Putting Out Fires: Managing Co-Occurring Disorders in Teen Substance Abuse Treatment

Treating teen substance abuse and co-occurring disorders is a complex undertaking, requiring a comprehensive approach that addresses all needs for lasting success. For adolescent clients, common treatment factors to consider include addressing mental health and behavioral concerns, home and family dysfunction, and establishing healthy coping mechanisms and life skills for a substance-free future. 

Early intervention for teen substance abuse is vital. Left unaddressed, teen drug and alcohol misuse can easily evolve into a lifelong struggle with addiction that leads to a myriad of social, economic, and physical health consequences. With the help of behavioral health specialists and addiction experts, teens and their families can find healing and growth through the recovery process.

During a recent clinician roundtable hosted by Safe Landing Recovery, our expert panel discussed the challenges of determining treatment priorities, navigating harmful preconceptions, and mediating client-family communication. 

Putting Out Fires: Determining Treatment Prioritization

As a complex disorder affecting mental, emotional, and physical health, treatment of teen substance abuse can feel like trying to put out multiple fires at once. Comorbid disorders often feed into each other, creating a harmful, self-destructive cycle that feels impossible to escape. In other cases, physical health needs must take priority in order to get the client to a place where treatment is possible. For clinicians, determining a starting point for treatment largely depends on the client’s present needs.

One participating clinician offers this example,

“I recently had a patient experiencing psychosis, but I didn’t know until she shared with me that her sugar levels were over 500. Not only that, but she had not taken her medication. So I said ‘before I can do this [address the symptoms of psychosis], I have to first get you cleared medically. I can’t send a client one direction when there’s also a medical crisis to consider. Sometimes there’s a decision to be made about what to take care of first, but in other cases like this one, certain things take clear priority.”

Megan Bush, the primary therapist at Safe Landing Recovery, further emphasized this point: 

“We have encountered cases where clients have an active eating disorder as well as a substance use disorder. We’ve had to turn around and tell mom and dad their child needs to go to an eating disorder treatment center because we cannot begin to treat the substance use or any co-occurring mental health diagnosis until they are able to keep food down and eat enough to sustain themselves.

If the client can’t remain conscious during therapy, there’s no point in putting them through the therapeutic process.”

“If they’re not stable in their physical wellness, they’re not going to be able to participate fully or effectively in any sort of therapy session,” adds Tiffany Krause, Safe Landing Recovery Adolescent Outreach Coordinator, “These are some of the things individuals or families have to consider when looking for different resources.”

This is all attributed to Maslow’s Hierarchy of Needs, a theory in psychology that uses a five-tier pyramid model to show what needs must first be met before someone can shift focus and tend to higher level needs. The five primary tiers are:

• Physiological: food, water, warmth, and rest
• Safety: a sense of security 
• Love and Belonging: intimate relationships with friends, family, or loved ones
• Esteem: sense of accomplishment and/or prestige
• Self-actualization: self-fulfillment and achieving one’s full potential
• These tiers are grouped into three categories: 
• Basic needs (physiological and safety)
• Psychological (Love, belonging, and esteem)
• Self-fulfillment (self-actualization)

Using Maslow’s Hierarchy of Needs, clinicians are able to create objective treatment plans and prioritize which concern should be addressed first. In some cases, this may require more niche care rather than a dual diagnosis approach. This way, clients receive the level of direct, focused care they need to unravel the underpinnings of their disorder. 

“It’s a balancing act,” offered one clinician, “There are a lot of instances where we would have to refer out, like in the case of an eating disorder or similar situations. We can’t get you to the therapeutic starting gate unless we address some of these other issues first.”

It was also noted that while general group therapy sessions can be helpful in some cases, they may also unintentionally bury or gloss over important factors that need to be addressed for dual diagnosis clients. Staying within the previous example of eating disorders among addiction treatment clients, the clinicians note that blasé passing comments from others who may not relate to such an experience can be harmful. Instead, some clients may benefit more from niche care specifically aimed toward addressing these concerns.

Other Treatment Factors to Consider When Working with Teens

Addiction recovery is not a cookie cutter process, even in seemingly straightforward cases. Because substance abuse is often a symptom of underlying distress or trauma, creating a personalized approach to care is important. For teen populations, this often means being mindful of continuing mental and physical development, maturation, and accounting for the challenges that may arise. The teenage years are notorious for being a time of rebellion and establishing independence. This can translate to treatment challenges such as defiance (not to be confused with Oppositional Defiant Disorder), emotional dysregulation, or inability or unwillingness to be honest and vulnerable. Working through these potential obstacles with compassion and empathy is a necessary component of effective care.

One unanticipated challenge to working with adolescent clients can be familial interference. Typically stemming from a desire to help or the need for a sense of control, parents, guardians, and other family members may unintentionally create preconceptions around the affected teen’s behavior, diagnoses, or conditions. Rigidity and inflexibility in the recovery process is unconducive to healing, so it is often up to clinicians to not only address client needs but also work through issues within the family system. 

A common source of resistance clinicians experience when working with children and families is resistance during the diagnosing process. These challenges may arise due to denial that a problem exists or conversely, hyperfixation on a specific diagnosis. Some family members may believe the teen is just attention seeking or simply making poor life choices. Others, especially parents and guardians, may be insistent on a specific diagnosis even when evidence exists that another condition may be present. 

As one clinician put it, “Some of the misdiagnoses we see can be attributed to normal growth — puberty and hormones and such. I can recall a specific case where the father would ‘shop’ for doctors who would give the diagnosis that he thought matched his child. The child came to our facility and was untethered from that constant barrage of ‘oh no, that’s your ADHD’ and ‘that’s your this’ and ‘you’re bipolar’. When left to her own devices, yes, she displayed a few issues, but not to the level of what was described by the parent.”

They went on to note that the client in question was quite stable and easy to redirect and work with through the therapeutic process once separated from the influence of the parent in question.

“It’s the overanalysis of the parents sometimes. Not to undermine that they are the frontline with the adolescent, but sometimes they’re too quick to go to WebMD or Google something and jump to a diagnosis.”

While getting to the root of problematic behavior and working to address it is a key component of addiction recovery, when mismanaged it can also be a driving factor behind the problem. Children and adolescents are vulnerable to misdiagnosis and overmedication because oftentimes the parent or guardian is their medical liaison. As Tiffany Krause states,

“It’s easier to slap a label on them and med them up than to work through what might be a different personality type or different energy level or whatever it may be. I think that’s something that happens a lot and we need to address it.”

Medication is not a substitute for meeting a child’s needs. As highlighted in Maslow’s Hierarchy of Needs, when basic and psychological needs aren’t being met, it creates a rippling effect that manifests through behavioral issues such as emotional dysregulation, self-harm, violent outbursts, and substance use. Most teens who are actively abusing substances do so as a means of self-soothing or escapism from issues in other areas of their lives. Safe Landing Recovery encourages family involvement throughout the entire recovery process for this reason. When dysfunction within the home is unaddressed, relapse into negative behaviors is nearly unavoidable.

For parents who are concerned about their teen’s drug and alcohol use, it’s important not to point fingers or place blame. Instead, focus on supporting your child through the recovery process and beyond. Having open and honest communication about the problem and its causes creates a safe space where your teen can begin to work through these root causes of addiction and heal. You don’t have to do it alone. Safe Landing Recovery is here to help you and your family. Contact us today to discuss your concerns and how we can help.