2. BAYLES & VILLALOBOS24
The youth caused many of the barriers themselves.
Many adolescents with dual diagnoses downplay the
need for services or refuse to stop their substance
use. Often the youth feels that nothing is wrong with
him or her; he or she can handle it alone. They also
believe there is no difference between themselves and
their friends (Cheng & Lo, 2010; Hawkins, 2009).
Older children are less likely to seek services than
younger children are.
As is usually the case with children with dual diag-
noses, because of genetic behavior influences, parents
with psychopathology or substance use disorders may
cause a barrier to treatment. Family members who
had prior services may prevent treatment to their
child or children since siblings are usually affected.
Parents may not have the financial resources or
insurance to afford treatment services (Cheng & Lo,
2010; Hawkins, 2009). Because of the educational
background and training required for treating clients,
licensing requirements vary between substance use
treatment and mental health care (Hawkins, 2009).
Most traditional practitioners prefer the individual
to be abstinent of substance use before beginning
treatment for mental illness (Bayles, 2014).
Services in the United States are often fragmented
and separated, which makes proximity to care a
factor to be considered. Children who live in the
urban areas are more likely to receive services than
children who live in rural areas. On the other hand,
since there are no clear government policies that
identify children with dual diagnoses, adolescents
who suffer from disruptive behaviors and substance
use disorders are usually recognized by the schools
or criminal justice systems. Many therapists report
that many participants, with dual diagnoses, receive
treatment because they are ordered by the criminal
justice system (Cheng & Lo, 2010).
Social-structural factors such as ethnicity and
education play an important role in the utilization
of services. Specifically, African Americans are less
likely to receive services than any other race to
receive mental health services (Cheng & Lo, 2010).
Cheng and Lo reported that older teens and boys
are more likely to receive a dual diagnosis, but
girls, with a dual diagnosis, are more likely to be
institutionalized than boys are. Hawkins (2009)
reported that there is a lack in the development
of appropriate and comprehensive treatment for
adolescents with dual diagnoses. As a result, treat-
ment agencies are unprepared to treat youth with
co-occurring disorders. They tend to lack provider
capacity, appropriate treatment models, adminis-
trative guidelines and quality assurance procedures.
Comprehensive screening, assessments, treatment
plans, and outcome evaluations are not commonly
used (Hawkins, 2009).
Funding for mental health and substance abuse
programs were limited and come from federal,
state, local, and private funding sources. Hawkins
(2009) suggested that coverage is limited and does
not cover the need in either system. Competition
is high, and only approximately one-third of those
in need of treatment receive it. Another factor to
be considered, in funding, is that Medicaid usually
covers mental health care, but substance abuse
treatment is optional (Hawkins, 2009).
Treatments
Both Kessler (2004) and Hawkins (2009) agree
that adolescents who suffer from dual diagnosis
must seek behavioral health services because of
its severity, difficulty to treat, and higher preva-
lence than those with a pure disorder. “Without
effective intervention, youth with co-occurring
disorders are at increased risk of serious medical
and legal problems, incarceration, suicide, school
difficulties and dropout, unemployment, and poor
interpersonal relationships” (Hawkins, 2009, p.
1). Mental health professionals who treat mental
disorders and substance use disorders typically use
cognitive behavioral therapy (CBT) and dialectical
behavior therapy (DBT). This approach is taken so
that the adolescents can overcome their substance
abuse problem and begin to deal with their mental
disorder (Grohol, 2010). CBT is the most common
and effective form of psychotherapy that is used
when treating individuals, such as adolescents, with
mental disorders and substance abuse. CBT uses four
strategies to change an individual’s thinking and
behavior. It uses skills training, exposure therapy,
cognitive therapy, and consistency management
(Jennings, Apsche, Blossom, & Bayles, 2013). Psy-
chotherapists use this form of treatment because
it allows the adolescent to alter their feelings and
behavior by exploring their past so that they can
fully understand how it affects their current situation
(Grohol, 2010).
Although Mode Deactivation Therapy (MDT)
has not been specifically utilized or validated as a
therapeutic intervention for adolescents with dual
diagnosis, the fact that MDT treats the adolescent by
bringing the past experiences to the present (Bass,
van Nevel & Swart, 2014) gives MDT an opportunity
to take the lead in dual diagnosis psychotherapy. As
Grohol (2010) suggested, CBT allows the adolescent
to alter their feelings and behavior by exploring
their recent experiences, without the use of any
psychoanalytic component to validate and/or accept
those feelings non-judgmentally. In the process of
identifying and challenging the validity of cognitions,
the individual is, repeatedly and systematically,
exposed to their disturbing and dysfunctional
thoughts and emotions in hopes that they will come
to accept these disturbing cognitions without negative
self-judgment (Jennings et al., 2013). Whereas, MDT
allows the youth to, not only explore their recent
past and present difficulties, but to become aware of
these experiences using mindfulness techniques and
accepting those experiences as truth. MDT allows
the adolescent to validate and accept his emotions,
feelings, and negative thoughts as having at least
a grain of truth, instead of refuting maladaptive
behaviors, as does CBT (Bass et al., 2014).
As Kessler (2004) described, male adolescents
with dual diagnosis are those who are most likely to
experience externalizing mental disorders. Literature
suggested that mental disorders are strongly related
to alcohol and substance use. Its association has
been positively linked to male adolescents with
externalizing mental disorders and disruptive disor-
ders such as oppositional defiant disorders, conduct
disorders, and those diagnosed with attention deficit/
hyperactive disorder (Kessler, 2004).
In 1993, Linehan’s dialectical behavioral therapy
was introduced and built on the foundations of
CBT. DBT teaches skills to cope with stress, regulate
emotions, and improve relationships with others
(Jennings, Apsche, Blossom, and Bayles, 2013). DBT
enhances its effectiveness and addresses specific
concerns of CBT (Grohol, 2010). The key component
of DBT is CBT, validation, dialectics, and radical
acceptance (Jennings et al., 2013). DBT emphasizes
the psychosocial aspects of treatment—how a person
interacts with others in different environments and
relationships (Grohol, 2010). The theory behind
the approach is that some people are prone to react
in a more intense and out-of-the-ordinary manner
toward certain emotional situations, primarily those
found in romantic, family and friend relationships.
“DBT was originally designed to help treat people with
borderline personality disorder, but is now used to
treat a wide range of concerns” (Grohol, 2010, p.1).
When professionals implement these forms of treat-
ment, they are hoping that the adolescent will begin
to address current issues that may have increased the
significance of their mental health status and their
substance abuse problems. By focusing on present
cognitions and behaviors, CBT will attempt to change
the adolescent’s way of thinking and, if possible,
change the environment that initiated the problem
(Bass, Van Nevel, & Swart, 2014). Again, MDT would
be very useful in helping adolescents address issues
from their past and bring them to the forefront to
understand what triggers their need/desire to use
drugs or other illicit substances (Bass et al., 2014). By
addressing these specific concerns and challenges
for the adolescent, they are more likely to graduate,
become employed, develop stable relationships, and
avoid being incarcerated.
When an adolescent is experiencing challenges
such as substance abuse problems and mental dis-
orders, it is important to understand that antide-
pressants have limited capabilities to act as a form of
treatment (Tartakovsky, 2010). Medication may be
beneficial, but it is crucial for the adolescent to receive
psychotherapy because they will learn new ways to
cope with their daily stressors (Tartakovsky, 2010).
Those suffering from mental disorders and substance
abuse problems may experience suicidal ideation.
DBT allows the psychotherapist to address the stress-
ors that create suicidal tendencies for the adolescent.
When treating the adolescent, the mental health
professional must assess the behavior, concerns and
stressors that lead to suicidal ideation so that they
can work on the issues, and the treatment will have
a higher success rate. It is crucial for a professional to
focus on rebuilding the quality of life for the adoles-
cent. DBT includes weekly, individualized, sessions
that offer the adolescent the opportunity to establish
a needed support system and learn to identify how to
control their emotions over a specific period. DBT co-
incides with CBT because it provides a sense of calm-
ness and allows the adolescents to regroup themselves.
This treatment is much similar to the treatment for
PTSD. The treatment emphasizes on problem solving.
Adolescents will begin to trust their first instincts and
decisions rather than base their decisions and judg-
ments based on those around them that increase their
mental health disorder and substance abuse problems.
3. USING MINDFULNESS WITH TREATMENT OF DUAL DIAGNOSIS IN ADOLESCENTS 25
Mindfulness treatment in dual diagnosis
Mindfulness is recognized as a mainstream method-
ology in the treatment of mental disorders. It uses a
non-judgmental approach and is new in the area of
treating adolescents (Jennings, Apsche, Blossom, &
Bayles, 2013). Although mindfulness has existed for
centuries, it was not used as a stand-alone practice
until 1969 when Psychologist, Fritz Perls, used it in
an attempt to unify the mind, body, and spirit with
Gestalt Therapy (Bayles, 2014). Perls understood
that all forms of immediate awareness, perception,
emotion, sensation, behavior, and bodily feelings,
were the natural therapeutic effects of staying in
the here and now experience. Perls recognized that
mindfulness is immediate awareness of being in the
moment and accepting oneself for who he or she is
without judgment. Non-judgmental acceptance is the
key to challenging negative cognitions (Bayles, 2014).
Although mindfulness has been used in the
treatment of mental health for several decades, it is
relatively new in the treatment of adolescents with
externalizing mental disorders (Jennings et al., 2013),
and in the treatment of substance use disorders
(Bayles, 2014). Mindfulness is not a common factor
in cognitive behavior therapy. Of the four strategies
of CBT, that were mentioned earlier, the exposure
therapy component of CBT could be viewed as the
process of immediate awareness. Although the this
process does not equate to mindfulness, exposure
therapy contains the essential elements of intense
focus on immediate awareness, incorporating
mental, physical, and emotional experience that
can bring therapeutic effects through acceptance of
the immediate discomfort and irritability (Jennings
et al, 2013).
The inclusion of mindfulness in the treatment of
substance abuse is gaining more attention in the
scientific literature. Sometimes used as an added
element in third-wave treatment programs for mental
health, Mindfulness has been combined with many
therapeutic orientations, such as Cognitive Behavior
Therapy (CBT), Mindfulness-Based Stress Reduction
(MBSR), Mindfulness-Based Cognitive Therapy
(MBCT). By combining mindfulness with traditional
cognitive-behavioral relapse prevention (CBRP),
research suggested that mindfulness may help detach
and decenter relationships to thoughts and feelings
that escalate and lead to relapse (Bayles, 2014).
Effectiveness of treatment
There is an enormous difference between the treat-
ment of adolescents and their adult counterparts,
and they have different treatment needs. Adolescents
may be susceptible to peer pressures where adults
are not. Adolescents may be more vulnerable to
adverse effects from substances than adults are,
such as toxicity to drugs due to smaller body sizes,
and lower tolerance levels (Tanner-Smith, Wilson,
& Lipsey, 2013). Because of their developmental
stage, they experience long-term cognitive and
emotional damage from substance abuse more than
an adult. For these reasons, evidence regarding the
effectiveness of treatment for adolescents need to
be based on research conducted on adolescents
(Tanner-Smith et al., 2013).
In a meta-analysis, completed by Tanner-Smith et
al. (2013), to synthesize research effects of outpatient
substance abuse treatment outcomes. The extensive
literature review showed 45 eligible experimental and
quasi-experimental studies reported 73 treatment
comparison groups that received substance abuse
treatment (Tanner-Smith et al., 2013). A couple of the
most prevalent treatment types were family therapy,
and CBT. Of the 250 effect sizes for the substance
abuse outcomes of adolescents in substance abuse
treatment, treatment as usual (TAU) proved to be
less effective than family therapy programs with a
mean effect size of −0.09. However, when CBT was
compared to family therapy, CBT proved to be less
effective than family therapy with a mean effect size
of −0.53. When CBT was compared to TAU, CBT was
more effective than TAU, resulting in a mean effect
size of 0.51. Family therapy proved to be statistically
significantly and compared favorably with every
treatment it was compared with (Tanner-Smith et
al., 2013).
Unmet treatment needs and consequences
Adolescents with co-occurring disorders are difficult
to treat (Hawkins, 2009). Their symptoms are more
difficult to treat than individuals are with only one
disorder. Adolescents with co-occurring disorders
tend to have multiple psychosocial and family prob-
lems that further complicate their care. The youths,
with externalizing disorders, recover slower than the
youths without externalizing disorders (Hawkins,
2009). Those, with externalizing and internalizing
disorders, had worse outcomes than those without
externalizing or internalizing disorders alone (Haw-
kins, 2009). Adolescents with co-occurring disorders
are more likely to relapse after treatment, and the
relapse occurs quicker than a relapse from substance
use disorder alone. Both treatment engagement and
retention are difficult to obtain, and intervention
outcomes tend to be poor (Hawkins, 2009).
Why MDT is effective
Mode Deactivation Therapy would be beneficial
in the probability of obtaining and maintaining
positive results with therapeutic intervention for
adolescents with dual diagnosis. Although CBT has
a larger body of evidence-based treatment than MDT,
MDT research has shown significant improvement
in behavioral therapy interventions that markedly
outperformed CBT-based TAU, with results that
lasted for a follow-up period up to 18 months (Bass
et al., 2014). Substance use is typical among abused
adolescents and those with comorbid health issues.
Literature has well documented that child abuse is a
direct pathway to adolescent problematic behaviors
such as conduct disorders, reactive aggression, sexual
abusiveness, and substance use. Swart & Apsche
(2014) reported on a meta-analysis, consisting of 21
previous substance users of either alcohol or drugs
(including prescription drugs). Fifty-one percent of
those adolescents presented with conduct disorder,
42% with oppositional-defiant disorders, 54% with
post-traumatic stress disorder (PTSD), and 56% of
the population presented with mixed personality
traits. The results of this meta-analysis suggested that
MDT significantly outperformed CBT and Treatment
as Usual (TAU). In addition, general recidivism was
reduced by 7% and sexual offense recidivism was
decreased to less than 4% after two years post MDT
treatment (Swart & Apsche, 2014).
In the most recent study by Swart and Apsche
(2014), 84 adolescent males, between 14 and 17
years old, assigned to a CBT control group or a MDT
experimental group, received structured treatment
for 6 to 8 months. This study established an evidence
base of the effectiveness of MDT on adolescents with
conduct disorders. Using the STAXI-2, the CBCL,
and other tests reconfirmed MDT’s effectiveness as
superior treatment for this population. Behavioral
outcome effects of the MDT experimental group
showed consistent improvement on an average of
36%, while outcome effects of the CBT control group
only showed improvement of approximately 5% in
treatment. Not only do these results reconfirm the
superiority of MDT as a treatment for multi-problem
psychopathology in adolescents.
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