Uncovering The Ingredients Of Successful Adolescent Recovery

Seven out of 100 adolescents attend addiction treatment each year. This study used an in-depth qualitative research approach to examine the processes underlying “successful” adolescent recovery.

What problem does this study address?

Of all individuals who seek treatment for alcohol and other drug use disorders (i.e., substance use disorder), 7% are adolescents between 12 and 17 years old. For these youngest treatment seekers, relapse rates are high, with estimates from different studies suggesting 55-90% drink or use other drugs within the first year after completing treatment. From a developmental perspective, adolescents have unique clinical qualities making them different from young adults and older adults in terms of the nature of their substance use problems, and the different factors that influence these problems positive and negatively. For example, research shows that environmental influences on substance use predominate among adolescents, while family history (e.g., genetic influences) becomes more prominent during young adulthood. Yet, we often conceptualize substance use disorder recovery in adolescents like we do adults: a lifestyle marked by abstinence with an emphasis on personal growth and citizenship. This study used an intensive, qualitative approach to describe and further our understanding of the critical elements of adolescent recovery among members of Teen and Family Services, an Alternative Peer Group in the Southwestern United States nested within a recovery oriented system of care, including a hospital based treatment facility and a recovery high school. Alternative Peer Groups, also referred to as APGs, are recovery support services for adolescents with substance use disorder that engage them in a community of other recovering adolescents, to capitalize on the same desire for peer acceptance that is known to drive, in part, adolescent motivations for substance use. Alternative Peer Groups are grounded in the theory that, if centered on fun activities with peers, recovery will be perceived as more rewarding than substance use.

How was this study conducted?

A qualitative approach called clinical ethnography was used in this study, which is characterized by immersion in the environment being examined, the Alternative Peer Group at Teen and Family Services in this study. The program was designed to last 9 to 12 months, and like other Alternative Peer Groups, its explicit goal is “full engagement in the 12-step program of recovery from substance use disorder”. Study methods include field notes, observation, records examination, as well as group and individual interviews. Participants were 14 alumni of the Alternative Peer Group (11 males and 3 females; 15-30 years old) with 1 or more years abstinent (1-11 years) who were actively involved in a 12-step program. In addition to program alumni, study authors also interviewed parents of Alternative Peer Group participants, and program staff/leadership.

What did this study find?

Study findings yielded two overarching themes of adolescent recovery: 1) “Journey” and 2) Relationships. The “journey” was marked by stages of preparation, engagement, “working a program”, and recovery maintenance. Relationships were key aspects of each of these four stages, with an emphasis on recovery role models, both with similarly-aged individuals as well as those who were older and had more experience in recovery. Participants identified the preparation stage (months 1-2) as most critical given that many adolescents entered the Alternative Peer Group with a great deal of resistance and ambivalence regarding changing their substance use. Young adult staff, who were in recovery themselves, helped adolescents through this ambivalence and provided support to help them get back on track if they drank or used drugs. To work through the preparation stage, participants outlined the importance of “fun friends” and an increased “sense of belonging” in order to help increase their recovery motivation. They also cited the importance of bonding with recovery role models who demonstrated “enthusiastic sobriety”. Engagement (months 3-6 months) was the result of preparation and was typically facilitated through the benefits of a relationship, with a 12-step mutual-help sponsor for example. “Working a program” was characterized by working the 12 steps and spending time with other individuals who had active recovery lifestyles (i.e., “sticking with the winners”). These processes helped individuals cultivate and build on skills and coping strategies they learned in treatment. Recovery maintenance was characterized differently by alumni and program staff. While the alumni all described recovery as maintaining abstinence, program staff felt abstinence was key through adolescence and until their brain development was complete (i.e., through mid to late 20s). They were more open-minded about adolescents being able to engage in low-risk drinking as they entered into adulthood.

Why is this study important?

Elements specific to adolescent recovery identified by this study included participants’ desire for recovery activities and programming to be fun. Other important elements included the structure, monitoring, and reinforcement of recovery activity attendance, and bonding with positive recovery role models. Participation in fun recovery activities and forming relationships with other, particularly more experienced, recovering individuals are characteristics that map onto other qualitative research findings with adolescents and young adults. Regarding their participation and perceived benefit from 12-step mutual-help organizations, like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), for example, research has shown that finding a sense of belonging and feeling a sense of universality — having a shared experience or problem — are important subjective experiences of youth recovery. In a related study, Labbe and colleagues showed that, for young adults, the degree to which other young people are present at AA and NA meetings is related to recovery benefit early on (i.e., 3-6 months after initiating recovery), while meetings with older, more experienced individuals is more strongly related to benefit later on (e.g., 6-12 months after initiating recovery). So while connection with both peers and more experienced recovering individuals may be important, these relationships could serve different purposes depending on a person’s stage of recovery.

The mention specifically of “fun activities” is consistent with adolescent treatments for substance use disorder, such as the Adolescent Community Reinforcement Approach. This evidence-based treatment, like alternative peer groups, emphasizes the benefit of engaging adolescents in rewarding activities while abstinent, to compete with the rewarding effects of alcohol and other drug use.

In addition, the “journey” of recovery described by authors parallels the well-known “stages of change” from the transtheoretical model of changing addictive behaviors delineated by Prochaska and DiClemente, and studied extensively among individuals with SUD. The stages of pre-contemplation and contemplation from the model pre-date the beginning of the “journey” as described in this study. That said, preparation, action, and maintenance from the transtheoretical model map well onto preparation, engagement/working a program, and recovery maintenance from this study.

Limitations of this study

This study was conducted in a single program with only 14 individuals all of whom were immersed in a 12-step focused program and had achieved 1 or more years of recovery. Also, the findings reflected perceptions of parents and staff members. Consequently, the findings may not represent the population of adolescents in, or seeking, substance use disorder recovery, or the multitude of settings where adolescents may seek treatment more generally (school, outpatient, residential, etc.). That said, the similarities between members of this Alternative Peer Group and other adolescent treatment and recovery theories described above raise confidence in the applicability of these general key recovery processes across a range of settings and adolescent clinical samples. Also of note, for some of the older young adults (e.g., in their late 20s), they were reflecting on experiences that occurred several years prior. These retrospective reports may have been influenced by more recent events in the participant’s life (i.e., shaping how they remember the past), and should be interpreted with some caution.

Next steps

Recovery definitions may be variable, but all allude to outcomes beyond abstinence, such as better emotional well-being. The recovery processes described here seemed to focus more on substance use. Future studies might help illuminate adolescent recovery processes in terms of other areas of their functioning. In addition, future work might investigate change more generally among adolescents with substance use disorder. For those not interested in a “program of recovery” closely linked with 12-step mutual-help organizations, for example, how do they initiate and sustain recovery? Are the processes similar or different from those described in this study of alumni in an Alternative Peer Group who were heavily involved in 12-step organizations?

Bottom line

For Individuals & families seeking recovery:

For adolescents, engaging in fun activities with other individuals in recovery, and establishing relationships with recovery role models may be key aspects of the recovery process.

For Scientists:

Clinical ethnography was used in this study to investigate the process of adolescent recovery from substance use disorder. This intensive qualitative approach is somewhat similar to community-participatory research where researchers become well integrated into the community over time. This

model may represent a valuable methodology to understand better the complex process of recovery in subgroups like adolescents that presumably have less traditional experiences compared to adults.

For Policy makers:

Adolescent recovery remains an important field of investigation. It is recommended that policy makers continue to allot funds to investigate optimal strategies to engage and retain adolescents in treatment and recovery support services, and help them successfully re-integrate into their communities.

For Treatment professionals and treatment systems:

Adolescent and adult recovery is likely to have areas where they are similar, like the importance of having a shared experience with other individuals in the program. There might also be processes that adult and adolescents have in common, but are particularly salient in adolescent recovery. These might include, for example, engagement in fun activities with other recovering individuals and cultivating relationships with older individuals who support the adolescent’s recovery. It may be helpful to brainstorm extensively with adolescents a menu of fun activities from which they can choose.

Source: Nash, A., Marcus, M., Engebretson, J., & Bukstein, O. (2015). Recovery From Adolescent Substance Use Disorder: Young People in Recovery Describe the Process and Keys to Success in an Alternative Peer Group. Journal of Groups in Addiction & Recovery, 10(4), 290-312. doi:10.1080/1556035X.2015.1089805

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