Treating Dually Diagnosed Adolescents

By BRENDA J. WRIGHT, NANCY J. SMYTH and ELAINE M. MACCIO

Published April 2001

• Cognitive behavioral (CBT) and interactional (IT) treatments both effective with dually-diagnosed adolescents. 
• CBT more effective at three months with equivalent treatment effects at 15-month follow-up.

This Research & Practice Dialogue highlights Kaminer and Burleson's (1999) pilot study of cognitive behavior treatment (CBT) versus interactional treatment (IT) that tested the general efficacy and treatment matching effects with dually diagnosed adolescents.

Kadden and colleagues (Kadden, Cooney, Getter, & Litt, 1989) had demonstrated positive outcomes at three and 15-month follow-up in general efficacy and treatment matching using CBT and IT with dually diagnosed adults. In this study CBT was more effective for adult alcoholics higher in sociopathy. IT was more effective for adults lower in sociopathy, as well as those higher in cognitive impairment. 

Based on the results of the study with adults, Kaminer and Burleson had three predictions for adolescents in this pilot study: (1) the general efficacy of CBT and IT would be similar for substance abusing adolescents, (2) CBT is better suited for adolescents with externalizing disorders and (3) IT is better suited for adolescents with internalizing disorders.

Thirty-two adolescents were matched, based on type of psychopathology, to either CBT (n = 17) or IT (n = 15). Externalizing disorders, such as conduct disorder, attention deficit disorder, or other type of disruptive disorder, were hypothesized to respond better to CBT, while internalizing disorders, such as anxiety, depression, and other mood disorders, were predicted to respond better to IT.

Adolescents participated in weekly 90-minute "manual guided" sessions over the period of 12 weeks in either the CBT or IT approach. The CBT intervention, originally founded on relapse prevention and coping skills procedures (Kadden et al., 1992; Monti, Abrams, Kadden, & Cooney, 1989), consisted of participants, in a highly structured group format, learning to recognize and manage high-risk relapse situations. From this standpoint, substance use is viewed as a learned, maladaptive way of coping with situations or meeting one's needs. Through the use of behavioral strategies, events that precede and maintain substance use are interrupted with interventions that offer the individual an alternative to drinking and using drugs. Each session focused on different coping strategy or skill building exercise, such as substance refusal skills, emergency planning, and relapse modeling, and homework assignments. 

The IT intervention, adapted from Brown and Yalom (1977), is process-oriented and based on interpersonal interaction within a group setting that promotes symptom relief and personality change. Groups tend to be small in size (6-9 members), which allows for bonding and peer influence. When the group commits and adheres to honesty and trust, interaction is grounded more in emotional expression. The atmosphere is supportive rather than confrontational, and promotes interpersonal learning, group cohesiveness, imitative behavior, and socialization skills among other change mechanisms. The focus of the group shifts over time from alcoholism toward examining the basic underlying dysfunctional interpersonal interactions that lead to maladaptive behavior, including substance use.

Kaminer and Burleson (1999) found:

• That treatment matching had no significant effect on adolescents' outcomes.
• Still, participants experienced substantial improvement in the domains of substance abuse, family function and psychiatric status at 15-month follow-up as a result of both interventions.
• Although CBT and IT had similar gains at 15-month follow-up, CBT demonstrated a significant reduction in severity of substance use at three-month follow-up. 
• A gender effect showed that girls had more psychiatric problems at baseline and at the end of the study follow-up period. 

Why a superiority of CBT at three months? Kaminer et al. (1998) felt that it may be due to one or both of the following: (1) CBT is highly structured, incorporates modeling, role playing, and practice exercises and homework; (2) CBT is substance focused, and sessions incorporate drug refusal skills & specific interventions for relapse prevention. Both characteristics of the treatment might account for it's faster effect.

Gender differences noted in this study warrant further investigation, as they could have important implications for treatment.

• Small sample size: Out of the initial 20 males and 12 females, 69 percent completed the three-month follow-up assessment and only 44 percent were interviewed at the 15-month follow-up.
• As in many studies involving human subjects at risk, there were no control groups, such as no treatment or minimal treatment groups. This makes it impossible to know how many participants would have improved without treatment.
• The authors of this study note that this is the 1st study reporting long term follow-up of treatment for dually diagnosed adolescents and, as such, it points the way to issues that deserve further investigation.  

Because both treatments were effective, either one would be appropriate treatment methods for this population. However, two factors may tilt the "scale" in favor of CBT at this time: (1) Manual guided CBT may provide treatment benefits faster than IT in an outpatient setting; (2) more complete treatment manuals for CBT currently exist (with handouts already prepared). See the reference list for manual citations.

The treatment approaches described in this study are based on CBT coping skills training (Monti et al., 1989) and its later modifications (Carroll, 1998; Kadden et al., 1992), and the IT group approach (Brown & Yalom, 1977). Kaminer and Burleson's (1999) research resembles a previous study (Kadden et al., 1989) that demonstrated positive treatment matching effects with adult substance abusers. Check out the reference list below for these and other treatment manuals discussed in the preceding paragraphs. Also, a complete downloadable (and html version) of a CBT manual for cocaine addiction in adults can be found at https://archives.drugabuse.gov/sites/default/files/cbt.pdf

² You will need Adobe Reader to view pdf documents. If you don't have the Adobe Reader (a free program) you can download it at http://www.adobe.com/products/acrobat/readstep.html

Brown, S., & Yalom, I. D. (1977). Interactional group therapy with alcoholics. Journal of Studies on Alcohol, 38 (3), 426-456.

Carroll, K.M (1998). A cognitive-behavioral approach: Treating cocaine addiction (Manual 1) (NIH Publication No. 98-4308). Rockville, MD: National Institute on Drug Abuse. Retrieved from http://www.nida.nih.gov/TXManuals/CBT/CBT1.html

Kadden, R., Carroll, K., Donovan, D., Cooney, N., Monti, P., Abrams, D., Litt, M., & Hester, R. (1992). Cognitive-behavioral coping skills therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence (DHHS Publication No. ADM 92-1895). Rockville, MD: U.S. Department of Health and Human Services.

Kadden, R. M., Cooney, N. L., Getter, H., & Litt, M. D. (1989). Matching alcoholics to coping skills or interactional therapies: Posttreatment results. Journal of Consulting & Clinical Psychology, 57 (6), 698-704.

Kaminer, Y., & Burleson, J. A. (1999). Psychotherapies for adolescent substance abusers: 15-month follow-up of a pilot study. The American Journal on Addictions, 8, 114-119.

Kaminer, Y., Burleson, J. A., Blitz, C., Sussman, J., & Rounsaville, B. J. (1998). Psychotherapies for adolescent substance abusers: A pilot study. The Journal of Nervous and Mental Disease, 186(11), 684-690.

Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989). Treating alcohol dependence: A coping skills training guide. New York: Guilford Press.

Note: The authors wish to thank Yifrah Kaminer of the University of Connecticut Health Center for his invaluable time and assistance with the aforementioned resources.

This summary has been made possible by the Northeastern States Addiction Technology Transfer Center (NSATTC), partnered with the University at Buffalo School of Social Work, 685 Baldy Hall, Buffalo, N.Y., 14260. Additional copies can be requested from the NSATTC office at 716-645-3381 x243. In part, the mission of the NSATTC is to increase the knowledge and skills of addiction treatment practitioners from multiple disciplines by facilitating access to state-of-the-art research, education and best practices.