by Cardwell C. Nuckols, Ph.D.by Cardwell C. Nuckols, Ph.D.
Over the last 20 years, an emerging population of younger and more chronic individuals have been entering the addiction and mental health treatment centers. The same trend exists in the criminal justice setting.
Often called "young chronic" or "multi-system, multi-problem" clients, these people are difficult to understand and to treat. There are three prominent features that developmentally impact this population. They are:
The past generation often initiated experimental use of alcohol (and sometimes low-potency marijuana) at age 13 or 14. Today's high-risk kids start three or four years earlier. These two populations exhibit definite developmental differences. Those using in an abusive fashion at age 9, 10 or 11 may show cognitive and social development arrest. At ages 10 through 14, important cognitive abilities are established. Piaget described this movement as developing from the concrete to a formal mode of thinking. Formal thinking includes the ability to abstract, conceptualize and problem-solve. During this period of time, the child moves from an egocentric posture toward an awareness of his or her position in the world (social consciousness). Socially, this is a time of best friend, boyfriend and girlfriend. Social skills are refined.
The beer, wine and low-grade marijuana of decades ago has now been replaced with extremely addicting substances. The use of alcohol is consistent across generations. However, the United States now grows the strongest marijuana in the world. Crack cocaine, high-grade heroin and a plethora of other substances are often readily available even to middle-school kids. The use of these strongly addicting drugs rapidly shifts values away from school accomplishments, hanging out with a positive social crowd, etc. Instead, the alcohol and drugs become the focal point of one's life. Prosocial development is compromised.
Since the 1960s,
behavioral scientists have documented the erosion of the American
family. Years ago when the family was not able to adequately rear the
child, the community, extended family, church, etc., filled in the
gap. Today, clinicians, school teachers, police officers and others
are asked to perform this task. In fact, many clinicians feel more
like parents than therapists in their daily work. Setting limits and
teaching problem-solving skills have replaced more advanced groups
and individual clinical work.
When added to the early use of substances, this lack of nurturing environment creates multiple difficulties. For example, a young man of 25 enters treatment for alcohol and drug addiction. He is a high-school dropout with limited vocational skills. At the age of 9 he started drinking, and by age 11 had used multiple drugs abusively. A drug bust and resulting brief incarceration round out the picture.
The case cited above poses numerous clinical problems. At the top of the list is the need for habilitation. Rehabilitation means the return of an individual to some past level of productive functioning. Since there is no history of prosocial or responsible functioning, educational and vocational options are often needed. A nurturing recovery-oriented environment is needed to promote positive personality development.
In designing treatment, it is important to enter the client's "map of the world." Treatment starts where they are, not where we think they should be. Client strengths should always be utilized when developing the treatment plan. It is critical to answer the question, "What do we have that the client wants and needs?"
All in all, conceptualizing treatment in a developmental way is not difficult. It is integrating all of the systems and services that becomes a nightmare. A pregnant, heroin-addicted, undomiciled HIV-positive female with a small child makes the point. How do you cross over and integrate all of the systems and services necessary? How do you provide child care, recovery transitional housing, job and educational opportunities, etc.? These are the challenges presented by this emerging population of clients. Over the next decade, these are the outcome challenges that will be faced by treatment providers.
Cardwell C. Nuckols is president of Cardwell C.
Nuckols and Associates. He is a sought-after clinical trainer and
program consultant. (407/299-8569)