment, it is critical that programs and policies take into account the gender differences.

The GAINS Center has published two useful monographs related to this topic titled Adolescent Girls with Co-occurring Disorders in the Juvenile Justice System (Prescott, 1997) and Improving Outcomes for Adolescent Girls with Co-occurring Disorders in the Justice System (Prescott, 1998). These monographs may be ordered by calling 800-311-4246 or by e-mail at gains@prainc.com.