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Adolescent Depression and Anxiety

Introduction

Adolescence is a tumultuous period in development. Independence is being sought, sexual development is at its peak, attachment and connectedness with parents are often riddled with conflict, peer pressure and conformity peaks (especially to antisocial standards), and social and cultural norms place outside pressure for conformity. The adolescent struggles with their own identity development, as they experiment with numerous roles and identities they draw from the surrounding culture. Erikson called this 5th stage of development, identity vs. identity confusion. This is the period between the security of childhood and the autonomy of adulthood. Those who successfully cope with these conflicting identities during adolescence, emerge with a new sense of self that is refreshing and acceptable. Adolescents who do not successfully resolve this identity crisis are confused. This confusion usually takes one of two courses; the individual withdraws isolating themselves from family and peers, or they lose their identity in the crowd. At this stage, externalizing (conduct disorder) and internalizing (anxiety and depression) problems, along with substance abuse, seem to increase substantially. The comorbidity of these problems and substance abuse present special challenges to clinicians in the areas of assessment, treatment, counseling, and the management of risky and self harmful behaviors. According to Stowell and Estroff (cited in King, Ghazzuiddin, McGovern, Brand, Hill, & Naylor, 1996), up to 50% of adolescents in treatment facilities for substance abuse have affective disorders, the majority of which are major depression and dysthymia. Deykin (1992; cited in King et al., 1996) found that 25% of adolescents in his study had a major depressive disorder. In a study of 547 adolescents with serious emotional disturbances, Greenbaum (cited in King et al., 1996) found that 48% of the adolescents with severe depression also had substance use disorders. There are many speculations as to the reasons why this comorbidity exists, with the most frequent being that one has a causative effect on the other. There does not appear to be much research in this area, probably because longitudinal data would be necessary from early childhood through adolescence in order to establish causal relationships. Neighbors, Kempton, and Forehand (1992) hypothesize that substance abuse relates to internalizing problems as it serves a form of self-medication to reduce the symptoms of anxiety and depression. According to Chiles (cited in Harris & Lennings, 1993), suicide attempts range between five and twenty times higher for substance abusers than for the general population. Gibbs (cited in Harris & Lennings, 1993) says depression is the single most prevalent characteristic of suicidal adolescents. Evidence supports that in 35% to 79% of suicidal cases depression is the most common clinical condition. The combination of these two disorders can be lethal for this population. Hafen and Frandsen (cited in Harris & Lennings, 1993) suggests that suicide rates are higher in adolescents who abuse substances because adolescents who use drugs indicate a reduced impulse control, a lowered threshold for frustration and boredom. In addition, substance abuse lowers teenager’s resistance and coping ability.

Adolescent struggles with identity development, parental conflict, peer pressure, externalizing and internalizing disorders, substance abuse, and suicidality present the clinician with numerous issues in the assessment, treatment, and counseling of adolescents and their families. The impairment of individuals with co-occurring disorders is more severe, and treatment is frequently more complicated. This paper attempts to elaborate on the research of the comorbidity issue, and ascertain common issues in the areas of assessment, treatment, and counseling.

Review of theoretical and empirical literature

According to Lewinsohn, Rohde, and Seeley (cited in Aseltine, Gore, & Colten, 1998) “previous research suggests that the rate of comorbidity for these disorders (depressed mood and substance abuse) is among the highest of any combination of diagnoses for both adolescents and adults, and that early onset of major depressive disorder doubles the risk for later drug abuse and dependence” (p. 550). Aseltine et al. attempt to present a detailed examination of the precursors of co-occurring problems in troubled adolescents by reviewing family, peer, and intimate relationships. Given the transitions in these relationships during this developmental period, they focused on both positive and negative aspects. They examine whether the precursors of co-occurring or singular substance abuse and mood problems differ qualitatively or quantitatively, or if these problems result from different configurations. Aseltine et al. (1998) gathered data by doing a prospective study of mental health and social adaptation on a sample of 9th, 10th, and 11th graders in three community schools in the Boston area. The sample size was 1208 students with a 73% overall retention rate over the four year period. Information and measures are from self-report data using interviewers from the Center for Survey Research at the University of Massachusetts. The students represent the public high school students in these three communities (Boston area) from a socioeconomic standpoint. The median household incomes of the three communities were $36,590, $43,490, and $60,566. There were 523 boys, and 685 girls. Seventy percent were living in intact families (two parent), 20% single parent families, 8% with a natural parent and a stepparent. Ninety-four percent were Caucasian. Black, Hispanic, and Asian youth represented approximately 2% each. According to the researchers, these sample distributions are consistent with norms from nationally representative samples.

The students were measured for depression using the Center for Epidemiological Scale, a 20 item index assessing self reported frequency of depressive symptoms over the past week. Asking the respondents two separate items; how often they had a drink of alcohol, and how many times they had five or more drinks in a row was the measure for alcohol use and abuse. An ordinal scale was used to assess the frequency of marijuana and cocaine use ranging from no use to ten or more times on a five point scale. Aseltine et al. (1998) found youths in the depressed category had an overall mean of 21.6 on the CES-D scale compared to 6.6 for the non-depressed. The depressed were more likely to have attempted suicide (13% vs. 5%), and more likely to have reported a lifetime episode of depression (31% vs. 12%). Substance abusers reported significantly more alcohol and drug use than non-abusers; i.e. drinking at least nine days as compared to three days over the past thirty, having at least 5.3 drinks per episode, reporting more binge episodes, and significantly higher use of marijuana and cocaine.

The independent variables in the study by Aseltine et al. (1998) were negative relations with parents, conflict with friends, and the role of peers in facilitating problem behavior. Negative relations with parents were measured by assessing the extent to which youths find parents to be domineering, overprotective, unsupportive, and demanding. The extent to which friends criticize, make demands, and create tension measures conflict with friends. Friends who influence to do the wrong things, and the youths feel the pressure to do so, measures the role of peers in facilitating problem behavior. The study used five control variables; family standard of living, family social class, family structure, youth’s sex and age. Reports on the study were based on Time1 (2nd year) and Time2 (4th year).

At time2, the fourth year of the study, Aseltine et al. (1998) found 17.5% (157) of the youths could be classified as substance abusers, while 23.2% (208) of the youths reported a depressed mood. However, 5.6% (68) of this non-clinical population had reported these co-occurring problems at Time1 and Time2. Also, 44% of those who reported both problems at Time1 reported depression only or substance abuse only at Time2. The most interesting results of the study were not so much the percentages, but the effects of the independent variables. “Higher levels of friendship conflicts and lower levels of peer and parent support were associated with co-occurring problems” (Aseltine, et al. 1998, p.564). According to Aseltine et al., attachment theory is “integral to internalized regulatory processes related to comorbid patterns of adaption” (p. 565). Possibly because of the emphasis on intimacy and self-disclosure during this period, peer support more so than family support is so often sought. It could be the lack of parental support that drives the adolescent to seek peer support. Aseltine’s et al. findings indicated friend support and conflict with parents and friends were important predictors of depressed mood. 

The author chose this study because this was one of few studies done on a sample of “normal” adolescents. Most of the other research reported on will focus on clinically based or residentially based treatment samples. Second, the fact that 70% of these adolescents come from intact families with high median incomes, does not appear to adequately represent the population nationally. Aseltine et al. (1998), regarding attrition, mention that those of lower socioeconomic status and non-intact families were less likely to be interviewed in Time2. However, these facts may highlight the parental and peer cohesion issue since they seem to lessen the poverty and single parent issues. The point the author of this paper is attempting to make is that the factors of poverty and single parent family do not seem to be adequately represented by this population. Removing those factors from the results heightens the effects of the parental and peer cohesion issues in the results of this study.

Deykin, Buka, and Zeena (1992) conducted a study in Massachusetts of 223 subjects (168 male and 55 female) drawn from seven residential treatment centers funded by the Massachusetts Department of Health. The average age was 16.5. Fifteen percent of the subjects were non-white, as compared to 12% of the overall state population. Over half of the subjects families had received some form of welfare assistance. Overall the group represented a disadvantaged population. The purpose of the study was to assess the prevalence of depression in the groups undergoing treatment for chemical dependence, examine potential correlates of depression, and investigate whether depression preceded or followed chemical dependence. To be eligible the participants needed to meet the criteria for diagnosis of substance dependence in DSM III-R, and must be 15 to 19 years of age. Trained research assistants administered the Mental Health Diagnostic Interview Schedule and the Family and Social History Interview to gather the data needed for the study.

Bear in mind the differences in the demographics of the populations in Aseltine et al. (1998) and Deykin et al. (1992). The results in Deykin et al. differ considerably from Aseltine et al. in the fact that 24.7% of the population in Deykin et al. had a comorbidity of major depression and substance dependence versus 5.6% (depressed mood and substance abuse) in Aseltine et al. In Deykin et al. (1992), gender differences varied with 16.9% of the male subjects and 48.2% of the female subjects being diagnosed with major depression. This seems to be consistent with other findings. In Pumariega, Johnson, Sheridan, and Cuffe (1996) 39% of the male population and 65.5% of the female population in their study of a high risk population showed signs of depression according to the CES-D scale. Galaif, Chore, Sussman, and Dent (1998) suggest that societal socialization processes and norms will differentiate self reported adolescent depression, with girls showing an internalization process of symptoms expression (i.e. depression, loneliness, and sadness) and boys showing an externalizing process (conduct disorders, substance use etc.). Is it possible that depression in adolescent females and conduct disorders and substance abuse in adolescent males are different expressions of the same underlying disturbance? Could it be those societal socialization processes and norms have so programmed males to manifest the underlying problem that would show as depression in girls as conduct disorders in boys? In a study by Riggs, Baker, Mikulich, Young, and Crowley (1995) of 139 boys, ages 13 to 19 admitted to a long term residential treatment program for delinquency and substance involvement, they found that depression was a common co-occurring disorder with a level of 21%. Ninety-five percent of the boys had at least one substance dependent diagnosis. Depression in these boys signaled for more diagnoses of substance dependence and regular use of more drugs. According to Riggs et al. this is more supportive evidence that depressed adolescent males have more serious drug and alcohol problems and use substances as medication. “Depressions in these boys did not remit after four weeks of abstinence, which makes it unlikely that these depressions were due directly to substance intoxication” (p. 769). In a study by Henry, Feehan, McGhee, Stanton, Moffit, and Silva (1993) of New Zealand adolescents, ages 11 to 15, they found the univariate analysis in males revealed conduct problems and depressive symptoms at age 11 predicted multiple drug use at age 15. However, depressive symptoms were more important. They concluded that the effects of depression mediate early conduct problems and substance use. However, in girls, the relation between depressive symptoms and substance use was mediated by conduct problems. Harrington, Rutter, and Fombonne (cited in Aseltine et al., 1998) “examined the pathways linking more and less serious childhood depression and conduct problems and these disturbances in adulthood” (p. 550). Their findings demonstrated distinctive characteristics in both these disorders in adulthood. These findings call into question the hypothesis that depression and conduct disorder are different expressions of the same underlying problems. While these findings are not definitive, and in fact contradictory,  they certainly create new hypotheses for research into depression, conduct disorders, and substance use disorders as they intercorrelate in males and females in adolescence.

Deykin et al. (1992) reviewed other sociodemographic variables that have been identified as possible correlates of depression; living apart from natural parents, parental psychopathology, school failure, low socioeconomic status, and victimization. They found that perception of low socioeconomic status, paternal psychopathology, and victimization (i.e. physical and sexual abuse) indicated an elevated risk of depression. It’s interesting that Ge, Conger, and Wu (cited in Aseltine et al., 1998) found fathers’ warmth and hostility also had a differentiating effect on the youth with dual disorders. Deykin et al. (1992) also found that the depression in males was twice as likely as the females to follow the onset of substance dependence, whereas the depression in the females was either a primary disorder or co-occurring with chemical dependence. According to Neighbors, Kempton, and Forehand (1992), a number of studies cited showed the following; internalizing disorders serve as an antecedent to substance abuse, individuals select drugs more often under conditions of dysphoria, and 74% of a sample of adolescents said they used drugs to reduce feelings of sadness and depression. Though Deykin et al. (1992) did not find the effects of parental psychopathology to be statistically significant, according to Su, Hoffman, Gerstein, and Johnson (1997) “parental substance use disorder and affective disorder increase the adolescents’ risk of experiencing more negative life events. Negative life events further lower family cohesion, which in turn leads to adolescents’ substance use and depressive symptoms” (p. 869). Several studies suggest that children subject to inept parenting and poor family cohesion develop a coercive, non-compliant style of interacting with people. This leads to difficulties at school, with peers, and at home. Proper attachment with parents lead to an adolescent with more prosocial attitudes. Adolescents with poor familial relationships tend to seek and associate with a deviant peer group. This association appears to lead to more substance use, depression, and conduct disorders (Simons, Whitbeck, Conger, & Melby, 1991).

A major point made in Deykin et al. (1992) is the effect of poverty on substance use and chemical dependence in adolescence. “Studies have repeatedly demonstrated the sizable impact of stressful family conditions…(e.g. economic problems…) on depressive symptoms in adolescence” (Aseltine et al., 1998, p. 550). In Pumariega et al. (1996) racial and ethnic differences found little support when clinically significant levels of symptomatology were concerned. However, a correlation between substance use and poverty was found. Strengthening the issue of poverty as a correlate in adolescence disorders is the fact that it is a chronic stressor rather than an acute one. According to McConagle and Kessler (cited in Dinges & Duong-Tran, 1993), chronic stress is more positively related to depressive symptoms than acute stress, and long term threat is the core factor associated with the onset of major depression. Racial, ethnic, and cultural differences are found in the weighting of generic life events, and also in special events that may have an effect on a specific culture (e.g. the effect on the Alaska Native population by the Prince William Sound oil spill), but the specificity of a causal relationship between substance disorders and depression, and race or ethnicity does not seem to have empirical support. Prevalence of types of substance use and the patterns of use differs in adolescents from different ethnic backgrounds, however ethnicity and race was not found to be significantly related to substance use (Galaif, Chore, Sussman, & Dent 1998).

Recent support has been given to conceptualizing suicidal behaviors along a continuum ranging from less serious (e.g. general thoughts of death and suicide) to more serious (e.g. suicide attempts, threats, and completions) (Windle & Windle, 1997). They cite numerous studies that show suicide ideators and attempters can be distinguished by some important variables, i.e. the prevalence of psychiatric disorders, the occurrences of stressful life events, degree of family dysfunction, and the use of alcohol and drugs. They sampled 975 high school students (53% sophomores and 47% juniors) from two suburban high schools in Western New York. Demographics were as follows: 98% were white, average age 15.5 years, 53% were female and 47 % male, median family income was approximately $40,000, and 88% were from intact families. Seventy-four percent of those eligible participated, and the retention rate was 90%. They obtained information on suicide behaviors, depressive symptoms, problem drinking, major stressful life events, perceived social support from the family, motives for drinking, percentage of friends who drink, and drinking disinhibitions. Their purpose was to test the independent and combined effects of depression and problem drinking behaviors on the occurrence of suicidal thoughts and attempts, to test the severity continuum hypothesis, and to investigate sex differences in these areas. Windle and Windle (1997) found “that the combination of depressive symptoms and problem drinking conveys a stronger risk for suicidal behaviors than does problem drinking or depressive symptoms alone” (p. 926). High levels of chronic and acute stressful life events, failing to implement constructive problem solving strategies, and use of alcohol and or drugs impair the adolescent’s coping ability and may contribute to the perception that suicide is the only way out. According to Steele and Joseph (cited in Reifman & M. Windle, 1995) “consuming alcohol restricts one’s attention to only immediately salient stimuli – a state these authors term ‘alcohol myopia’ ” (p. 335). Consequences of “alcohol myopia” are the inability to be aware of inhibitory factors when contemplating risky behaviors, and the intensifying of a single emotional state. Alcohol has the potential of magnifying the depressed person’s woes. Reifman and M. Windle (1995) support R.C. Windle and M. Windle (1997) in the findings that there are some causal relations between the predictors of depression, substance use, and suicidal behaviors. In addition, Windle and Windle (1997) found that a differentiation of suicidal subgroups on a continuum was possible. Attempters reported higher levels of depression and illicit drug use as compared to the thoughts only groups. Attempters also reported a greater number of significant stressors. The sex differences found in this study were congruent with other literature in suggesting “adolescent females experience higher rates of non-fatal suicidal behaviors and higher levels of depressive symptoms than do their male counterparts” (Windle & Windle, 1997, p. 927).

In a study on the gifted and suicide cited in Metha and McWhirter (1997), Shneidman found a series of signatures among men who successfully committed suicide and those who did not. “These signatures included drug and alcohol abuse, previous suicide threats or attempts, depression, chronic stress in the family of origin or adult family, and early problems in the child’s relationship with parents” (p. 286). Similar signatures were found in women who successfully committed suicide. Like other adolescents the gifted children indicated socioemotional problems in the area of pressure from parents and peers, loneliness, and an internal pressure to be perfect (Metha and McWhirter, 1997). In a study by Lewinsohn, Rohde, and Seeley (1995) of 1700 adolescents in Oregon, 65% of those treated for substance use showed signs of major depression, 44% of those treated for substance use had poor global functioning, 34.6% had attempted suicide, and 13.6% of those treated showed elevated conflict with parents.  

The interpretation of all these findings are to be tempered with studies’ limitations. As previously mentioned, some studies samples were relatively homogeneous, therefore generalizing to other populations is risky. Studies relying on self-reports run the risk of intentional distortion and faulty recall. Most studies can be found with limitations. However, there seem to be areas of consistency in these studies that warrant attention in the areas of assessment, treatment, and counseling, despite these limitations.

Implications for assessment

Berenson (1998) in discussing frequently missed diagnoses in adolescents says that symptom overlap, high rates of comorbidity in youth with mental illness, perceptions of informants who are necessary in the assessment of children and adolescents, and the effects of development on symptom presentation are prominent issues often overlooked in the assessment process of adolescents. Another factor that may hinder assessment is the rigidity of training in the DSM IV criteria requisites for diagnosis. The criteria often don’t explore development, risk factors, environment, current stressors, and family dynamics in the adolescent. According to Berenson (1998), there is almost a certain co-occurrence with other DSM IV disorders in the substance-abusing adolescent. This problem of comorbidity may have an impact on effective treatment planning and its implementation. The assessment of adolescent substance abusers should involve evaluation of the possibility of comorbid psychiatric disorders that may be contributing to or preventing improvement in substance use, and those with psychiatric disorders should be evaluated for substance use (Whitmore et al. 1997). “Biological, social, parenting style, and peer influences, as well as personality, coping style, and reporting influences may contribute to the severity of substance disorder” (p. 94). These factors also play a role in other comorbid disorders. Proper assessment in these areas leads to a more effective treatment plan. The preceding information has clear implications for assessment. First, assessment should be ongoing as the adolescent and parents feel more comfortable with the process they will have a tendency to be more open and involved. Second, because of the information gathered in previous research cited in this paper regarding parents, siblings, and peer influences during this developmental period, a systems approach to assessment seems warranted. This would involve assessing the role of the family, parent-adolescent interactions, parental psychopathology, attachment to parents, family conflict, and peer and sibling influences in the psychopathology of the adolescent. Third, suicidal ideation and thoughts should be addressed in the early stages of the assessment process. Necessary precautions should be taken to protect the adolescent from self-inflicted harm. Fourth, since the rate of comorbidity is so high in adolescence, it may be wise to assume one exists until proven otherwise. With comorbid disorders in adolescence, which one is primary or secondary is important to treatment planning, e.g. if depression and substance abuse are comorbid, and the adolescent is using the substance as a medication, treating for substance abuse alone would be ineffective. If depression is secondary, then treating for substance abuse should effectively remove depressive symptoms. Fifth, the use of testing and assessing instruments (e.g. Beck Depression Inventory, Adolescent Alcohol Involvement Scale, Personal Experience Inventory, Problem Oriented Screening Instrument for Teenagers, etc.) is encouraged when suspicion of other disorders is present. These can help confirm or negate the suspicion. An example of the previous mentioned assessment vehicles is the Personal Experience Inventory. According to the Mental Measurements Yearbook (1995), the inventory is consistent with the current views of substance abuse as multidimensional disorder defined both by excessive use and by adverse psychosocial, health, and related consequences. It is written at the sixth grade reading level and costs $17.50 per test. 

It assesses multiple dimensions in two major domains:

Severity of chemical involvement

Associated psychosocial dysfunctions 

The chemical involvement problem severity area asks 153 questions and also describes to the clinicians the rewards, consequences, and social effects of drug use as seen by the person taking the test. The psychosocial portion asks 147 questions and assesses personal and environmental risk factors important in treating drug abuse (i.e. Personal risk factors such as  Negative self-image, Psychological disturbance, Social isolation, Deviant behavior, Absence of goals – Environmental risk factors such as Peer chemical involvement, Family pathology, Family estrangement)

The assessment of the adolescent clearly needs to involve a complete biopsychosocial history, including the present environmental climate at home (including family child rearing practices), school, peer, and work (if necessary). Also, assessment should involve the mental status of the individual, the individuals reaction to stress, coping skills, their developmental history, and the social support and resources available to assist the individual on the path to recovery.

Implications for Treatment

Treatment for patients that are dually diagnosed is more complicated than those with a single diagnosis. Lysaught and Wodarski (1996) suggest that both disorders be dealt with concurrently to meet the needs of the dually diagnosed patient. This presents a problem in treatment if the counselor is not properly trained in working with the psychiatric illness and the substance disorder. Therefore, one of the main aspects of treatment planning is the assuredness of the competencies of those delivering treatment in the fields necessary for effective treatment, e.g. case work, inpatient, psychiatry, medicine, and counseling. 

Suicidality is the first issue of effective treatment. The lethal comorbidity of depression, substance use, and suicidal ideation or a recent attempt account for 58.4% of the successful suicides in adolescents (Dinges & Duong- Tran, 1993). Effectively addressing and treating the suicidality issue can be a matter of life and death. Treatment of this issue may involve intensive in-patient, parental and peer support, individual or group counseling, and possible psychopharmacology. “Treatment interventions targeted at increasing adolescents knowledge and use of more constructive coping strategies, such as problem focused coping skills, may be effective in decreasing suicidal ideation and attempts” (Windle & Windle, 1997, p. 927). 

The counselor and patient should set treatment goals that are realistic and reachable. Treatment should involve changing pathogenic aspects of the environment and enhancing the competencies of the patient. Family support programs such as family groups, reducing family stress, enhancing family communication skills, and family modeling programs may be used to release tension in the environment. Parents would be encouraged to join a parent group offering education, problem solving skills modeling, structural parental discipline methods, and behavioral management. 

Treatment in adolescence is different from adults in the fact that they are trying to be restored to a level of competency so they can continue to develop, whereas adults are restored to levels of premorbid or normal activity. The developmental level found in the assessment is important in the treatment planning. Usually the developmental level, because of the effects of the disorders, environmental stress, SES, etc., is lower than normal for the patients chronological age. Therefore treatment should also involve “education, reduction of anxiety, increased use of social skills and coping mechanisms, relaxation strategies, assertive/refusal skills, and anger management skills” (Lysaught & Wodarski, 1996, p.62).

Be it the case manager, or the counselor the treatment plan should involve enhancing the physical, mental, emotional, and spiritual well being of the patient. As assessment follows up to see if the treatment plan is successful, changes may need to be made to the treatment plan. The case worker or counselor not only need to be concerned for the patients internal disorders and his or her well being, but may also need to be an advocate with environmental forces with which the patient is involved. Enhancing and finding outside support groups for the adolescent including family, peer, and social (e.g. church and community) groups are an effective adjunct to counseling.

Implication for Counseling

Treatment goals set in treatment planning need to be reviewed and objectives laid out systematically to reach those goals. The counselor first needs to be aware of his or her own limitations and field of expertise. The counselor should be familiar with adolescent development and the disorders diagnosed. Knowledge of the order of treatment regarding the co-occurring symptoms is necessary for effective counseling. The counselor needs to be aware of the demographics of the patient, SES, home and school environment, peer associations, and level of identity development if race and ethnicity are involved, and any adverse effects that unhealthy situations have on the patient and his or her symptoms. The counselor needs to address these issues in two ways. First, search for cognitive distortions and faulty beliefs in the patient regarding these issues and help the patient correct them. This can be done through cognitive restructuring i.e. assisting the patient in changing the way he or she thinks about them, and/or changing behaviors that reinforce them. Second, the problem may not all lie in the patient, but in the environment. The counselor may need to act as an advocate and assist the patient in addressing these issues, hopefully resulting with a change in the environment. As stated earlier in this paper, poor parental cohesion and parental psychopathology have been associated with low self-esteem, depression, and substance abuse. One model posited by Robertson and Simons (1989) says the effect comes from the loss of a parent as a confidant in rejecting families. The counselor has the opportunity and responsibility to be the confidant the adolescent does not have. As a confidant, with unconditional positive regard, the counselor can have quite an effect on the adolescent’s self-esteem. Depression, substance abuse, or conduct disorder are merely symptoms in most cases of underlying problems (e.g. abuse, maltreatment, etc.). Patience, kindness, love, and concern are of the utmost importance in dealing with these adolescents.

Especially in depressive disorders, coping seems to be a major problem with the adolescent. Lazarow and Folkman (cited in Herman-Stahl, Stemmler, & Petersen 1995) define coping as “cognitive and behavioral efforts to manage external and /or internal demands that are appraised as taxing or exceeding the resources of the person” (p. 650). It is an important mediator between negative life events and psychological well being. One of the main goals of counseling should be to increase the adolescents coping skills. These may involve problem solving, cognitive coping, social entertainment, physical exercise, and peer support. Approach oriented coping, acting on, or modifying stressors by cognitive behavioral means has been linked to more positive well being (Herman-Stahl et al., 1995). Herman-Stahl et al. found the cognitive behavioral approach to be very effective with adolescents.

Remember this patient is an adolescent, and as such has probably had his or her development interrupted by these disorders and substance abuse. As the counselor it is important to help this patient get to the point where they can continue successful development. Depending on the needs of the client, determined in the assessment stage, cognitive behavioral techniques such as social skills training, communication skills training, social modeling, behavioral rehearsal, self management skills training, anger management training, assertiveness training, correction of deficits in expressing one’s self, and problem solving techniques are all viable options in the counseling of adolescents. 

Conclusion

One of the most difficult developmental periods for the human is adolescence. At this stage, depression and substance use are major concerns of health, and appear to have a high correlation with suicide attempts and completions. Research suggests the rate of comorbidity in the disorders of depression and substance abuse in adolescents is among the highest of any diagnosed. In addition, suicide in this population has increased three fold in the last thirty years. There are volumes of information that link poverty, lack of parental support and cohesion, and lowered peer support with depression and substance use in this population. Effective assessment, treatment, and counseling adolescents with these disorders and risk factors not only involves methods developed to deal with these disorders in any population, but also requires contact with the adolescents’ environment, education, and assistance in development physically, emotionally, and socially.

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Whitmore, E.A., Mikulich, S.K., Thompson, L.L., Riggs, P.D., Aarons, G.A., and Crowley, T.J. (1997). Influences on adolescent substance dependence: conduct disorder, depression, attention deficit hyperactivity disorder, and gender. Drug and Alcohol Dependence, 47, 87-97.

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Spirituality, the twelve steps, and substance use syndrome

Spirituality, Twelve Steps, and substance use syndrome

The purpose of this paper is to review why spirituality and the Twelve Steps of AA have been significant in addressing treatment for Substance Overuse Syndrome. Though recognized as different diagnoses in the DSM IV, the terms substance dependence and substance abuse, along with the terms alcoholism and addiction, will be used interchangeably for the purpose of this paper, and will be referred to as Substance Overuse Syndrome. This paper will not approach the topic of the diversity in opinions of using spirituality for treatment of Substance Overuse Syndrome. As of 1990 over 88% of hospital based treatment programs used AA as a primary intervention (Ellis & Schonfeld, 1990). This paper will address why this path has worked for many. The author of this paper believes this is not the only path of treatment for recovery, however, for the sake of brevity, it will be the only topic of this paper.

Substance Overuse Syndrome

In order to prepare for treatment, it is important to search for the etiology of the disease or malady that one is going to treat. First, let’s look at some of the causes of Substance Overuse Syndrome. “Addiction is a state of compulsion, obsession, or preoccupation that enslaves a person’s will and desire….We succumb because the energy of our desire becomes attached, nailed to specific behaviors, objects, or people. Attachment, then, is the process that enslaves desire and creates the state of addiction” (May, 1988, p.14) The term behavior is often used in the definition of addiction because action is essential to addiction. Thinking is also a behavior, thus images, memories, fantasies, ideas, concepts, and certain feeling states can become objects of attachment.

Brown (1992), indicates that there is strong evidence that psychiatric symptoms manifested by a substantial percentage of substance abusers were not transient, but rather constituted symptoms of more chronic, severe, and often preexisting character pathology ranging from severely unhappy to fairly well adjusted individuals though often conflicted. The personality pattern of the substance abusing population is characterized by disregard for established social customs, lack of control and foresight, inability to maintain lasting personal commitments, and a need for unusual and varied experiences. Alcoholic men are four times more likely than non alcoholic men to present with antisocial personality disorder, while the figure for women is twelve times. “It would appear that descriptively oriented research generally supports the view that substance abusers…generally present a wide range of maladaptive personality profiles that fall along a continuum from a psychologically – distressed, severely neurotic, or ‘borderline’ personality subtype to a non – symptomatic, pronounced anti-social, or extremely narcissistic profile subtype, with perhaps a middle third major subtype being comprised of personalities presenting less pathological profiles, but whose symptoms represent various combinations or features of the other two” (Brown, 1992, p.5). He is making the point that there have been clinical observations demonstrating a strong relationship between substance abuse and the ‘disorders of the self’. Disorders of the self are referring to a constellation of pathological character traits or impairments having as a common denominator the presentation of a false, defensive self in an attempt to ward off intrapsychic conflict and avoid painful feelings. The psychodynamic theorists cite a vulnerability of the self as the basic or core problem with substance abusers. Brown (1992) states that Masterson believes the DSM-IV personality disorders can be conceptualized in four clinically relevant clusters: Borderline, Narcissistic, Antisocial, and Schizoid, and that development of these disorders can be traced to specific abnormalities in either, nature (genetic heritage of the individual), nurture (child rearing practices), fate (unavoidable traumatic experiences in life growing up), or a combination of these. Brown (1992) uses the Millon Clinical Multiaxial Inventory (MCMI), an instrument of 175 items used to measure disorders closely related to the DSM IV’s concepts of personality disorders, to support a strong relationship between substance abuse disorders and the ‘disorders of the self’. For substance abusers, relationships with the self, others, and God are unsatisfactory mainly because of attitudes of negative spirituality.

These theories by May, Brown, and Masterson are not contradictory to the principles taught in AA about alcoholism. In Alcoholics Anonymous (1976), Bill Wilson, one of the cofounders, states that alcohol was but a symptom of the problem. He goes on to say that the real problem lay rooted in the ‘self’, particularly in what Wilson called “defects of character”. Warfield and Goldstein (1996) define “character defects” as feelings, beliefs, and behaviors that lead the alcoholic to seek a sense of well being by abusing alcohol. They are frequently reflective of a pathological narcissism, in which the alcoholic behaves as though he or she were the center of the universe. “Self centeredness… is the root of our troubles. Driven by a hundred forms of fear, self-delusion, self seeking, and self pity…but we invariably find that at some point in the past we have made decisions based on self which later placed us in a position to be hurt….So our troubles, we think, are basically of our own making. They arise out of ourselves.” (Alcoholics Anonymous, 1976, p.62). AA’s basic tenet is that alcoholism is a disease of the self, a physical, mental, and spiritual malady.

Carroll (1991) cites in her research that one of the significant factors in the etiology of alcoholism is the vain attempt to satisfy deep religious needs by means of alcohol. She cites that of ten groups studied by Clinebell in 1963 and administered the Purpose in Life Test (PIL), alcoholics registered as the lowest in PIL. She believes this can be seen as the cause and effect of drinking.

Chapman (1996) discovered alcoholism to be described as a disease by Johnson with affective symptoms, and an emotionally based etiology. Chapman proceeds in his article to discuss how Vaillant argued that alcohol dependence exists on a continuum with a biopsychosocial explanation of this diagnosis.

The author of this paper is attempting to show the major roles that psychological and social disorders play in the development of Substance Overuse Syndrome. Chapman (1996), “addressing the physical and mental symptoms of alcoholism represent the logical, pragmatic, temporal approach to treatment. Though necessary, this approach is not sufficient to ensure a lasting recovery. It is by considering spiritual issues, issues related to connectedness, a sense of purpose in being, and relationship with others, …a platform is created that enables the person with alcoholism to reach recovery” (p42).

A Brief History

It was in the early 1930’s that spirituality was introduced into the treatment of alcoholism. One alcoholic, Ebby, was seeking help from the Oxford Group, which had an intense religious identity. Another gentlemen, by the name of Rowland, sought help from Dr. Carl Jung. It was Dr. Jung that told this gentlemen, he had seen people recover from the illness, as serious as he had it, only if they had a ‘deep religious experience’. These messages eventually came to Bill Wilson, a New York stockbroker, and co-founder of AA, who on numerous occasions had unsuccessfully attempted to stop drinking. History then tells the story of how Bill Wilson had such an intense spiritual experience when he was in the hospital for the last time. Wilson then embarked on the path Ebby talked to him about when he had previously visited Wilson at his home. This path led to a meeting with Dr. Bob Smith in Akron, Ohio around June 1935. It was from this point that Alcoholics Anonymous was founded and the Twelve Steps developed.

In a letter, dated January 30,1961 addressed to Bill Wilson, Jung wrote regarding Rowland, “His craving for alcohol was the equivalent, on a low level, of the spiritual thirst of our being for wholeness….The only right and legitimate way to such an experience is, that it happens to you in reality and it can only happen to you when you walk on a path which leads you to a higher understanding”. (Language of the Heart, 1988, p280). Jung went on to say, one can be led to that goal by grace, through personal and honest contact with others, or through higher education of the mind beyond the confines of mere rationalism.

In the forward of Alcoholics anonymous (1976), Dr. Silkworth wrote in the Dr.’s Opinion, “We doctors have realized for a long time that some form of moral psychology was of urgent importance to alcoholics” (p.xxv). This was the modern beginning of the use of spirituality in the treatment of alcoholism. Presently “attention to the spiritual aspects of the patient with substance abuse problems is mandated by the Joint Commission on Health Care Organizations for all substance abuse treatment facilities” (Peteet, 1993, p.263). Despite this fact mental health professionals are skeptical about the relevance of the spiritual approach to treatment effectiveness.

What is spirituality?

One would hope that after reading 25 to 30 articles, books, and journals regarding spirituality, that one could come up with a concrete, comprehensive, and understandable definition, a definition that would be empirically measurable and testable. However, this was not the case. One hundred writings may produce as many definitions of this term. It is the vagueness of this term, though, that may give it its strength. The vagueness allows the individual to apply his or her own meaning to the term, within the confines of certain common concepts. Presently, spirituality is being recognized as personal and subjective.

Historically, religion and spirituality were not distinguished from one another. It may be this close relationship in the two terms that hinders the definition of spirituality. Religion is a social institution in which people participate, whereas, spirituality is more of an individual searching for meaning. It has really been in the past twenty-five years that interest in spirituality has increased, and the term has shifted to include more elements.

“What is spirituality? To have the answer is to have misunderstood the question.” (Kurtz, 1992, p.15). Kurtz goes on to say that spirituality is an intangible and ineffable reality that we can’t define, but that defines us. In an attempt to define spirituality we see our own limitation, and not the limitation of spirituality. “Elusive in the sense that it cannot be ‘pinned down’, spirituality slips under and soars over efforts to capture it, to fence it in with words. Centuries of thought confirm that mere words can never induce the experience of spirituality.” (Kurtz, 1992 p.16). Yet, he goes on to say we all have spirituality, either a negative one that leads to isolation and self destruction, or one that is more positive and life giving. Negative spirituality is indicated in one who is insecure, defensive, and lacking in self-esteem.

“The self, others, and God provide the key elements within a definition of spirituality, and that other emerging themes, namely meaning, hope, relatedness/connectedness, beliefs/belief systems, and expressions of spirituality, can be articulated in the context of these key elements” (Dyson, Cobb, & Forman, 1997, p.1183). Dyson et al. (1997) identify the importance of spiritual well being as depending on a right relationship between self, others, and God. They continue that spirituality occurs in the context of communities, and that the state of the self is reliant upon the relationships with others. In a number of studies reviewed by Dyson et al. (1997) the following characteristics or needs of spirituality were found:

•Giving and receiving love and forgiveness from others is a spiritual need

•Also, having a common bond with others

•Affiliation and interdependence

•A person’s highest value in life can be his or her God, suggesting that spirituality is based on the person’s life principle

•Purpose and meaning in life are critical attributes to spirituality which includes a search for relationships that give a sense of worth and a reason for living.

Some common concepts of spirituality described by Zinnbauer et al. (1997) are; individual phenomena; identified with such things as personal transcendence, supraconscious sensitivity, and meaningfulness; ultimate purposes, higher entities, God, love, compassion, and purpose.

Pauly (1990) defines spirituality as a consciousness and a way of life. It may be understood as experiencing a sacredness of self, life, and the world. This acknowledgment of sacredness within then becomes the meaning and purpose for one’s life as a whole. A sense of connectedness is produced when one appreciates a sense of meaning and purpose, and the sacredness of oneself and all of life.

In Kus (1995), Father Leo Booth says “I define spirituality as the relationship between body, mind, and emotions that allows people to be positively and creatively connected to others and the world around them….Spiritual power is within us: it is manifested in our self esteem, in our ability to make choices, and take responsibility for our lives” (p.6). This relationship within the self of the body, mind, and emotions, shapes one’s ability to relate to others, and the spiritual power of the universe. Depression, addictions, compulsive behaviors, and low self-esteem are symptoms of a faulty relationship with the self, and of wounded spirituality. Spirituality cannot be measured. However, one can evaluate the degree of spiritual wounding based on the mental, emotional, and physical problems a patient presents (Kus, 1995).

Warfield and Goldstein (1996) state that of all the basic needs, belongingness is the most spiritual. Belongingness, “can be described as enjoyment of loving, accepting, and trusting relationships with one’s self, other people, the world in all aspects of life’s experiences, and the God of one’s understanding” (p.198).

Spirituality, though not necessarily definable in exactness, can be thought to have some basic characteristics. Those would be:

•Personal subjectivity

•Relatedness and connectedness with others and the world

•A sense of purpose in life

•A transendence of the self to some Higher Entity

•A loving and accepting relationship with the self.

The original founders of AA described the spiritual experience they were talking about as a personality change, a profound alteration in the alcoholic’s reaction to life (Alcoholics Anonymous, 1976). Fr. Booth believes spiritual empowerment puts people in charge of the changes in their lives. He believes “we are most spiritually healthy when we allow ourselves to be real, to be imperfect” (Kus, 1995 p.10).

In the previous discussions on Substance Overuse Syndrome and spirituality, some common points are found. If we plotted people with these points on a continuum, we would have persons who have Substance Overuse Syndrome on one end of the continuum, and Spiritual people on the other end, with a number of points in between. Common characteristics found in people with Substance Overuse Syndrome are ‘disorders of the self’, antisocial personality disorders, an emotionally based etiology (affective symptoms), a vulnerability of the self, and low self-esteem. Spirituality, on the other hand, encompasses the other end of the continuum, shown as a connectedness to self and others, an interdependence and interrelatedness with others, sacredness of self, self acceptance, acceptance of others, and self empowerment. The goal of treatment would be to move one’s patients along the continuum towards spiritual growth. O’Murchu (1994) states that if one can find a means of fostering spiritual growth, and increasing self esteem, then a natural process of inner healing can take place, and one can overcome this illness.

AA and the Twelve Steps

It is at this point that AA and its Twelve Steps can be used as an adjunct to treatment or personal counseling. The fellowship of AA is designed to instill in the alcoholic “the level of trust necessary to risk exposing their vulnerable selves to honest examination and correction of their dysfunctional behaviors and beliefs” (Warfield & Goldstein, 1996 p.196). This is done through the “suggested” Twelve Steps of recovery. The Steps represent the actions taken by the original members of AA to assure their own recovery from alcoholism. The Steps are found in chapter five of the Big Book (Alcoholics Anonymous, 1976) titled “How It Works”. This chapter starts by saying, “Rarely have we seen a person fail who has thoroughly followed our path” (p.58). Warfield and Goldstein (1996) summarize the steps as follows:

•Step 1. We admitted that we were powerless over alcohol, and that our lives had become unmanageable. The self-centeredness of a willful and irresponsible ego is recognized as the root cause of the destructive use of alcohol. Acceptance of powerlessness lays the groundwork for the transcendence of the faulty ego self. “This begins the process of breaking down the typical personality characteristic of obsessive control on the part of the alcoholic. If powerlessness is not internalized, a sense of spirituality cannot and will not exist” (Watkins, 1997, p.582).

•Step 2. Came to believe that a power greater than ourselves could restore us to sanity. The problems or ‘character defects’ that sustain alcoholism are a form of mental illness that is not conducive to self-treatment. It takes a power greater than the ego self. AA says God, as one understands God, is that power. However, until such time as the alcoholic accepts this, the group is an acceptable substitute. Alcoholics have used the phrase “Good Orderly Direction” as another understanding of God.

•Step 3. Made a decision to turn our wills and our lives over to God, as we understand Him. One makes the commitment to overcome their narrow ego self and grow spiritually by giving up his or her willfulness and surrendering to this power.

•Step 4. Made a searching and fearless moral inventory of ourselves. The alcoholic makes an account of his or her character defects and positive traits. There is an awareness of an acceptance from the fellowship despite one’s character defects. This is where the ego defenses begin to be surrendered.

•Step 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. The alcoholic now takes responsibility and acceptance for the past. This honesty helps to increase self-esteem.

•Steps 6 and 7. Were entirely ready to have God remove all those defects of character, and humbly asked Him to remove our shortcomings. This willingness to depend on God and the humility involved are evidence of the lessening of the influence of the ego.

•Steps 8 and 9. Made a list of all persons we had harmed and became willing to make amends to them all, and made direct amends to such people wherever possible, except when to do so would injure them or others. The process of making amends erodes egocentricity and constructs positive spiritual relationships with others. Spiritual growth is enhanced as one accepts responsibility for wrongs done to others.

•Step 10. Continued to take personal inventory, and when we were wrong promptly admitted it. Self-responsibility is taken for ones behavior and actions. Commitment to honesty in relationships helps the development in self-esteem.

•Step 11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for the knowledge of His will for us and the ‘power to carry that out. The ego is forsaken to the dependence of God’s will and grace.

•Step 12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and practice these principles in all our affairs. “Ego transcendent spirituality is practiced in all relationships, and strengthened through helping other alcoholics.” (Warfield & Goldstein, 1996, p.201). The alcoholic does not stop here, but continues to rework the steps while new and more powerful patterns of beliefs and attitudes are established.

These Twelve Steps attempt to assist the individual in reconnecting to self and others, connecting to a Higher Entity in the universe, and restoring one’s purpose in life which is to carry this message.

Warfield and Goldstein (1996) summarize it so eloquently when they state, “As recovering alcoholics ‘work the steps’ of the AA program, guided by their sponsors in the supportive family environment, they begin to develop positive spirituality. This is reflected in the blossoming attitudes of unconditional love, acceptance, and trust in relationships with themselves, others, the world, life, and the God of their understanding. They come to believe that they are fundamentally okay even if their behaviors sometimes are not. They begin to love, accept, and trust themselves” (p.202). They continue that because of this, recovering alcoholics in AA learn to develop more satisfying relationships, in and out of AA. They learn to trust life and others as being fundamentally okay, and develop a trusting, accepting, and loving relationship with them.

Khantzian and Mack (1994) state there is increasing evidence that AA not only helps the members to succeed in arresting their uncontrolled drinking, but also in the positive transformation of their lives physically, emotionally, and spiritually. They go on to say that AA is based on group psychology that addresses, interrupts, and modifies core problems in self-regulation. AA benefits people in their feeling life by helping them access, experience, and express their emotions.

Summary

The descriptions earlier in this paper of Substance Overuse Syndrome indicate “disorders of the self” as a primary characteristic. This is presented as a false, defensive self with intrapsychic conflict and avoidance of painful feelings. Brown (1992) characterizes the personality pattern of the abuser as having a disregard for established social customs, lack of control and foresight, and having difficulty in maintaining lasting personal relationships. In contrast, a spiritually sound personality is characterized by personal subjectivity, relatedness and connectedness with others and the world, a sense of purpose in life, a transcendence of the self to some Higher Entity, and a loving and accepting relationship with the self.

Warfield and Goldstein (1996) observe that alcoholism is essentially cognitive (AA members refer to it as ‘stinking thinking’), behavioral (habitual and dysfunctional actions), and spiritual (relationship centered) in nature. Therefore, achievement of wellness must focus on all three elements. Most treatment centers address the cognitive and behavioral components, and pay little attention to the spiritual one. Alcoholics Anonymous incorporates all three components in its program of recovery. It provides the alcoholic with both a fellowship and program of rehabilitation. The steps are designed to confront a diseased ego and promote its transcendence through creation and maintenance of positive spirituality. It promotes loving, accepting, and trusting relationships with self and others, and ultimately the God of one’s understanding.

A treatment facility or counselor that truly encompasses spiritual growth in one’s treatment plan, would include the following:

•The concept of self would be “we” oriented rather than “I” oriented.

•The life goals would be harmony with nature, rather than achievement, accomplishment, and acquisition.

•Humility and acceptance would play a role in recovery.

•Behaviors that show coexistence and sharing would be exemplified rather than control and dominance.

•Intervention would be to address the disharmony

•Understanding recovery would mean acceptance and serenity.

•Harmony and a sense of belonging would indicate recovery (Chapman, 1996).

References

AA World Services, Inc. (1976). Alcoholics Anonymous: The story of how many thousands of men and women have recovered from alcoholism. (3rd. ed.). New York: Author.

Booth, L. (1995). A new understanding of spirituality. In R. L. Kus (Ed.). Spirituality and Chemical Dependency, (pp. 5-17), Binghamtom, N.Y.: Haworth Press.

Brown, H. P. (1992). Substance abuse and the disorders of the self: examining the relationship. Alcoholism Treatment Quarterly, 9(2), 1-27.

Carroll, S. (1993). Spirituality and purpose in life in alcoholism recovery. Journal of Studies on Alcohol, 54(3), 297-301.

Chapman, R. J. (1996). Spirituality in the treatment of alcoholism: a worldview approach. Counseling and Values, 44(1), 39-50.

Dyson, J., Cobb, M., & Forman, D. (1997). The meaning of spirituality: a literature review. Journal of Advanced Nursing, 26(6), 1183-1188.

Ellis, A., & Schonfeld, E. (1990). Divine intervention and the treatment of chemical dependency. Journal of Substance Abuse, 2(4), 459-468.

Khantzian, E. J., & Mack, J. E. (1994). How AA works and why it’s important for clinicians to understand. Journal of substance Abuse Treatment, 11(2), 77-92.

Kurtz, E., & Ketcham, K. (1992). The spirituality of imperfection. New York, N.Y.: Bantam Books.

May, G.G. (1988). Addiction and grace. New York, N.Y.: Harper-Collins.

O’Murchu, D. (1994). Spirituality, recovery, and transcendental meditation. Alcoholism Treatment Quarterly, 11(1-2), 169-184.

Pauly, L. E. (1990). Depression and spirituality: toward a holistic formulation of depression. Unpublished doctoral dissertation, Marquette University.

Peteet, J. R. (1993). A closer look at the role of a spiritual approach in addictions treatment. Journal of Substance Abuse Treatment, 10(3), 263-267.

The Language of the Heart. (1988). Grand Central Station, N. Y.: The AA Grapevine, Inc.

Warfield, R. D., & Goldstein, M. B. (1996). The key to recovery from alcoholism. Counseling and Values, 40(3), 196-205.

Watkins, E. (1997). Essay on spirituality. Journal of Substance Abuse Treatment, 14(6), 581-583.

Zinnbauer, B. J., Pargament, K. I., Cole, B., Rye, M. S., Butter, E. M., Belavich, T. G., Hipp, K. M., Scott, A. B., & Kadar, J. L. (1997). Religion and spirituality: unfuzzying the fuzzy. Journal for the Scientific Study of Religion, 36(4), 549-564.