How Effective is Outpatient Treatment in The Case Of Substance Abuse in Teens?

Drug use among adolescent is a serious issue in the U.S., made more serious by the emotional, psychological, and behavioral stressors teens faced over the past two years, during the upheaval caused by the coronavirus pandemic.

The latest data on drug use among adolescents, published in the 2020 Monitoring the Future Survey (2020 MTF) shows the following:

Lifetime Drug Use Among Teens: Drug Taken at Least Once

• Any illicit drug:
  • 4% of 8^th graders, 37.5% of 10^th graders, and 47.4% of 12^th graders
• Illicit drug other than marijuana:
  • 8% of 8^th graders, 13.8% of 10^th graders, and 18.4% of 12^th graders
• Marijuana:
  • 2% of 8^th graders, 34.0% of 10^th graders, and 43.7% of 12^th graders

Thirty Day (Past Month) Drug Use: Drug Used at Least Once in the Past Month

• Any illicit drug:
  • 8.5% of 8^th graders, 19.8% of 10^th graders, and 23.7% of 12^th graders
• Illicit drug other than marijuana:
  • 3.4% of 8^th graders, 4.3% of 10^th graders, and 5.3% of 12^th graders
• Marijuana:
  • 6.6% of 8^th graders, 18.4% of 10^th graders, and 22.3% of 12^th graders

When we read those numbers, we realize millions of teens each year experiment with drugs, and millions more use them regularly. Regular use of illicit drugs increases risk of developing a substance use disorder (SUD), which can lead to a wide range of physical, emotional, psychological, social, and behavioral problems.

To learn more about the negative consequences of drug use during adolescence, please read our article The Role of Outpatient Treatment for Teens with Mental Health and Substance Abuse Issues.

Experimenting with drug can lead to regular drug use, which can lead to SUD. Here’s the latest data on SUD – and treatment for SUD – among people over age 12 in the United States:

• 7 million meet the criteria for SUD
• Of those 20.7 million, 4.0 million received treatment

Those numbers tell us that eighty percent of the people who needed treatment for a substance use disorder did not get the treatment they needed. That’s something we need to fix – and we can. The first step is to spread awareness about treatment. Many people – especially teenagers – fear treatment, because they think the only real option is residential rehab. While residential treatment is appropriate in some cases, it’s not the only approach to SUD treatment for teens.

This article will examine the latest data on the effectiveness of outpatient treatment for teen SUD. We’ll define what outpatient treatment means, discuss its effectiveness, and finish by listing the most effective, evidence-based treatments for SUD available to your teen.

What is Outpatient Addiction Treatment for Teens?

In a nutshell, outpatient treatment for teens is any kind of addiction treatment during which the teen lives at home while participating in treatment. There are three kinds of outpatient treatment:

Regular Outpatient: Simply known as outpatient treatment, teens attend treatment in an office-based setting once or twice a week, for about an hour each session.

Intensive Outpatient (IOP): Teens in IOP programs attend treatment 2-3 hours a day, 3-5 days a week, in an office-based setting, or in an office in a specialized adolescent treatment facility.

Partial Hospitalization (PHP): Teens in PHP programs attend treatment 4-6 hours a day, five days a week. PHP programs most often take place in an office setting located in a specialized adolescent treatment facility.

The data in this article describe the effectiveness of treatment in regular outpatient/intensive outpatient treatment. We’ll use the information provided in the article Evidence Base on Outpatient Behavioral Treatments for Adolescent Substance Use, 2014–2017: Outcomes, Treatment Delivery, and Promising Horizons. This article helps us understand the big picture on outpatient treatment for adolescent addiction, because it’s a meta-analysis. A meta-analysis is a study that looks at all the relevant evidence on one topic – in this case outpatient treatment for teen substance abuse – and identifies the trends present in the data.

We prefer these types of analyses, because individual studies often present conflicting data. Meta-analyses, however, go one step further. They look at all the data – including the conflicting information – and make generalizations based on not just one group of study participants, but many. The study we cite above considered 11 large-scale studies on outpatient treatment for teen substance use disorder.

Let’s take a look at what they found.

Outpatient Treatment for Teen Addiction: What Treatments Work Best?

In 2008, the Journal of Clinical Child and Adolescent Psychology (JCCAP) published the first evidence-based update (EBU) on outpatient treatment for teen substance abuse/addiction. Researchers identified two categories to describe the treatments they reviewed: Well-Established Treatments and Probably Efficacious Treatments.

In 2008, Well-Established Treatments included:

• Multidimensional family therapy (MDFT)
• Functional family therapy (FFT)
• Group cognitive-behavioral therapy (CBT-G)

Probably Efficacious Treatments included:

• Brief strategic family therapy (BSFT)
• Behavioral family-based treatment (FBT-B)
• Multisystemic therapy (MST)

In 2014, the JCCAP published an update on that first study. Here’s what changed in each category:

The updated Well-Established Treatments category in 2014 included:

• Ecological family-based treatment (FBT-E)
• Group cognitive-behavioral therapy (CBT-G)
• Individual CBT (CBT-I)
• Multicomponent treatments:
  • Motivational enhancement therapy + CBT (MET/CBT)
  • MET/CBT + FBT-B.

The updated Probably Efficacious Treatments category in 2014 included:

• Behavioral family-based treatment (FBT-B)
• Motivational interviewing/motivational enhancement therapy (MI/MET)
• Ecological family-based treatment (FBT-E) + Contingency management (CM)
• Motivational enhancement therapy + cognitive-behavioral therapy (MET/CBT)
• Behavioral family-based treatment + contingency management (FBT-B + CM)

The latest study, published in 2020, places five treatments in the Well-Established category:

• Ecological family-based treatment (FBT-E)
• Individual cognitive-behavioral therapy (CBT-I)
• Group cognitive-behavioral therapy (CBT-G)
• Motivational enhancement therapy + cognitive-behavioral therapy (MET/CBT)
• Motivational enhancement therapy + cognitive-behavioral therapy + behavioral family-based treatment (MET/CBT + FBT-B)

We’ll spend the rest of this article focusing on these Well-Established Treatments. We’ll describe each one, beginning with Ecological family-based treatment (FBT-E).

What Works: Well-Established Treatments for Adolescent Substance Abuse

Let’s jump right in with the first treatment on the list.

Ecological Family-Based Treatment (FBT-E)

According to the California Evidence-Based Clearinghouse for Child Welfare, FBT-E, or EFBT, is based on:

“…the recognition that substance use and related individual and family problems derive from many sources of influence and occur in the context of [complex and dynamic] personal systems.”

A therapist trained in EFBT operates under the following assumptions:

• The family is the foundation of a teen’s life
• Everyone in the family play a role in the development and resolution of problems in a teen’s life
• Family dysfunction impacts functioning in other settings
• Family participation improves outcomes for teens in addiction treatment
• Treatment should focus on the social interactions among all participants

Finally – and this is essential – therapists assess the specific circumstances in each family, and tailor treatment based on their strengths, deficits, and needs.

Individual Cognitive-Behavioral Therapy (CBT-I)

When people think about psychotherapy in the 20^th century, it’s likely what they envision is cognitive behavioral therapy. Most of us have moved past the idea of reposing on a couch while a man who looks like Sigmund Freud says, “Tell me about your mother.”

Although family dynamics are a part of almost all psychotherapy, CBT narrows the focus.

Therapists help teens in addiction treatment understand the connection between their patterns of thought, their patterns of feeling, and their patterns of behavior. The idea is that when a teen can identify disruptive, counterproductive patterns of thought, they can learn to replace them with positive, productive patterns of thought. These new patterns of though lead to new patterns of feeling. The new patterns of feeling lead to new patterns of behavior. For teens in treatment for addiction, those new patterns of behavior include sobriety and abstinence, as opposed to drug use and abuse.

Group Cognitive-Behavioral Therapy (CBT-G)

There are three foundational principles in CBT:

1. We all have a set of core beliefs that we carry in our minds, about our self, about the world, and about the future, that develop over time.
2. Sometimes these core beliefs are based on dysfunctional assumptions – called cognitive distortions – that give us a distorted view of the world.
3. Many of us – especially people with mental health disorders – default to automatic negative thoughts that are based on our core beliefs and cognitive distortions.

While a therapist in individual CBT teaches that these automatic negative thoughts can be challenged and replaced in a one-on-one setting, a group CBT adapts the one-on-one techniques to a group setting. The benefits of group CBT for teens include:

• Instant feedback on behavior from peers
• The ability to role-play in small groups, watch other groups, and give and receive feedback
• Normalization: when a teen learns others have similar experiences – and sometimes have the same thoughts that lead to the same behaviors – they learn that they’re not alone. This reduces the stigma and shame associated with SUD and promotes the open communication necessary for learning and growth
• The ability to test coping skills and stress management techniques in real situations. This is different than the roleplaying mentioned above, because teens in addiction treatment often face real emotions in group therapy – and learn how to apply their new coping skills then and there.

In addition, creating therapeutic peer relationships promotes treatment success. When teens in addiction treatment spend time helping – and receiving help – from their peers, they learn the value of a positive, supportive social environment, and understand that they can seek that out in their own lives, not just in treatment.

Motivational Enhancement Therapy + Cognitive-Behavioral Therapy (MET/CBT)

Motivational enhancement therapy is designed to get a treatment resistant individual to commit to treatment. The process of MET is relatively short. Therapists conduct a series of motivational interviews with a teen diagnosed with SUD. During these interviews, the therapist:

• Develops a trusting partnership with the teen
• Accepts the teen’s point of view and their autonomy
• Elicits a desire to change
• Creates a plan for change, directed by the teen

Evidence shows that MET is effective in getting people to commit to treatment, but not effective at actual treatment of keeping people in treatment. That’s why it’s followed immediately with additional evidence-based therapies such as CBT, which we describe above.

Motivational Enhancement Therapy + Cognitive-Behavioral Therapy + Behavioral Family-Based Treatment (MET/CBT + FBT-B)

At first blush, this appears to be an all of the above approach. It is – with one important caveat. Its elements are the three most effective known approaches to treating adolescent addiction/substance use disorder. Therefore, we can think of it as a combination of the most effective techniques: CBT, FBT, and MET. We describe these techniques above, but there’s a small difference: the type of family therapy in this subset is behavioral family therapy. What that means is that its family therapy – including everything we list above under FBT-E – with a focus on changing behavior. Whereas a teen with SUD might leave a typical family therapy session with a greater understanding of themselves, their parents, their family dynamic, and how that influences their drug use, a teen might leave a behavioral family therapy session with all that and a plan for behavioral change.

Why Outpatient Treatment?

The simple answer: it works.

Evidence indicates that every technique described above reduces drug use and promotes long-term recovery for teens with substance abuse or addiction issues.

That’s the most important thing to understand.

Next, if you’re the parent of a teen with a mild or moderate substance use disorder, it’s important to understand that residential treatment – what most people think of as drug rehab – is not the only option. When they learn their teen uses drugs, or experiments with drugs, many parents jump to the nuclear option: they consider a military boarding school, then, when someone even-tempered talks them down, they think of residential rehab. What we want those parents to learn from this article is to listen to their teen’s assessing therapist: if they recommend outpatient treatment for mild or moderate SUD, the evidence is on their side.

Finally, parents and teens need to know that outpatient treatment is still real treatment. A teen may only go to therapy alone once a week, and the family may join the teen in therapy on an additional day, but what both parents and teens learn is that recovery is a daily process. It takes time, commitment, and effort, but it’s well worth it. When a teen and family participate in treatment together, they learn about one another and grow in new ways. In almost all cases, family therapy – which evidence shows is essential for treating teen SUD – strengthens the family unit and improves the family dynamic. That’s good for the teen, good for the family, and should give parents reading this real hope for the future.