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Dial for Therapy: Aftercare for Adolescent Substance Use Disorders
Associate Editor: Michael S. Jellinek, M.D.
CLINICAL PERSPECTIVES
Dial for Therapy: Aftercare for Adolescent Substance Use Disorders YIFRAH KAMINER, M.D.,
AND
Substance abuse among American youths continues to pose a serious public health concern. However, only a small segment of the adolescent subpopulation with alcohol and other substance use disorders (AOSUD), in particular those with high severity of AOSUD, comorbid psychiatric disorders, and legal problems, usually end up in treatment (Kaminer, 2001). The more therapeutic services received during treatment, the better is the short-term outcome. The more therapeutic services received post-treatment, however, the poorer is the short-term outcome. Use of outside services after treatment completion presented a response to rather than a cause of substance use (Kaminer and Burleson, in press). Maintenance of treatment gains in the months after treatment has been problematic in youths with AOSUD. An approximately 60% relapse was reported during the first 3 months after treatment completion and an additional 20% relapse during the rest of the first year (Brown et al., 1989). Approximately 60% of adolescents continued either to vacillate in and out of recovery after discharge from the Cannabis Youth Treatment study (Dennis et al., in press) or to manifest at least some form of substance abuse (Kaminer et al., 2002).
Accepted March 1, 2004. From the Alcohol Research Center and Department of Psychiatry, University of Connecticut Health Center, Farmington. The preparation of this article was supported by grant RO1 AA12187-01A2 from the National Institute on Alcohol Abuse and Alcoholism.The authors acknowledge the contribution of Dr. James McKay to the evolution of the IBTPC manual. Inquiries regarding the manual should be addressed to kaminer@ psychiatry.uchc.edu. Correspondence to Dr. Kaminer, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-2103; e-mail: kaminer@ psychiatry.uchc.edu. 0890-8567/04/4309–1171©2004 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000133260.98666.bf
CHRIS NAPOLITANO, M.S.
Lack of continuity of care or aftercare programs for adolescents with AOSUD is the rule rather than the exception. There is a need to increase the overall effectiveness of treatment as well as maintain treatment gains by developing and testing the efficacy of behavioral aftercare interventions and services tailored to match the adolescent daily lifestyle. The only aftercare intervention with youths successfully tested so far has been the Assertive Community Reinforcement Approach (Godley et al., 2002). DEFINING AFTERCARE/CONTINUITY OF CARE
There has not been a consensus regarding what terms should be used to describe posttreatment interventions. Partially overlapping terms such as aftercare, continued care, or transition of care have been used interchangeably. We have conceptualized aftercare for adolescents who have made treatment gains as a phase of 3 to 12 months post-treatment defined by the employment of a less intense schedule of active aftercare. This is essentially a step-down intervention characterized by the following components. First, a short hiatus of as long as a 2-week period after planned treatment completion devoted to preparing a functional analysis, i.e., reviewing written personalized feedback from the therapist who provided treatment to the therapist assigned to providing aftercare. Second, both therapist and patient conduct a joint evaluation of the functional analysis addressing the patient’s vulnerabilities and personal resources in preparation for the singular or integrative intervention(s) by using the personalized feedback Finally, implementation of the plan, taking into consideration matching patient needs and available resources. RATIONALE FOR AND THE ELEMENTS OF AFTERCARE PLANNING NEEDED
Correlational studies that have examined the relationship between participation in aftercare interven-
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:9, SEPTEMBER 2004
1171
KAMINER AND NAPOLITANO
tions and AOSUD outcomes consistently concluded that greater participation in aftercare was associated with a reduced risk of relapse (McKay, 1999). Aftercare was associated with enhanced maintenance of treatment gains on proximal outcomes (Finney et al., 1999). These findings suggest first that aftercare is a promising intervention for enhancing relapse prevention and second that a possible mechanism that accounts for the relationship between aftercare and ultimate outcomes is the maintenance of duringtreatment proximal outcome gains afforded by continuing care (e.g., improved self-efficacy). The specificity, frequency, and dosage of planned aftercare should take into account the severity, chronicity, and response to previous episodes of treatment for AOSUD. Similar to treatment episodes, periodic functional analysis of the adolescent vulnerability to high-risk situations and individual resources that might contribute to resilience (i.e., drug refusal skills) should be considered. Individuals whose AOSUD have not improved or even worsened during treatment or aftercare need a step-up approach that might translate into a more intense (i.e., frequency, dosage, integrative approach) intervention and/or a more restrictive setting (i.e. residential, inpatient). The American Society of Addiction Medicine (2001) placement criteria for adolescents may be used as guidelines for matching severity of AOSUD and therapeutic setting. RATIONALE FOR THE USE OF INDIVIDUAL BRIEF THERAPEUTIC PHONE CONTACTS (IBTPC) IN AFTERCARE
There is a need for reliable, brief, and cost-effective ways of providing clinical aftercare. Progress made in communication technology using the telephone, computers, electronic mail, and Web sites has the potential to overcome impediments in the realms of transportation, staffing, time, and other resources that may pose limitations on the traditional delivery of face-to-face therapy. The telephone in particular as a readily accessible interpersonal medium can be used in therapy and has a variety of therapeutic uses. Reports supporting the feasibility and utility of telephone communication during aftercare for adults have been encouraging. Its use in crisis intervention with suicidal youths (Spirito et al., 2002), advice provision, and after-hours triage is common among adolescents and their caregivers (Baker 1172
et al., 1999). In developing the IBTPC, it has been important to identify the therapist and patient roles in the specified treatment. Even if traditionally the therapist is more familiar with face-to-face therapy, the telephone offers some flexibility for short-term interventions as those proposed here. Therapists’ as well as adolescents’ resistance to, ambivalence about, and unfamiliarity with telephone therapy could be addressed with appropriate training. APPLICATION AND IMPLEMENTATION OF THE IBTPC
This specific manual-based, guided intervention for aftercare should be implemented during the critical phase for relapse (i.e., 0–6 months posttreatment completion). It is composed of one face-to-face 50minute session of cognitive-behavioral therapy (CBT), followed by several brief (i.e., 15 minutes in duration) phone contacts scheduled at 2- to 3-week intervals (Napolitano and Kaminer, unpublished manual, 2003). The therapist examines the abstinence/relapse status and motivation and readiness to change of the participant, identifies problem areas, and provides skill guidelines and problem-solving strategies. The specific components of the IBTPC consist of three phases: an initial joining phase, an intervention phase, and a closing phase (Fig. 1). Within each phase of the phone call, the clinician focuses on specific strategies aimed at several factors that are tailored to each adolescent. These factors are determined in the initial individual in-person session and are facilitated by the use of two forms that are included in the manuals, the Patient Summary Sheet for Aftercare (CSSA) and a Goal-Setting Worksheet. The CSSA is a form that provides useful information for the preparation of the functional analysis. This includes the adolescent’s recent history of drug and alcohol use, situations that pose high risk of continued use or relapse, a measure of readiness to change drugseeking behavior, and a summary of the patient’s situational confidence levels (i.e., perception of selfefficacy) for substance use in high-risk situations. The Goal-Setting Worksheet prompts the adolescent to identify specific goals and objectives related to substance use. These two forms are used to facilitate topics for discussion and negotiation for the following IBTPC sessions. Preliminary results show that therapists and patients alike find the approach acceptable, feasible, and useful
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:9, SEPTEMBER 2004
CLINICAL PERSPECTIVES
Fig. 1 Individualized brief therapeutic phone contact (IBTPC): diagram of steps 1 through 3.
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:9, SEPTEMBER 2004
1173
KAMINER AND NAPOLITANO
(Kaminer, 2003). We had contrasted responses of subjects assigned to the phone aftercare condition with responses of their respective therapists. We found that there were no significant differences between (1) expressed acceptability of the phone intervention, (2) feasibility to reach participant by phone, (3) privacy to maintain confidentiality, and (4) satisfaction with this treatment modality. All scores ranged between mean = 1.4 and mean = 2.6 (that is, on the positive end of a 5-point scale where 1 = strongly agree and 5 = strongly disagree). Furthermore, preliminary findings regarding efficacy of manual-based phone interventions based on integrated motivational enhancement therapy (MET) + CBT are promising (Kaminer et al., 2004). This technique has served best adolescents with mild to moderate severity of AOSUD. At this juncture, phone therapy is not a reimbursable therapeutic service. However, following the mounting evidence of the efficacy of brief phone intervention either as an adjunct or an alternative to individual therapy in our study as well as that of McKay et al. (in press) and Spirito et al. (2002), it is reasonable to consider proposing a new coding for phone psychotherapy. A new formula for accounting purposes will be based on billing for smaller units equivalent to individual psychotherapy such as 15 or 20 minutes CONCLUSION
To expand understanding of how to improve efficacy as well as enhance the implementation of effective aftercare programs, there is a need to study the following issues: how to operationalize aftercare as usual, how to improve retention and engagement in aftercare, and how to determine or match the optimal duration, dosage, and specificity of interventions to the individual needs of patients (i.e., patient–treatment matching). In this era of increasing demand for services and growing competition for dwindling federal and state resources, phone interventions might offer additional
1174
resourceful, innovative approaches to maximize treatment effectiveness. IBTPC may be a reasonably costeffective method for providing aftercare, particularly compared with no aftercare. Finally, this approach could be adopted for use with other psychiatric disorders in youths. REFERENCES American Society of Addiction Medicine (2001), ASAM PPC2R (Patient Placement Criteria for Treatment of Substance Related Disorders). Chevy Chase, MD: ASAM Baker RC, Schubert CJ, Kirwan KA (1999), After-hours telephone triage and advice in private and nonprivate pediatric populations. Arch Pediatr Adolesc Med 153:292–296 Brown SA, Vik PN, Creamer V (1989), Characteristics of relapse following adolescent substance abuse treatment. Addict Behav 14:291–300 Dennis ML, Godley SH, Diamond G et al. (in press), Main findings of the Cannabis Youth Treatment (CYT) randomized field experiment. J Subst Abuse Treat Finney JW, Moos RH, Humphreys K (1999), A comparative evaluation of substance abuse treatment: linking proximal outcomes of 12-step and cognitive-behavioral treatment to substance use outcomes. Alcohol Clin Exp Res 23:537–544 Godley MD, Godley SH, Dennis ML, Funk R, Passetti LL (2002), Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment. J Subst Abuse Treat 23:21–32 Kaminer Y (2001), Adolescent substance abuse treatment: where do we go from here? Psychiatr Serv 52:147–149 Kaminer Y (2003), Aftercare for adolescents with alcohol and other substance use disorders (AOSUD): Feasibility and acceptability of phone therapy. The 2nd Annual Meeting of the Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE), June 20, Miami, FL Kaminer Y, Burleson J (in press), Correlation between ancillary community services with adolescent substance use disorders treatment outcome. Subst Abuse Kaminer Y, Burleson J, Goldberger R (2002), Psychotherapies for adolescent substance abusers: short-and long-term outcomes. J Nerv Ment Dis 190:737–745 Kaminer Y, Burleson J, Haberek R, Hundt A (2004), Aftercare for adolescents with alcohol and other substance use disorders (AOSUD): interim results. Presented at the 27th Annual Meeting of the Research Society on Alcoholism, June 26–30, Vancouver, Canada. McKay JR (1999), Studies of factors in relapse to alcohol and drug use: a critical review of methodologies and findings. J Stud Alcohol 60:566– 576 McKay JR, Lynch KG, Shepard DS et al. (in press), The effectiveness of telephone-based continuing care in the clinical management of alcohol and cocaine use disorders: 12 month outcomes. J Consult Clin Psychol Spirito A, Boerges J, Donaldson D, Bishop D, Lewander W (2002), An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt. J Am Acad Child Adolesc Psychiatry 41:435–442
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:9, SEPTEMBER 2004
CLINICAL PERSPECTIVES
Dial for Therapy: Aftercare for Adolescent Substance Use Disorders YIFRAH KAMINER, M.D.,
AND
Substance abuse among American youths continues to pose a serious public health concern. However, only a small segment of the adolescent subpopulation with alcohol and other substance use disorders (AOSUD), in particular those with high severity of AOSUD, comorbid psychiatric disorders, and legal problems, usually end up in treatment (Kaminer, 2001). The more therapeutic services received during treatment, the better is the short-term outcome. The more therapeutic services received post-treatment, however, the poorer is the short-term outcome. Use of outside services after treatment completion presented a response to rather than a cause of substance use (Kaminer and Burleson, in press). Maintenance of treatment gains in the months after treatment has been problematic in youths with AOSUD. An approximately 60% relapse was reported during the first 3 months after treatment completion and an additional 20% relapse during the rest of the first year (Brown et al., 1989). Approximately 60% of adolescents continued either to vacillate in and out of recovery after discharge from the Cannabis Youth Treatment study (Dennis et al., in press) or to manifest at least some form of substance abuse (Kaminer et al., 2002).
Accepted March 1, 2004. From the Alcohol Research Center and Department of Psychiatry, University of Connecticut Health Center, Farmington. The preparation of this article was supported by grant RO1 AA12187-01A2 from the National Institute on Alcohol Abuse and Alcoholism.The authors acknowledge the contribution of Dr. James McKay to the evolution of the IBTPC manual. Inquiries regarding the manual should be addressed to kaminer@ psychiatry.uchc.edu. Correspondence to Dr. Kaminer, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-2103; e-mail: kaminer@ psychiatry.uchc.edu. 0890-8567/04/4309–1171©2004 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000133260.98666.bf
CHRIS NAPOLITANO, M.S.
Lack of continuity of care or aftercare programs for adolescents with AOSUD is the rule rather than the exception. There is a need to increase the overall effectiveness of treatment as well as maintain treatment gains by developing and testing the efficacy of behavioral aftercare interventions and services tailored to match the adolescent daily lifestyle. The only aftercare intervention with youths successfully tested so far has been the Assertive Community Reinforcement Approach (Godley et al., 2002). DEFINING AFTERCARE/CONTINUITY OF CARE
There has not been a consensus regarding what terms should be used to describe posttreatment interventions. Partially overlapping terms such as aftercare, continued care, or transition of care have been used interchangeably. We have conceptualized aftercare for adolescents who have made treatment gains as a phase of 3 to 12 months post-treatment defined by the employment of a less intense schedule of active aftercare. This is essentially a step-down intervention characterized by the following components. First, a short hiatus of as long as a 2-week period after planned treatment completion devoted to preparing a functional analysis, i.e., reviewing written personalized feedback from the therapist who provided treatment to the therapist assigned to providing aftercare. Second, both therapist and patient conduct a joint evaluation of the functional analysis addressing the patient’s vulnerabilities and personal resources in preparation for the singular or integrative intervention(s) by using the personalized feedback Finally, implementation of the plan, taking into consideration matching patient needs and available resources. RATIONALE FOR AND THE ELEMENTS OF AFTERCARE PLANNING NEEDED
Correlational studies that have examined the relationship between participation in aftercare interven-
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:9, SEPTEMBER 2004
1171
KAMINER AND NAPOLITANO
tions and AOSUD outcomes consistently concluded that greater participation in aftercare was associated with a reduced risk of relapse (McKay, 1999). Aftercare was associated with enhanced maintenance of treatment gains on proximal outcomes (Finney et al., 1999). These findings suggest first that aftercare is a promising intervention for enhancing relapse prevention and second that a possible mechanism that accounts for the relationship between aftercare and ultimate outcomes is the maintenance of duringtreatment proximal outcome gains afforded by continuing care (e.g., improved self-efficacy). The specificity, frequency, and dosage of planned aftercare should take into account the severity, chronicity, and response to previous episodes of treatment for AOSUD. Similar to treatment episodes, periodic functional analysis of the adolescent vulnerability to high-risk situations and individual resources that might contribute to resilience (i.e., drug refusal skills) should be considered. Individuals whose AOSUD have not improved or even worsened during treatment or aftercare need a step-up approach that might translate into a more intense (i.e., frequency, dosage, integrative approach) intervention and/or a more restrictive setting (i.e. residential, inpatient). The American Society of Addiction Medicine (2001) placement criteria for adolescents may be used as guidelines for matching severity of AOSUD and therapeutic setting. RATIONALE FOR THE USE OF INDIVIDUAL BRIEF THERAPEUTIC PHONE CONTACTS (IBTPC) IN AFTERCARE
There is a need for reliable, brief, and cost-effective ways of providing clinical aftercare. Progress made in communication technology using the telephone, computers, electronic mail, and Web sites has the potential to overcome impediments in the realms of transportation, staffing, time, and other resources that may pose limitations on the traditional delivery of face-to-face therapy. The telephone in particular as a readily accessible interpersonal medium can be used in therapy and has a variety of therapeutic uses. Reports supporting the feasibility and utility of telephone communication during aftercare for adults have been encouraging. Its use in crisis intervention with suicidal youths (Spirito et al., 2002), advice provision, and after-hours triage is common among adolescents and their caregivers (Baker 1172
et al., 1999). In developing the IBTPC, it has been important to identify the therapist and patient roles in the specified treatment. Even if traditionally the therapist is more familiar with face-to-face therapy, the telephone offers some flexibility for short-term interventions as those proposed here. Therapists’ as well as adolescents’ resistance to, ambivalence about, and unfamiliarity with telephone therapy could be addressed with appropriate training. APPLICATION AND IMPLEMENTATION OF THE IBTPC
This specific manual-based, guided intervention for aftercare should be implemented during the critical phase for relapse (i.e., 0–6 months posttreatment completion). It is composed of one face-to-face 50minute session of cognitive-behavioral therapy (CBT), followed by several brief (i.e., 15 minutes in duration) phone contacts scheduled at 2- to 3-week intervals (Napolitano and Kaminer, unpublished manual, 2003). The therapist examines the abstinence/relapse status and motivation and readiness to change of the participant, identifies problem areas, and provides skill guidelines and problem-solving strategies. The specific components of the IBTPC consist of three phases: an initial joining phase, an intervention phase, and a closing phase (Fig. 1). Within each phase of the phone call, the clinician focuses on specific strategies aimed at several factors that are tailored to each adolescent. These factors are determined in the initial individual in-person session and are facilitated by the use of two forms that are included in the manuals, the Patient Summary Sheet for Aftercare (CSSA) and a Goal-Setting Worksheet. The CSSA is a form that provides useful information for the preparation of the functional analysis. This includes the adolescent’s recent history of drug and alcohol use, situations that pose high risk of continued use or relapse, a measure of readiness to change drugseeking behavior, and a summary of the patient’s situational confidence levels (i.e., perception of selfefficacy) for substance use in high-risk situations. The Goal-Setting Worksheet prompts the adolescent to identify specific goals and objectives related to substance use. These two forms are used to facilitate topics for discussion and negotiation for the following IBTPC sessions. Preliminary results show that therapists and patients alike find the approach acceptable, feasible, and useful
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:9, SEPTEMBER 2004
CLINICAL PERSPECTIVES
Fig. 1 Individualized brief therapeutic phone contact (IBTPC): diagram of steps 1 through 3.
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:9, SEPTEMBER 2004
1173
KAMINER AND NAPOLITANO
(Kaminer, 2003). We had contrasted responses of subjects assigned to the phone aftercare condition with responses of their respective therapists. We found that there were no significant differences between (1) expressed acceptability of the phone intervention, (2) feasibility to reach participant by phone, (3) privacy to maintain confidentiality, and (4) satisfaction with this treatment modality. All scores ranged between mean = 1.4 and mean = 2.6 (that is, on the positive end of a 5-point scale where 1 = strongly agree and 5 = strongly disagree). Furthermore, preliminary findings regarding efficacy of manual-based phone interventions based on integrated motivational enhancement therapy (MET) + CBT are promising (Kaminer et al., 2004). This technique has served best adolescents with mild to moderate severity of AOSUD. At this juncture, phone therapy is not a reimbursable therapeutic service. However, following the mounting evidence of the efficacy of brief phone intervention either as an adjunct or an alternative to individual therapy in our study as well as that of McKay et al. (in press) and Spirito et al. (2002), it is reasonable to consider proposing a new coding for phone psychotherapy. A new formula for accounting purposes will be based on billing for smaller units equivalent to individual psychotherapy such as 15 or 20 minutes CONCLUSION
To expand understanding of how to improve efficacy as well as enhance the implementation of effective aftercare programs, there is a need to study the following issues: how to operationalize aftercare as usual, how to improve retention and engagement in aftercare, and how to determine or match the optimal duration, dosage, and specificity of interventions to the individual needs of patients (i.e., patient–treatment matching). In this era of increasing demand for services and growing competition for dwindling federal and state resources, phone interventions might offer additional
1174
resourceful, innovative approaches to maximize treatment effectiveness. IBTPC may be a reasonably costeffective method for providing aftercare, particularly compared with no aftercare. Finally, this approach could be adopted for use with other psychiatric disorders in youths. REFERENCES American Society of Addiction Medicine (2001), ASAM PPC2R (Patient Placement Criteria for Treatment of Substance Related Disorders). Chevy Chase, MD: ASAM Baker RC, Schubert CJ, Kirwan KA (1999), After-hours telephone triage and advice in private and nonprivate pediatric populations. Arch Pediatr Adolesc Med 153:292–296 Brown SA, Vik PN, Creamer V (1989), Characteristics of relapse following adolescent substance abuse treatment. Addict Behav 14:291–300 Dennis ML, Godley SH, Diamond G et al. (in press), Main findings of the Cannabis Youth Treatment (CYT) randomized field experiment. J Subst Abuse Treat Finney JW, Moos RH, Humphreys K (1999), A comparative evaluation of substance abuse treatment: linking proximal outcomes of 12-step and cognitive-behavioral treatment to substance use outcomes. Alcohol Clin Exp Res 23:537–544 Godley MD, Godley SH, Dennis ML, Funk R, Passetti LL (2002), Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment. J Subst Abuse Treat 23:21–32 Kaminer Y (2001), Adolescent substance abuse treatment: where do we go from here? Psychiatr Serv 52:147–149 Kaminer Y (2003), Aftercare for adolescents with alcohol and other substance use disorders (AOSUD): Feasibility and acceptability of phone therapy. The 2nd Annual Meeting of the Society for Adolescent Substance Abuse Treatment Effectiveness (SASATE), June 20, Miami, FL Kaminer Y, Burleson J (in press), Correlation between ancillary community services with adolescent substance use disorders treatment outcome. Subst Abuse Kaminer Y, Burleson J, Goldberger R (2002), Psychotherapies for adolescent substance abusers: short-and long-term outcomes. J Nerv Ment Dis 190:737–745 Kaminer Y, Burleson J, Haberek R, Hundt A (2004), Aftercare for adolescents with alcohol and other substance use disorders (AOSUD): interim results. Presented at the 27th Annual Meeting of the Research Society on Alcoholism, June 26–30, Vancouver, Canada. McKay JR (1999), Studies of factors in relapse to alcohol and drug use: a critical review of methodologies and findings. J Stud Alcohol 60:566– 576 McKay JR, Lynch KG, Shepard DS et al. (in press), The effectiveness of telephone-based continuing care in the clinical management of alcohol and cocaine use disorders: 12 month outcomes. J Consult Clin Psychol Spirito A, Boerges J, Donaldson D, Bishop D, Lewander W (2002), An intervention trial to improve adherence to community treatment by adolescents after a suicide attempt. J Am Acad Child Adolesc Psychiatry 41:435–442
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 43:9, SEPTEMBER 2004