Blackwell Publishing LtdOxford, UKADDAddiction0965-2140© 2006 American Psychiatric Association, Journal compilation © 2006 Society for the Study of Addiction
2006
1014047
Original Article
Cultural issues and psychiatric diagnosis
Javier I. Escobar & William A. Vega
RESEARCH REPORT
Cultural issues and psychiatric diagnosis: providing a
general background for considering substance use
diagnoses
Javier I. Escobar & William A. Vega
Department of Psychiatry, University of Medicine and Dentistry, Robert Wood Johnson Medical School, Piscataway, NJ, USA
ABSTRACT
Aims To establish a general context on the topic of cross-cultural diagnosis and suggest how it can be applied to substance use disorders. Methods Critical reviews of the literature on psychiatric diagnosis, cross-cultural issues and the
concept of ethnicity were conducted to provide a framework for making specific recommendations for substance use
diagnoses. Results Cross-cultural diagnosis remains in a state of flux. Key questions on ethnicity and psychopathology have not yet been fully answered by existing research. The broad use of the Diagnostic and Statistical Manual for
Mental Disorders (DSM) system world-wide requires a careful look at its cross-cultural applicability. Conclusion For
DSM-V, cultural/ethnic issues have to be clearly defined in clear terms that lend themselves to operational definitions.
Recommendations should be research-based and testable. Meaningful cultural annotations and a glossary of cultural
terms that are applicable in daily clinical practice and not limited to less frequently encountered syndromes (culturebound) would be highly desirable.
Keywords
Addiction, cross-cultural diagnosis, psychiatric diagnosis, substance use disorders.
Correspondence to: Javier I. Escobar, Professor and Chairman, Department of Psychiatry, University of Medicine and Dentistry, Robert Wood Johnson
Medical School, 675 Hoes Lane, Piscataway, NJ 08854-5635, USA. E-mail: escobaja@umdnj.edu
RESEARCH REPORT
INTRODUCTION
The goal of this review is to establish a general context on
the topic of cross-cultural diagnosis and suggest how it
can be applied to substance use disorders.
Psychiatric diagnosis has advanced considerably since
the development of the third edition of the Diagnostic and
Statistical Manual for Mental Disorders, third edition
(DSM-III) and there is a good deal of confidence among
researchers and practitioners about their ability to make
psychiatric diagnoses that seem valid and reliable. Thus,
in the last two decades, psychiatric diagnosis has attained
an aura of respectability in North America and many other
countries of the world. Although reliability of research
diagnoses elicited with structured diagnostic instruments
is reasonably good, this does not appear to be the case in
day-to-day practice. While developed for a North American population, DSM has been exported to the rest of the
world, a fact that raises a number of issues about its cross-
cultural applicability. The cross-cultural limitations of the
DSM system have been raised by many authors, particularly those trained in a sociological or anthropological tradition who practice in North America [1]
Despite questions raised about its cross-cultural equivalence, DSM is used widely across the world, particularly
for research purposes by investigators who seek publication in North American journals. Albeit imperfect, the
DSM system appears to offer a rational, criteria-based
framework suitable for research and clinical practice, at
least according to anecdotal reports of colleagues from
Europe and Latin America.
In the following paragraphs we will highlight relevant
issues related to ethnicity and psychiatric diagnoses in
efforts to provide a general background that may inform
the re-examination of substance use diagnostic categories and their applications. To conclude, we will attempt a
few specific recommendations on this topic as part of the
development of DSM-V.
© 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction
Addiction, 101 (Suppl. 1), 40–47
Cultural issues and psychiatric diagnosis
KEY DEFINITIONS
Race
The use of race as a way to classify humans originated
with Linnaeus, in his 1758 Systema Naturae. Blumenbach, a German anthropologist, outlined five divisions of
race (Caucasians, Mongolian, Ethiopian, American and
Malay). However, population and genetic studies have
questioned the use of racial divisions for humans as lacking a scientific foundation. Indeed, hundreds of human
races have been proposed using anthropological criteria,
and the US 1990 census elicited more than 300 races in
questionnaire responses [2]. In 1999, the Institute of
Medicine (IOM) in its report The Unequal Burden of Cancer
[3], recommended that the National Institutes of Health
(NIH) re-evaluate the use of ‘race’, defined as ‘a construct
of human variability based on perceived differences in
biology, physical appearance and behavior’. According to
the IOM, the traditional conception of race rests on the
false premise that there are natural distinctions grounded
in significant biological and behavioral differences but
actually rooted in physical features characteristic of
diverse continental origins. Therefore this concept lacks
any biogenetic or anthropological justification in cancer
surveillance and other population research. The IOM
advised using the term ‘ethnic group’ instead of ‘race’ in
future endeavors.
Ethnicity
This concept defines the ways in which one sees oneself
and how one is seen by others as part of a group on the
basis of cultural background and shared historical experience. Common elements often associated with a given
ethnic group include skin color, religion, language,
ancestry, customs and occupational or regional features.
Ethnicity boundaries are dynamic and imprecise, and
further confounded with nationality. For proper clinical
or research use, the concept should be defined and operationalized precisely.
Problems with the ‘ethnicity’ concept
While the IOM report suggested that ethnicity was a more
neutral, less pejorative term than race, the problem is
that it is difficult to define operationally, and often individuals responding to queries do not endorse unambiguously the choices offered in census gathering and other
surveys. The ‘Hispanic’ or ‘Latino’ ethnicity group, in
particular, is too broad and heterogeneous and it is not
possible to draw inferences that universally apply to Hispanics given their diverse origins (traced to more than 20
countries), their various phenotypic admixtures, divergent historical origins and diverse social and educational
levels. One consequence of this is that Hispanics were the
41
ethnic group most likely to endorse ‘mixed race’ in the
latest US Census.
Race and ethnicity issues in the United States
Historically, there has been a long-standing preoccupation in the United States with race and ethnicity issues,
particularly a need to label ethnic and racial groups for
operational reasons such as population enumeration and
health assessments. Interestingly, since 1997 the US
Office of Management and Budget (OMB), the agency that
ultimately determines NIH’s population taxonomy, recognizes only two categories of ‘ethnicity’. These are ‘Hispanic’ or ‘Latino’ versus neither. However, despite the
IOM report, OMB continues to recognize five categories of
‘race’, namely, Asian, American Indian or Alaska Native,
Native Hawaiian, or other Pacific Islander, black or African-American and white, and these continue to be used
in the literature. An essential point is that the US ethnic
and race categories, which are growing more inaccurate
with the passage of time in the United States, are even less
useful when used in other nations. Thus, while many
countries in western Europe, the Pacific and even Latin
America have their own immigrant sets and minority
groups, ethnic categories are not articulated the way they
are in the United States. International studies have
shown that US ethnic categories have little meaning elsewhere. For example, a study of depression and painful
symptoms in several Latin American countries reported
that a great majority of people in Mexico and Argentina
did not identify themselves as ‘Hispanics’ [4]. Also,
according to reports from the Fogarty International Center, US ethnic and racial categories cannot be properly
applied to international research projects funded by NIH
(personal communication, 2004).
Ethnicity and medicine
In US clinical medicine, references to race are standard in
clinical rounds and medical records, and continue to be
an integral part of clinical patient documentation. For
example, a medical history or a clinical presentation
invariably starts as the ‘. . . -year-old Hispanic, African
American, Asian or White male or female presenting
with such and such a symptom’, possibly reflecting the
historical importance in the pregenomic era of racial
background for diagnosing disorders such as sickle cell
anemia, Tay Sachs disease, thalassemia and cystic fibrosis, among others. Unfortunately, used in such a fashion
the concept of ‘ethnicity’ is imperfect as it is too often
inferred by the examiner on the basis of observed traits.
For obvious reasons, the use of ethnic identification and
concerns about cultural orientation have had significantly more influence in psychiatry and psychology
compared with the rest of medicine. For example,
anthropologically and socially oriented psychiatrists
© 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction
Addiction, 101 (Suppl. 1), 40–47
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Javier I. Escobar & William A. Vega
continue to insist on the formal use of the ‘cultural formulation’, a process that takes into account the person’s
cultural identity and background for formulating diagnosis and treatment plans. Indeed, the Review of Psychiatry,
the traditional text updating progress in psychiatry in
North America, states that ‘a consideration of culture is
essential in the process of the interview, case formulation,
diagnosis and treatment of culturally diverse individuals’
[5].
The relevance of ethnic or cultural formulation has
gained visibility following the recent Surgeon General’s
report on ‘health disparities’ (which in psychiatry have
only applied to access and treatment quality issues rather
than disorder phenomenology or diagnosis). This has led
to positive developments such as the requirement that
‘cultural competence standards’ (ensuring practitioner’s
awareness on such issues as culturally related attitudes,
symptoms, language and interpretation of clinical data)
be developed in state systems in efforts to improve access
and quality of care. However, it has been difficult to define
with any precision the key ethnic issues, or a modus operandi, to be taken into account for making valid psychiatric diagnoses. Also, specific applications of this to the area
of substance use disorders are not documented clearly.
Country of origin and immigrant status
In our view, these are less ambiguous items, easier to
define and elicit precisely and have proven less controversial and transferable for international use. For example,
epidemiological studies in the United States have shown
that these variables, and related markers such as age of
arrival and time in country among immigrants, have
utility for demarcating important differences in levels of
psychopathology and general health. The observation
that immigrants from Latin America have superior
health and mental health status than those born in the
United States [6–8] was coined the ‘the Latino paradox’
by Scribner [9], who suggested that much could be
gained from identifying the determinants of these differences. These findings illustrate the utility of carefully constructed demographic descriptors for deriving subgroup
comparisons. Regarding issues of self-report veracity
about substance use, and potential variations among and
within ethnic groups, it has yet to be demonstrated that
these problems have resulted in serious under-reporting
or systematic biasing of substance use information.
‘Universalistic’ versus ‘relativistic’ perspectives
In cultural psychiatry, the terms ‘emic’ and ‘etic’ illustrate these two perspectives in diagnosis. The concept of
emic (from phonemics) refers to culture-specific patterns
of psychopathology, while the concept of etic (from phonetics) presupposes that psychopathology is universal.
Kraepelin was perhaps the first to use the universalistic
(etic) approach to psychopathology. This approach signified a departure from a system of classification based on
etiological assumptions, and was representative of philosophical realism or positivism that was ultimately incorporated into diagnostic classifications in North America
by the pioneering research group at Washington University in St Louis. These criteria, known as the St Louis or
Feighner criteria, set the pace for the new diagnostic
developments that would evolve into the Research Diagnostic Criteria (RDC) and then the DSM-III classification.
The emic, or ‘relativistic’, point of view observes psychiatric disorders within their respective cultural context
and argues that the content of psychiatric diagnosis will
vary to some degree inherently by cultural context. This
is the position adopted by anthropologically, socially oriented psychiatrists, particularly in North America. In the
case of alcohol disorders, this tradition is represented in
the subtypes of alcoholism [10]. There is evidence that
intra-ethnic group variance in emic perspectives exists in
self-rated health among Latinos underscoring the difficulty of applying specific criteria of illness and dysfunction with acceptable precision [11]. To the extent that
normative definitions of severity or of ambiguous symptoms are inferred by individuals of differing cultural backgrounds during psychiatric evaluations, some cultural
variance can be anticipated in applying diagnostic criteria. Strategies for overcoming these challenges to diagnostic accuracy are not readily available for practitioners.
Evolution of psychiatric diagnosis
Diseases cause symptoms and these are experienced and
expressed by patients and elicited by physicians. Obviously, unpleasant physical symptoms are easier to define
and recognize than psychological or behavioral manifestations. Physical characteristics such as sweating or
trembling are not necessarily symptomatic of a disorder
just because they are ‘physical’. A. J. Lewis [12] coined
the term ‘psychological dysfunction’, which he defined as
a deviation from a standard of normal psychological
functioning. With scientific progress, the hope was that
these ‘psychological dysfunctions’ would be linked eventually to abnormalities of biological functioning [13]. Relevant examples of these are symptoms such as obsessions
and other psychological dysfunctions that can be defined
precisely, may have biological underpinnings and can be
separated clinically from one another (e.g. ‘phobias’,
‘thought insertion’, etc.). In traditional psychopathology,
there has been an effort to utilize well-defined symptoms
as much as possible and a tendency to avoid the inclusion
of purely social or experiential factors in criteria and definitions. The more exclusive the social component in
defining deviance, the less applicable is the symptom
label. For example, undesirable behaviors defined in
purely social terms such as drug addiction, shoplifting
© 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction
Addiction, 101 (Suppl. 1), 40–47
Cultural issues and psychiatric diagnosis
and vandalism are relatively easy to define reliably. However, while biological theories can be invoked to help
explain some aspects of these behaviors in some people,
they are highly unlikely to account for a useful proportion of the variance or to offer a comprehensive explanation [13]. As disease theories become more successful in
providing a solid basis of knowledge about abnormalities
of psychological and biological functioning, the dimensional aspects of measurement within and between clinical syndromes become apparent. According to Wing
et al. [13], a system of clinical measurement cannot be
purely categorical or purely dimensional. The most obvious example of the dimensional approach is in defining
severity of symptom types (be it for investigation, treatment purposes or assessment of outcomes), but the symptoms themselves have to be defined first.
In the last two decades, there has been a mushrooming of the type and number of psychiatric diagnoses.
Thus, the very few classical psychiatric syndromes
refined over one-and-a-half centuries such as mania,
melancholia, hysteria and hypochondriasis, rose to 14 in
the Washington University Criteria, exceeded 100 in
DSM-III, and topped the 300 mark in DSM-IV. Despite the
progress made, and the revolutionary process of building
diagnoses, the official additions to the DSM books often
reflect capricious actions of committees or opinions of single individuals [14].
Language and translation issues
Considering socio-linguistic implications is a critical step
in adapting diagnostic instruments and criteria to other
countries. Equivalence has to be attained in a number of
dimensions (semantic, conceptual and technical). Even
words such as ‘depression’ and ‘anxiety’ are difficult to
translate precisely into some languages. Also, certain
somatic or mental experiences that are clearly a sign of
disease in some cultures may be very important to
patients from these specific cultural backgrounds, but
others pay little attention to them (‘loss of semen’ is
viewed as a significant problem in India, but is given little
or no attention in other countries). Embarrassment or
loss of face may be a reason for suicide in some cultures,
while it may be irrelevant in others. Symptoms such as
tremor, a common physical symptom and a sign of
pathology in most cultures, may be advantageous in
Mali, where ‘trembling hands’ is a sign of virility [15].
Heuristic models for psychiatric diagnosis
The definition of disease, disorder or abnormality is a critical element for classification systems. There are several
models for psychological abnormalities in the literature.
A biological model defines abnormality using biological
criteria; a statistical model defines it as deviation from the
norm; a subjective discomfort model as suffering experi-
43
enced by an affected individual; a subjective value model
defines it as what is viewed as undesirable for society.
Because all these models are incomplete, Wakefield [16]
proposed that the definition of abnormality requires both
social and biological criteria. He proposed a ‘harmful dysfunction analysis’ as a model for developing meaningful
diagnoses in psychiatry and psychology. This model uses
a ‘Darwinian’ principle, of failure of systems to function
as designed by natural selection, and was proposed to
apply to both physical and mental diseases. Key elements
of the model are, first, subjective value that a condition is
harmful or undesirable and, secondly, objective identification of a malfunctioning internal mechanism [16].
This has stimulated lengthy, philosophical, epistemological and methodological debates [17].
KEY QUESTIONS RELATED TO
ETHNICITY AND PSYCHOPATHOLOGY
A critical issue is to examine whether or not symptoms
and syndromes can be reliably elicited and recognized,
not only as part of research collaborations launched to
confirm the ‘universality’ of psychiatric syndromes and
the reliability of structured diagnostic instruments, but in
‘real world’ day-to-day clinical practice. That the system
is far from perfect in this particular instance can be
deduced from a recent statement by the system’s pioneer,
Robert Spitzer, quoted as saying that ‘to say that we’ve
solved the reliability problem is just not true. It has been
improved. But if you are in a situation with a general clinician, it’s certainly not very good’ [14]. Even the fidelity
of clinical research interviews with field interviews using
fully structured diagnostic interviews for case ascertainment are inconsistent, although substance disorders
have been the most likely to achieve adequate ‘procedural
validity’ compared to non-addictive disorders.
World Health Organization (WHO) international studies
These studies have provided strong support for the universal presence of major mental disorders such as depression and schizophrenia.
In depression, the weight of somatic and affective
dimensions and narrative context may differ from culture
to culture [18]. For example, major depression is conceptualized differently in Native American populations,
involving at least five illness categories [19]. In anxiety
syndromes there is significant cross-cultural variation in
type of specific fears as well as associated somatic, dissociative and affective symptoms [20]. Obviously, culture
‘colors’ these syndromes and their basic elements may
not be elicited or recognized everywhere. A few
syndromes have been designated as ‘culture-bound’,
indicating their exclusive presence in some countries.
Nevertheless, if proper training is provided and struc-
© 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction
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Javier I. Escobar & William A. Vega
tured instruments are used to elicit the symptoms, an
acceptable level of comparability is usually possible in
international clinical and epidemiological studies [21].
WHO classifications and culture
WHO endorses a universalistic view of psychiatric disorders. Curiously, in international settings, there seems to
be much less preoccupation with cultural psychiatry in
clinical practice than is the case in the United States.
Thus, international classifications have been much less
concerned about cross-cultural issues. There have been a
few exceptions: the tenth edition of the International Classification of Diseases (ICD-10) incorporated an international psychiatric lexicon that contains a description of
culture-bound syndromes as well as an international
casebook [21]. Also, the more recent ICD-10 Diagnostic
Criteria for Research included an appendix on crosscultural issues [21].
The contribution of epidemiology to cross-cultural
diagnosis
Comparative studies in the United States and abroad have
supported the ‘universalistic’ view of psychiatric diagnosis
by showing that major disorders can be elicited in many
countries and various ethnic groups through the use of
structured interviews, such as the Diagnostic Interview
Schedule (DIS) and the Composite International Diagnostic Interview (CIDI). The WHO World Mental Health Surveys reported diagnostic data using population samples
with rigorous epidemiological designs and reported wide
international variability in rates of DSM-IV disorders and
in related impairments, especially for drug dependence
[22]. Similar population differences were reported in the
United States. Two epidemiological studies showed lower
prevalence rates for psychiatric disorders in Mexico-born
Mexican Americans compared with non-Hispanics and
that years in the United States influenced these trends
[23,24]. This was particularly salient for substance use
disorders, a finding validated with anonymous urine toxicology screening [25]. While instruments appeared to
work well in these studies, it is not clear if these low rates
were influenced by such factors as differential reporting of
symptoms due to misunderstanding or social desirability,
or non-equivalence of certain symptoms or syndromes.
However, the prevalence rates in Mexico-born Mexican
Americans were very similar to those found in Mexico City
using the same instrument [26]. These results have been
replicated in at least one other large national surveys in
the United States [27].
A recently published study on American Indians [28]
found that alcohol disorders and post-traumatic stress
disorder (PTSD) were more common in American Indian
populations compared to other populations. Interestingly, the prevalence of depression was low, a finding the
authors attribute to cultural factors. Diagnoses of major
depression were based on the endorsement of at least five
of the nine major depressive episode symptoms and
yielded low prevalence. Patients with disorders sought
help primarily from traditional healers, not physicians.
Diagnoses such as psychoses are excluded from studies of
Native American populations because of cultural concerns (seeking of ‘visions’ is a trait traditionally nurtured
in those cultures). Also, cognitive dysfunction elicited
with the Mini Mental Status Examination could not be
utilized in the Epidemiologic Catchment Area (ECA)
study due to educational and linguistic issues [29].
Somatic presentations
In most cultures, the presentation of personal/social ‘distress’ in the form of somatic complaints appears to be the
norm [30].
Dominant cultural tendencies influence the expression of ‘proper’ behavioral displays for each society, reciprocally influenced by the culture of current medical
practice [31]. Thus, patients tend to develop symptoms
that are ‘medically correct’ (what doctors expect and
understand) and cluster commonly into recognizable patterns. Moreover, a great majority of these patients present
to primary care and a large proportion of them are found
to have psychiatric disorders including substance abuse/
dependence [32,33]. Tien et al. [34] reported that high
levels of unexplained physical symptoms predicted
‘extreme alcohol use’ in an epidemiological sample, and
concluded that self-reported somatization symptoms
could add to the detection of severe substance abuse.
Because somatic presentations appear to be more common in developing societies, and the symptoms themselves may differ across cultures [31], they need to be
incorporated in the diagnostic formulations.
Diagnostic disparities
A number of clinical reports have documented that clinicians are more likely to give a diagnosis of psychosis, or to
prioritize signs of substance abuse over other primary disorders, in minority patients, particularly African Americans [35–37]. A recent study using a large data set in a
mental health system found that clinicians in a large
mental health system diagnose psychosis in African
Americans and depression in Latinos disproportionately
[38]. The reasons for this are unclear, and potentially
include information variance, deficiencies in patient–clinician communication and inadequate diagnostic criteria. The frequent presentation of psychotic symptoms by
certain ethnic groups with common mental disorders
and medical conditions (e.g. Latinos and African Americans) contributes to diagnostic ambiguities and misdiagnoses, yet empirically supported guidelines to assist
clinicians are not available [39].
© 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction
Addiction, 101 (Suppl. 1), 40–47
Cultural issues and psychiatric diagnosis
DSM-IV’S CULTURAL APPENDIX
The increased visibility and enhanced political voice of
some minority psychiatrists within the American Psychiatric Association (APA) would eventually bring awareness on culture to the official diagnostic manual. In 1988
the APA appointed a task force, one of whose subcommittees addressed the area of cultural issues in psychiatric
diagnosis. While a specific proposal for a ‘cultural axis’
never came forward, there were ambitious recommendations including a complementary cultural formulation,
cultural statements in the introduction to manual, annotations under each diagnostic category and a glossary of
culture-specific terms. However, the major piece related
to culture in DSM-IV is a brief appendix placed at the end
of the rather massive manual. This section outlines the
relevance of culture and provides an exhaustive list of
‘culture bound syndromes’. Many of those entities
included in the appendix are rare, uncommon conditions, some poorly defined and others that can be classified in areas of general psychopathology. As a result they
have limited practical relevance as they are encountered
infrequently by a majority of practicing psychiatrists in
the United States and other countries.
It is our impression that in its current state the appendix is of limited utility in the absence of additional technical information and supporting research to provide
guidance to clinicians. Many of the general recommendations provided are based on anecdotal, ‘commonsense’ observations. They are, of necessity, very broad
because inadequate research is available to develop
guidelines for practitioners working with ethnically
diverse patients. A major challenge is that given the heterogeneity of these groups, research is not easily generalized. On the biological side, there are only a few
pharmacogenetic clues from recent research that appear
to be practically relevant only to certain Asian American
groups and we await research advances for other ethnic
groups. Other than endorsing and promoting ‘cultural
competency’ (a field which is struggling to define its clinical domain aside from language) the cultural appendix
does not offer either an adequate framework or clinical
guidelines for the scope of applications originally envisioned. Regrettably, the research envisioned as an essential step in implementing the cultural formulation into
clinical practice has not been advanced adequately,
resulting in inadequate empirical validation.
RECOMMENDATIONS FOR DSM-V AND
ICD-11 REGARDING CULTURAL AND
ETHNIC ISSUES
Beyond the general recommendations already made by
Alarcon et al. [40], regarding culture/ethnicity issues in
DSM V we wish to add the following caveats:
45
1 Cultural/ethnic issues have to be clearly defined in
clear terms that lend themselves to operational definitions.
2 The ‘ethnicity’ concept has to be defined much more
precisely. Demographic descriptors are needed that
coincide with ethnic subgroup variations in prevalence
of substance disorders and related patterns of patient
presentation of disorders including beliefs and behaviors that have value for refining cultural aspects of DSMV. For example, Mexican Americans, Puerto Ricans,
Cubans, South Americans and other Latino populations should not continue to be blended into a ‘Hispanic’
group for the sake of convenience, as research is showing significant differences among these groups in prevalence of DSM-IV disorders and use of services.
Moreover, behavioral genetics research involving even
one Latin American nationality of mixed historical
ancestry (Indian, African and European) must contend
with complex genetic heterogeneity.
3 Ethnicity can be characterized according to (a) the ethnic group to which that person most closely relates, (b)
their ethnic ancestry, which may range from one to
four categories, (c) the language spoken by their parents and (d) the language most commonly spoken at
home. In analyses of ethnic influences on substance
use symptoms and syndromes we recommend that
these elements be entered as variables rather than one
overarching ‘ethnic group’ variable. In this regard,
there is a need for nationally representative surveys
that are either larger than those conducted so far or
over-sample populations of interest.
4 Recommendations should be research-based and testable. The necessary research in this area should be
articulated in a more practical, hierarchical fashion, so
that these goals can become attainable in stages.
5 At the current level of knowledge, a well-defined
research program is needed to support and justify a
cultural axis with practical utility or scientific
validation.
6 An effort should be made to provide crisp, practical
examples, including illustrative clinical vignettes in
key areas. The use of brief, precise, illustrative appendices may be helpful.
7 Also, meaningful cultural annotations and a glossary
of cultural terms that are applicable in daily clinical
practice and not limited to less frequently encountered
syndromes (culture-bound) would be highly desirable.
Of high value for practitioners would be explanations
of terms used in different cultures to express signs and
symptoms of specific DSM disorders and information
about cultural assumptions regarding substance use
problems and related behaviors and impairments. This
may include a dictionary with key words in several languages.
© 2006 American Psychiatric Association. Journal compilation © 2006 Society for the Study of Addiction
Addiction, 101 (Suppl. 1), 40–47
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Javier I. Escobar & William A. Vega
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Addiction, 101 (Suppl. 1), 40–47
Understanding Adolescent Substance
Abuse: Prevalence, Risk Factors, and
Clinical Implications
Jason J. Burrow-Sanchez
From a developmental perspective, adolescence is a time of gaining independence, experimentation, and taking
risks. One area of experimentation associated with adolescence is substance use. For counselors working with
adolescents who use or abuse substances, or both, it is important to understand the scope of the problem and ways
to effectively work with this population. This article provides counselors with current information on adolescent
substance abuse and suggestions for clinical work.
and the data from the MTF provide a reasonable picture of
the level of substance use for adolescents across the United
States. Data from the 2002 MTF report, based on a nationally representative sample of more than 43,000 adolescents
in the 8th, 10th, and 12th grades, are presented in Figures 1
and 2. As can be seen in the figures, alcohol, cigarettes, and
marijuana were the most frequently reported drugs used by
adolescents in each grade. More specifically, Figure 1 presents data for adolescents who reported at least a one-time
use of a specific drug during their lifetime. The data on
lifetime use provide an estimate of the number of adolescents who have experimented with a particular substance.
Figure 2 presents data for adolescents who reported using a
specific substance in the past 30 days. The data for the past
30 days provide an estimate of the number of frequent users
of a particular substance. Alcohol was reported as being the
most used substance across all adolescents in the sample.
For example, more than 70% of adolescents in the 12th
grade reported having used alcohol in their lifetime, and
Adolescence is an important developmental period for
young people. They are faced with a number of challenges,
including gaining a greater sense of independence,
strengthening relationships with peer groups, and planning future career goals, during this period of their lives. In
addition, one of the many challenges that adolescents face
in the United States is the decision about whether to use
substances. Although some experimentation with substances is typical for many young people, fortunately most
adolescents who experiment with drugs do not go on to
develop substance abuse problems later in life (Newcomb,
1995; Shelder & Block, 1990). A small portion of adolescents, however, do develop problems with substances that
substantially affect their development and future adult
lives. The purpose of this article is to describe the prevalence of adolescent substance use, the associated risk of
developing a substance abuse problem and the protective
factors that militate against developing this type of problem, and the four key clinical areas for counselors to consider when working with adolescents with substance abuse
problems. For purposes of this article, the terms substances
and drugs are used interchangeably.
Prevalence of Adolescent Substance
Use and Abuse
Most adolescents are exposed to substances (e.g., alcohol,
marijuana) at some point in their young lives and subsequently make decisions about their use of them. One important source of information on the prevalence of adolescent substance use comes from the Monitoring the Future
National Results on Adolescent Drug Use: Overview of
Findings, 2002 (MTF) study (Johnston, O’Malley, &
Bachman, 2003). MTF is a longitudinal research project
that has consistently collected data on the reported use of
substances in national samples of adolescents since 1975,
FIGURE 1
Percentage of 8th-, 10th-, and 12th-Grade Students
Reporting Lifetime Use of Various Substances
Note. Data from Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2002 (NIH Publication No. 03-5374) by L. D. Johnston, P. M. O’Malley, and J. G.
Bachman, 2003, Bethesda, MD: National Institute on Drug Abuse.
Jason J. Burrow-Sanchez, Department of Educational Psychology, University of Utah. Correspondence concerning this
article should be addressed to Jason J. Burrow-Sanchez, Department of Educational Psychology, University of Utah, 1705
Campus Center Drive, Room 327, Salt Lake City, UT 84112-9255 (e-mail: sanchez_j@ed.utah.edu).
© 2006 by the American Counseling Association. All rights reserved.
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FIGURE 2
Percentage of 8th-, 10th-, and 12th-Grade Students
Reporting Past 30-Day Use of Various Substances
Note. Data from Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2002 (NIH Publication No. 03-5374) by L. D. Johnston, P. M. O’Malley, and J. G.
Bachman, 2003, Bethesda, MD: National Institute on Drug Abuse.
almost 50% reported using alcohol in the past month. The
above data clearly indicate that many adolescents report
an experimental use of certain substances; however, a much
smaller percentage report frequent use of substances
(Johnston et al., 2003).
Smaller percentages of adolescents report current use or
abuse, or both, of substances as indicated by data from the
National Survey on Drug Use and Health (NSDUH; Substance
Abuse and Mental Health Administration [SAMHSA], 2003b).
The 2002 NSDUH included a sample of 68,126 individuals
ages 12 and older in the United States, and data from this
survey are used to provide national prevalence estimates on
drug-related behaviors. For example, 11.6% of adolescents
ages 12 to 17 years were estimated to be current (i.e., use
within the past month) illicit drug users in 2002 (SAMHSA,
2003b). Furthermore, 8.9% of this age group could be classified with a diagnosis of substance abuse or dependence based
on criteria from the Diagnostic and Statistical Manual of
Mental Disorders (4th ed.; American Psychiatric Association,
1994). In addition, the estimated rates of current illicit drug
use for adolescents ages 12 to 17 years varied according to
race/ethnicity: White (12.6%), African American (10%), American Indian/Alaskan Native (20.9%), Asian (4.8%), Hispanic
(10.%), and two or more races (12.5%). In sum, the data from
the NSDUH reveal that in 2002 more than 11% of the adolescent population was using drugs on a regular basis and that
almost 9% met the diagnostic criteria for a substance use disorder. Some of the major theoretical and practical reasons that
roughly 10% of the adolescent population may transition
from experimental use of substances to more frequent use or
abuse, or both, are discussed in the following section.
The Development of Substance Abuse
Problems
There are many theories regarding the reasons why certain
individuals develop problems with substances. Popular
theories include a range of diverse views such as 12-step-ori-
284
ented approaches, psychoanalytic, behavioral/cognitive–behavioral, and family systems (see Leeds & Morgenstern, 2003;
McCrady, Epstein, & Sell, 2003; Rotgers, 2003; Wallace, 2003).
For example, one of the more popular theories about the development and maintenance of substance abuse is cognitive–behavioral. Cognitive–behavioral theory combines learning
theory (e.g., classical, operant), cognition, and social learning
(e.g., modeling; Rotgers, 2003). Generally, cognitive–behavioral theorists believe that substance abuse originates in an
interaction between the person and his or her environment.
Regarding adolescents, when they are faced with stressful situations (e.g., argument with a parent), they may manage these
situations by using relevant coping skills. Most adolescents
develop and use a range of healthy coping skills (e.g., talking it
out, calming down); however, others possess a more limited set
of coping behaviors, some of them unhealthy (e.g., using drugs),
to manage the stressful situation. Thus, cognitive–behavioral
therapists typically work with adolescents to increase their coping skills in order to successfully manage difficult situations.
Other theoretical approaches are briefly discussed in the Treatment Approaches for Adolescent Substance Abuse section later
in the article. Regardless of the specific theory about substance
abuse, most researchers agree on the influence of risk and protective factors related to the development of a substance abuse
problem in children and adolescents (Benman, 1995; Clayton,
1992; Hawkins, Catalano, & Miller, 1992; Weinburg, 2001).
A risk factor is typically defined as anything that increases
the probability of a person using drugs, whereas a protective
factor is anything that protects or decreases the probability of a
person using drugs (Clayton, 1992). For example, a risk factor
for substance abuse may be having a parent with a drug abuse
problem, and a protective factor may be having high academic
achievement in school. Risk and protective factors are found in
all contexts (e.g., school, family, peers) of an adolescent’s life
and are mediated and moderated by variables such as age, gender, and ethnicity (Hawkins et al., 1992; Moon, Hecht, Jackson,
& Spellers, 1999; Vega & Gil, 1998). In general, the higher
number of risk factors present for a given adolescent, the more
at risk he or she is for developing substance abuse problems.
Risk Factors
Hawkins et al. (1992), in their seminal article, defined two
categories of risk factors for adolescents: contextual (e.g.,
drug laws, availability of drugs) and individual (e.g., temperament, family practices). Two influential contextual risk
factors are current drug laws and the availability of substances. For example, lower legal drinking ages and lower
taxation of alcohol are risk factors for the potential use and
abuse of alcohol in a given geographical region. When the
legal age of drinking is increased, fewer alcohol-related traffic incidents are reported (Saffer & Grossman, 1987). Similarly, a higher taxation of alcohol in a geographic area is
related to overall decreases in consumption (Levy & Sheflin,
1985; Saffer & Grossman, 1987). Another influential con-
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textual risk factor is availability of drugs. The availability
of drugs will vary across communities, partly related to the
laws of the geographic region and the social norms of that
area regarding drug use. In general, the more available drugs
are in a given community, the more likely it is that adolescents will report using them (Gorsuch & Butler, 1976;
Maddahian, Newcomb, & Bentler, 1988). For example, data
from the NSDUH provide estimates that more than 50% of
adolescents ages 12 to 17 years consider marijuana fairly or
very easy to acquire in their communities (SAMHSA, 2003b).
Furthermore, marijuana is the third most common drug used
by adolescents in the United States (see Figures 1 & 2). The
risk factors described above are by no means exhaustive,
and additional contextual factors (e.g., poverty, neighborhood conditions, cultural norms about drug use) also need
to be considered when working with adolescents.
The second category of risk factors defined by Hawkins et
al. (1992) includes individual risk factors. Individual risk factors are such things as experiencing problem behaviors from an
early age (e.g., aggressiveness, negative moods and withdrawal,
impulsivity), having a coexisting mental health diagnosis (e.g.,
conduct disorder, attention deficit hyperactivity disorder
[ADHD], depression) or a learning disorder, problems in the
family (e.g., low bonding to parent, parent abuse of substances,
poor parenting practices), problems in school (e.g., low academic achievement, low commitment to school), association
with drug-using peers, and early initial use of drugs (Benman,
1995; Hawkins et al., 1992; Weinburg, 2001). Two influential
individual risk factors for adolescents are having a family member who abuses substances and associating with drug-using
peers. For example, the risk of using drugs increases when an
adolescent has a parent or older sibling who uses drugs (Brook,
Whiteman, Gordon, & Brook, 1990; Johnson, Schoutz, & Locke,
1984). In addition, adolescents who associate with drug-using
peers have consistently been found to have higher levels of
drug use (Barnes & Welte, 1986; Kandel & Andrews, 1987;
Weber, Graham, Hansen, Flay, & Johnston, 1989); therefore,
when an adolescent associates with other people (e.g., family
member, peer) who use drugs, his or her risk of substance use
increases. Although the risk factors described increase the probability of an adolescent using or abusing substances, protective factors act to buffer the adolescent against such risks.
Protective Factors
As previously noted, protective factors decrease the probability that an individual will use or develop problems with
drugs. Even though peer groups become more important
during adolescence, parents still have much influence on
adolescent behavior. For example, parental attitudes toward
drug use are related to adolescents’ drug use behavior
(Hawkins et al., 1992). Recent data from the NSDUH indicate that adolescents who were 12 to 17 years old and who
were less likely to use drugs also perceived that their parents
would strongly disapprove of drug use (SAMHSA, 2003b).
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More specifically, of the 89.1% of adolescents who perceived
that their parents would strongly disapprove of their using marijuana, only 5.5% had used it in the past month (SAMHSA,
2003b). These data, therefore, suggest that parents’ views of
drug use are likely to influence children’s drug use behavior.
Additional examples of protective factors include good mental
health, exposure to effective parenting practices (e.g., high
monitoring, consistency, clear limits), association with prosocial
peers, high achievement in school, good problem-solving skills,
and strong connections to positive community organizations
(e.g., church, youth groups; Glantz & Sloboda, 1999; Hawkins
et al., 1992). Protective factors act to increase the adolescent’s
ability to resist pressures to use or abuse substances, or both.
Although no single protective factor has been shown to prevent drug use, the higher the quantity and quality of protective
factors that are present, the stronger effect they will have on
limiting drug use in adolescents (Newcomb, 1995). The remainder of the article addresses four key clinical areas for counselors to consider when working with adolescents who have
substance abuse problems.
Four Key Clinical Areas for Counselors
This section provides a description of four key clinical areas
that are important for counselors to consider when working
with adolescents who use or abuse substances, or both. In
each area, the relevant research is cited for further review
and the counselor is provided with ideas and suggestions for
clinical practice. The four key clinical areas are (a) establishing a working relationship, (b) assessing the severity of
the problem, (c) identifying a treatment approach, and (d)
acknowledging the potential for relapse.
Establishing a Working Relationship
With the Adolescent
One of the potential difficulties in working with adolescents
with substance abuse problems is that they are typically reluctant to talk openly about their drug abuse and will tend to
underreport it (Winters, Stinchfield, Henly, & Schwartz, 1992).
In most cases, adolescents with substance abuse problems are
referred to counselors by juvenile justice courts, schools, parents, or some other entity (Muck et al., 2001). By the time
adolescents reach a counselor’s office for substance abuse
concerns, they most likely feel (or concretely know) they are
in trouble with someone (e.g., parents, school officials, probation officer). They may also anticipate that adults in positions of authority (e.g., parents, counselors) will tell them
such things as “You must stop using immediately” and “This
is a bad thing you are doing.” Therefore, it is not unreasonable
for adolescents with substance abuse problems to approach
the counseling situation with a high degree of resistance.
Working with the adolescent’s resistance (not against it)
is one of the most important first steps in building a therapeutic relationship with the young client (Miller & Rollnick,
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2002). Building a sense of trust and understanding early in the
relationship will help to reduce the adolescent’s resistance to
talking about his or her substance use. One particular strategy
is to initiate a discussion with the adolescent about what will
be done with the information discussed in treatment. For example, many adolescents will be apprehensive about discussing their drug use history because they fear that the information
will be given to others (e.g., parents, probation officers). Initiating a discussion about the limits of confidentiality and what
will be done with the information they provide can go a long
way toward lowering adolescents’ resistance to talking about
their substance use in an initial session.
A second strategy a counselor can use to lower resistance
is to listen for information about challenges that the adolescent is currently facing (e.g., mandated treatment, problems
at home, school) and to use the skills of reflection to echo
his or her statements in a way that communicates the
counselor’s understanding (e.g., empathy) of his or her situation (Miller & Rollnick, 2002). The use of this technique
allows the adolescent to feel heard by the counselor and
typically leads to greater exploration of the issue at hand.
Counselors will likely find that adolescents initially respond
better in therapy when the environment is supportive and
nonthreatening and the emphasis is on understanding the
problem instead of placing blame on the adolescent (Baer &
Peterson, 2002). Lowering adolescents’ resistance allows
them to communicate more openly about their substance
use and leads to a more accurate assessment of the problem.
Many of the strategies for lowering resistance in substance
abuse counseling are drawn from the concepts and techniques
of Motivational Interviewing (MI) developed by Miller and
Rollnick (2002). MI is a brief counseling intervention designed to reduce a client’s ambivalence toward change while
increasing his or her motivation to engage in the behaviorchange process. One of the central premises of MI is that
clients come to the counseling session with various levels
of motivation in regard to behavior change. The level of
client motivation is thought to be related to one of five
stages of change suggested by Prochaska, DiClemente, and
Norcross (1992). From a MI perspective, the counselor works
collaboratively with a client to address his or her ambivalence and reduces barriers toward behavior change. Simultaneously, the counselor reinforces the client’s behaviors that
are congruent with the desired behavior change. In addition, it is important for the client to feel understood and
supported by the counselor within the context of the working relationship in order for MI to be most effective. Counseling strategies in MI are largely drawn from a clientcentered perspective and include skills such as active
listening, reflection, and reframing. A manualized treatment,
based on MI, called Motivational Enhancement Therapy
(MET) was evaluated in a large-scale national study of alcohol treatments (Project Match Research Group, 1997). The
interested counselor can obtain a copy of the MET manual
286
from the National Institute on Alcohol Abuse and Alcoholism (see Miller, Zweben, DiClemente, & Rychtarik, 1995).
More detailed information on the use of MI with adolescents can be found in Baer and Peterson (2002).
Assessing the Severity of the Substance
Abuse Problem
Understanding the level of the adolescent’s drug use or dependence will assist the counselor in determining the extent
of the problem and what type of treatment will be most appropriate (e.g., outpatient, inpatient treatment). For example,
adolescents with some experimental use of substances will
require a lower level of treatment (e.g., psychoeducation)
compared with an adolescent with a long-standing drug
abuse problem (e.g., intensive outpatient, inpatient). It is
important for the counselor to keep in mind that some level
of experimentation with substances is highly likely for many
adolescents during their development, as can be seen from
the statistics on drug use presented earlier (Johnston et al.,
2003). However, the counselor will need to make a distinction between experimental use and abuse/dependency in
order to match the appropriate level of treatment needed.
Winters (2001) recommended considering adolescent substance use along a continuum of problem severity, with six
categories anchored with abstinence on one end; then followed by the categories of experimental use, early abuse, abuse,
and dependence; and recovery on the opposite end. The recovery category includes adolescents who have relapsed and
gone through each of the above categories more than once
(Winters, 2001). When assessing the adolescent’s history of
substance use, it is important for counselors to keep in mind
that clients initially tend to underreport their substance use
because of some of the resistance issues previously discussed;
therefore, an assessment that takes place in the context of a
working relationship with low client resistance (even if the
relationship is new) will likely produce a more accurate picture of the adolescent’s level of substance use.
Specific content areas for counselors to assess include
the types of drugs being used by the adolescent and the frequency of use (e.g., daily, weekly, monthly). For example, counselors should identify the adolescent’s preferred drug (e.g., marijuana) as well as any other drugs (e.g., alcohol, methamphetamine) that are part of the problem. In addition, they should
establish the initial onset of drug use by the adolescent and
relevant time lines for all drugs used. In general, an earlier
initial use of substances predicts more problems with substances
in the future (Anthony & Petronis, 1995; Hawkins et al., 1992).
One of the instruments that has been used for research purposes
and can be applied in clinical settings is the Timeline Follow
Back (TLFB; Sobell & Sobell, 1992). This instrument was originally developed to be used with adults regarding their alcohol
use but has been adapted for use with adolescents (Liddle,
Rowe, Dakof, Ungaro, & Henderson, 2004; Waldron, Slesnick,
Brody, Turner, & Peterson, 2001). It can be administered as a
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semistructured interview, a paper-and-pencil measure, or on
a computer and is available in several languages (Sobell &
Sobell, 2003). The TLFB is designed to retrospectively record
an adolescent’s drug use over a specified period of time (e.g.,
past 30–90 days). Administration time depends on the length
of time probed; however, the typical administration time
ranges from 10 to 30 minutes. Scoring time is minimal, and
scoring can be completed by hand or computer. The counselor can tailor the TLFB to record the levels of use for the
most relevant drugs and time periods for a specific adolescent. The TLFB can also be administered at different points
in time (e.g., pretreatment, posttreatment) to assess for any
change in levels of drug use. In addition, the use of an
instrument such as the TLFB will likely increase the accuracy of recall, given that relevant memory cues (e.g., birthday, holidays) for the adolescent can be indicated on the
time line. In sum, understanding the types of drugs being
used and the frequency of use will help the counselor obtain a clearer picture of the actual drug problem.
Two additional areas the counselor should assess include
the adolescent’s reasons for drug use and the existence of
any co-occurring disorders. For example, the counselor can
ask the adolescent about reasons (e.g., coping with stress,
self-medicating for depression) and any negative consequences (e.g., problems with law enforcement, physical symptoms) of drug use. Assessing this area with the adolescent
will help illuminate both the positive and negative consequences of drug use. Exploring the consequences of drug
use with the adolescent can assist him or her in understanding the pros and cons of changing problem behavior or of
not changing the behavior (Miller & Rollnick, 2002). The
counselor should also assess for the presence of any cooccurring disorders, including, but not limited to, conduct
disorder, ADHD, depression, anxiety, and learning disorders
(Riggs, 2003; Weinburg, 2001). Greenbaum, Foster-Johnson,
and Petrila (1996) estimated that approximately 50% of
adolescents who abuse substances have a co-occurring
disorder; therefore, screening for the presence of any cooccurring disorders should always be part of the assessment
process for substance abuse. In addition, counselors may
have access to outside sources of information (e.g., parents,
teachers, probation officer) regarding the adolescent’s history of drug use. As needed, outside information should be
gathered with the full awareness of the adolescent in order to
promote trust and lower resistance in the relationship.
Screening instruments can also be used to obtain more
information about an adolescent’s level of substance use
and related problem behaviors (Winters, 2001). Initially,
some adolescents may be more comfortable answering questions on a paper-and-pencil measure rather than talking to a
counselor about their drug use. There are many screening
instruments available for adolescents that can be used as a
more objective assessment of a potential drug problem and
related areas. Screening instruments are typically self-
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report, and the number of items range from fewer than 20 to
more than 100. Some instruments are designed to focus on a
specific drug (e.g., alcohol); others are more global and cover
a wide range of substances and potential problem areas (e.g.,
mental/physical health, family relationships). For example,
the Problem-Oriented Screening Instrument (POSIT; Rahdert,
1991) is a 139-item measure that was developed to screen
for problems in 10 specific areas, including substance abuse,
mental/physical health, family relationships, and peer relations, among others. The POSIT is designed to be used with
adolescents from 12 to 19 years of age and can be easily
administered and scored by a range of professionals in a variety of settings (e.g., schools, medical clinics, drug treatment
programs). The questions are designed to be answered in a
“yes” or “no” format. It can be administered as a paper-andpencil measure or on a computer. Administration time for the
paper-and-pencil version is approximately 20 to 25 minutes,
and hand scoring takes about 2 minutes. The POSIT, which
can be obtained from the National Clearinghouse for Alcohol
and Drug Information, is available both in English and Spanish versions. The use of screening instruments, such as the
POSIT, provides the counselor with more objective assessment information and indicates other potential problem areas
(e.g., family/peer relations).
Decisions about the selection of an instrument will depend on many factors, typically including (a) type of information needed; (b) adequate psychometric properties; (c) appropriate norms; (d) length; and (e) ease of use, scoring, and
so forth. The counselor will also need to be familiar with the
technical aspects (e.g., proper administration, norms, validity) of any screening instrument prior to its use. The length of
this article prohibits a detailed review of adolescent substance
abuse screening instruments; however, the interested counselor is referred to other sources (see Winters, 2001; Winters,
Latimer, & Stinchfield, 2001) for more specific information
on this topic. In sum, accurately assessing the scope of the
problem will assist the counselor in determining the severity
of substance use or abuse and the need for treatment.
Treatment Approaches for Adolescent
Substance Abuse
In 2002, more than 156,000 adolescents between the ages
of 12 to 17 years (8.3% of all treatment admissions) were
admitted to substance abuse treatment facilities in the
United States (SAMHSA, 2004). The three types of approaches most frequently used for substance abuse treatment are outpatient, residential, and inpatient. For example,
74% of all treatment facilities offer regular outpatient services, whereas 44% offer intensive outpatient services
(SAMHSA, 2003a). In contrast, only 26% of all facilities
offer residential treatment, and 4% offer inpatient treatment in a hospital. In addition, 37% of all substance abuse
treatment facilities offer specialized services for adolescents (SAMHSA, 2003a).
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For adolescents, the most common substance treatment models identified by Muck et al. (2001) are 12-step, cognitive–
behavioral, family-based, and therapeutic communities models. Twelve-step approaches, also referred to as the Minnesota
Model or Alcoholics Anonymous (AA), generally view the addiction to substances as a disease; therefore, individuals must
consistently manage their health behavior (i.e., sobriety) during the remainder of their lives and strive toward maintaining
abstinence from substances (Winters, Stinchfield, Opland,
Weller, & Latimer, 2000). In contrast, cognitive–behavioral
approaches view substance abuse from a learning perspective
and believe that individuals can learn ways (e.g., coping skills)
to make changes in their lives (Monti & Rohsenow, 2003;
Rotgers, 2003). Family-based approaches, also referred to as
family systems, view substance abuse problems from the contexts of the overall immediate family system, extended family
system (e.g., child–grandparent), and family subsystems (e.g.,
child–parent, siblings; Ozechowski & Liddle, 2000). Thus,
family-based approaches treat individuals within the context of the family system and use theory and strategy from
family therapy models such as multisystemic, structural, strategic, functional, and cognitive–behavioral (Liddle & Rowe,
2004; Muck et al., 2001). Finally, therapeutic communities
are generally long-term (up to 2 years) residential treatment
facilities that view individuals with substance abuse problems as experiencing a disruption in normal psychosocial
development (Jainchill, 1997; Muck et al., 2001). The goal
of therapeutic communities is to provide a safe and highly
structured environment for the individual to develop the
necessary personal and social skills needed to function in
daily life without the use of substances (Jainchill, 1997).
All of the above treatment models have been tested, with
varying degrees of success, for their efficacy with adolescents
(Deas & Thomas, 2001; Muck et al., 2001; Williams & Chang,
2000). In a recent comprehensive review of the outcome of
substance abuse treatment with adolescents by Williams and
Chang, the authors were not able to determine the comparative
effectiveness of different treatment types because of “insufficient evidence” in the literature. They were, however, able to
determine that outpatient family therapy currently appears to
be more effective than other forms of outpatient treatment for
adolescents (Williams & Chang, 2000). In another review of
adolescent treatment research, Deas and Thomas stated that “it
is premature to conclude that one modality is more effective
than another” (p. 187). They did suggest that family-based
and cognitive–behavioral treatments seem to be promising
approaches for treating adolescent substance abuse; however, more controlled research is needed (Deas & Thomas,
2001). As these reviews suggest, there is currently no definitive answer about what type of treatment works best to treat
adolescent substance abuse; however, one can conclude from
the research that treatment is more effective than no treatment for adolescents, involving the adolescents’ families in
the treatment process is important for success, and aftercare
288
programs should be available to the adolescent (Williams &
Chang, 2000). Therefore, counselors are encouraged to use
treatments that are based on evidence, include supportive
others (e.g., family, relatives), and provide support to adolescents to minimize the potential for relapse.
Acknowledging the Potential for Relapse
It is not safe to assume that adolescents with a substance problem will completely recover and abstain from substances after
treatment services terminate. In fact, there is a high rate of relapse for adolescents who complete treatment programs
(Pagliaro & Pagliaro, 1996; Williams & Chang, 2000). For example, it is estimated that approximately 50% of adolescents
will relapse within the first 3 months after the completion of
treatment (Pagliaro & Pagliaro, 1996). Williams and Chang
found that the posttreatment variables most related to successful treatment outcome included participation in aftercare and
social support from others (e.g., parents, peers). Given these
findings, counselors are encouraged to discuss the potential
for relapse with the adolescent and the importance of attending
aftercare services to support the gains made in treatment. Examples of aftercare include follow-up appointments with the
treatment counselor over a specified period of time (e.g., 3 to 12
months) and attendance in peer support groups offered by community agencies or school districts (Gonet, 1994). Adolescents
may also find support when participating in self-help groups
such as AA or Narcotics Anonymous (McCrady, Horvath, &
Delany, 2003). Some adolescents will likely find that participation in aftercare services provides the necessary support they
need to cope with a relapse; however, the research in this area is
still limited (Williams & Chang, 2000).
The skills to prevent relapse can also be integrated into
the treatment process to assist the adolescent in managing
slips and relapses. A slip is generally defined as a brief period
of temporary substance use, whereas a relapse is defined as
full-blown return to a previous drug-using behavior (Fisher &
Harrison, 2000). The prevention of relapse from a cognitive–
behavioral view generally teaches individuals how to identify potential high-risk relapse situations, use appropriate
coping skills for such situations, and effectively manage times
when slips occur (Monti & Rohsenow, 2003; Witkiewitz &
Marlatt, 2004). For example, coping-skills treatment approaches teach individuals how to minimize the effect of a
slip when it occurs so that it will not develop into a complete
relapse (i.e., the previous drug-using behavior; Monti &
Rohsenow, 2003). Therefore, given the high likelihood that
many adolescents will relapse after the completion of treatment, counselors are encouraged to address the issues of aftercare and relapse prevention in their clinical work with clients.
Summary
On the basis of the current research, there is little doubt that
many adolescents experiment with and use drugs in their
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schools and communities (Johnston et al., 2003). From a developmental perspective, adolescence is a time of gaining independence, experimentation, and taking risks. One area of experimentation associated with adolescence is substance use.
Fortunately, only a small percentage of adolescents who experiment with substances go on to develop more severe problems (Newcomb, 1995; Shelder & Block, 1990). Certain risk
factors are related to the development of substance abuse problems in adolescents, whereas certain protective factors provide
a buffer against drug use and abuse (Benman, 1995; Hawkins et
al., 1992; Newcomb, 1995; Weinburg, 2001). In addition, four
key clinical areas for counselors to consider when working
with adolescents with substance abuse problems are establishing a strong working relationship, accurately assessing the severity of the problem, identifying and understanding the major
treatment approaches, and acknowledging the potential for relapse. Finally, it is especially important for counselors with
limited training in substance abuse to familiarize themselves
with the clinical areas mentioned above. Counselors who have
the necessary education and training will be better equipped to
serve the growing numbers of adolescents with substance abuse
problems in the United States.
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Substance Related and Addictive Disorders
Substance Related and Addictive Disorders
Program Transcript
[MUSIC PLAYING]
FEMALE SPEAKER: He's-- he's always doing things on the computer. He talks
on the telephone, texting. He never stops, not even to eat. He never eats much
anymore.
MALE SPEAKER: Eat your veggies. Drink your milk. Eat your veggies. Drink
your milk. Who needs to eat?
Seen any good movies lately? I like horror movies, myself. Zombies, especially.
The fast ones.
FEMALE SPEAKER: There's no alcohol or drugs in our house, none. We've
never done that. We don't leave drink wine. That's why I wanted our minister to
talk to him.
MALE SPEAKER: Talk about zombies.
FEMALE SPEAKER: He's the one who suggested that we come here and talk to
because he was thinking that maybe something's going on.
MALE SPEAKER: Yuck! I hate booze. I don't do drugs, either. I say no every day.
FEMALE SPEAKER: Personally, I think it's the music he's listening to.
MALE SPEAKER: Oh, brother.
FEMALE SPEAKER: I mean, the screaming. It's so aggressive and angry.
MALE SPEAKER: Feels good.
FEMALE SPEAKER: Maybe you agree with your mom that you've been
depressed and angry in the past, Do you remember, maybe, why you felt that
way?
MALE SPEAKER: Because I'm stupid.
FEMALE SPEAKER: You're not stupid, honey. See, he had to repeat the fifth
grade, so he's a year behind all his friends at school.
MALE SPEAKER: They're not my friends. You hate my friends.
©2013 Laureate Education, Inc.
1
Substance Related and Addictive Disorders
FEMALE SPEAKER: I don't hate them. It's just I don't think you should be
hanging around boys who are that much older than you.
Substance Related and Addictive Disorders
Additional Content Attribution
IMAGES:
Images provided by http://www.istockphoto.com/
MUSIC:
Creative Support Services
Los Angeles, CA
Dimension Sound Effects Library
Newnan, GA
Narrator Tracks Music Library
Stevens Point, WI
Signature Music, Inc
Chesterton, IN
Studio Cutz Music Library
Carrollton, TX
Special Thanks:
Fairland Center/Region One Mental Health
©2013 Laureate Education, Inc.
2
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All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
12
Substance Use, Eating,
and Sexual Disorders
The Boundaries of Substance Use
and Addiction
Substance use and addiction provide an instructive instance of
how difficult it can be to define a boundary between normality and
mental disorder. We live in a culture in which most people drink
alcohol and in which excess intake from time to time is far from
unusual. Since the 1960s, one could say much the same about marijuana. Also, the definition of addiction has become broader. The
chapter in DSM-5 now includes addictions to behaviors, not only
to substances.
The main modification in DSM-5 is that there are no longer any
categorical difference between substance use and addiction. The
media have duly noted that more people can be diagnosed as having
an addiction. But what determines the boundary between use and
addiction? DSM, in its various editions, has focused on maladaptive patterns of use leading to “clinically significant impairment or
distress.” But that is a vague concept that lacks a precise definition.
Less sensitive criteria such as “committing illegal acts” have been
removed, and a new criterion of “craving” has been added. Even so,
deciding what is or is not clinically significant requires a judgment
call. Does impairment depend on losing one’s job and/or losing intimate relationships? Can one be sure that these outcomes would not
have happened anyway? One is on safer ground in focusing on the
152
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12 S ubs ta nc e Us e, Ea ti ng, a nd S e x u a l D i so rd e r s | 1 5 3
physical effects of substance use. But those sequelae only emerge
after years of use.
These boundary problems help to explain why substance use
disorders have such a high prevalence in epidemiological studies. In
the Epidemiologic Catchment Area study, approximately 10% of all
men in the United States met lifetime criteria for alcoholism (Robins
& Regier, 1991). In the National Comorbidity Survey Replication
(NCS-R), 13.2% met lifetime criteria for alcohol abuse, and with a
further 5.4% for alcohol dependence, the total was more than 18%
(Kessler et al., 2005a). Reflecting the tendency of alcoholism to remit
over time, the National Epidemiologic Survey on Alcohol and Related
Conditions (NESARC; Grant et al., 2004b) reported a 12-month prevalence for alcohol abuse of 4.7%, with 3.8% for dependence. A high
lifetime prevalence of alcoholism could be a cause for alarm, given
that many who abuse alcohol never seek treatment. But it is also possible that these numbers are inflated by an overly broad definition of
the disorder.
Substance Use and Addiction in DSM-5
DSM-5 defines a substance use disorder as a maladaptive pattern
leading to clinically significant impairment or distress for at least
12 months. These features must meet 2 or more of the following 11
criteria: recurrent substance use leading to a failure to fulfill major
role obligations, associated with social and interpersonal problems, in situations that are physically hazardous, tolerance (need
for increased amounts or diminished effect of the same amount),
withdrawal effects, taking the substance in larger amounts and for
longer than intended, unsuccessful efforts at cutting down, spending time to obtain or use the substance, giving up other activities,
continuing despite the problem, and craving the substance. (This
last criterion—“craving or a strong desire or urge to use a specific
substance”—is new). A previous criterion describing legal problems
has been dropped because it is not predictive of dysfunction. There
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154 | Part II Specific D i ag n ose s
are severity specifiers, depending on the number of criteria met
(greater than 4 is considered severe). DSM-5 also describes course
specifiers (early full remission, early partial remission, sustained
full remission, and sustained partial remission on agonist therapy
in a controlled environment).
Each drug follows the same general guidelines. Clinicians are
also asked to specify whether physiological dependence is present.
The term “dependence” is reserved for tolerance and/or withdrawal
symptoms. This definition is broad and dimensional, but many
patients can be diagnosed if they meet only two criteria, which is
a rather lower bar (Martin et al., 2011). Yet it goes along with the
manual’s overall philosophy, which is to include subclinical phenomena within a spectrum.
The chair of the workgroup (O’Brien, 2011) defended these
changes. “Dependence” was eliminated because it is a confusing concept that conflates physical and psychological need for a substance.
The logic depends on research suggesting that addiction is dimensional (Hasin & Beseler, 2009). Thus, each disorder can be rated on
a continuum of severity, coded for physiological dependence, with
addictions coded for severity (Shields et al., 2007).
In the past, the term “addiction” always required physiological
dependence. It might increase stigma to use this term for binge
drinkers and for anyone else who misuses alcohol. Once again, viewing everything on a continuum seems to run the danger of watering
down diagnostic concepts. Moreover, different clinical presentations may require different treatment.
One question is whether DSM-5 will make addiction diagnoses
more frequent. An Australian survey (Mewton et al., 2011) found
that using the DSM-5 criteria could lead to a 60% increase in prevalence in substance use disorders as a whole. An American study
(Agrawal et al., 2011) found only a 10% increase with the new criteria. Either way, this would be a significant change.
This brings us back to the same problem: the absence of a clear
boundary between using and having an addiction. Everything
depends on assessment of impairment. At what point is a patient
who drinks to excess failing to meet major role obligations? In
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12 S ubs ta nc e Us e, Ea ti ng, a nd S e x u a l D i so rd e r s | 1 5 5
severe cases, the answer is obvious. In the more common and milder
cases, it may not be.
Behavioral Addictions
DSM-5 applies the same concepts to “behavioral addictions.”
Pathological gambling is an example. In the NCS-R (Kessler et al.,
2008), this diagnosis had a lifetime prevalence of 0.6%, although it
was highly comorbid with other disorders.
Gambling problems have a similar form and function to substance
abuse. There is an attraction to this behavior, resulting in failure to
perform major role obligations, as well as continuance despite negative consequences. DSM-5 has therefore moved “disordered gambling” from the DSM-IV group of impulse disorders to the substance
use group. Yet other addictive behaviors are still classified elsewhere.
Bulimia nervosa also resembles an addiction in that the process of
binging and purging can provide quick relief from dysphoric emotions
(Brisman & Siegel, 1984). Another example is self-harm, common in
borderline personality disorder, which can be addictive because it provides immediate relief for dysphoric emotions (Linehan, 1993).
Internet addiction, a more recent phenomenon, was not
included in DSM-5. (A proposal for this diagnosis is listed in Section
III.) Research has described people who give up all other activities
to be (or to live) online (Block, 2008). Yet caution is needed because
one would have to define a boundary between addiction and the difficulty many people have in ending sessions on the Internet. We also
do not know whether this problem is a reflection of other mental
disorders or a disorder in its own right.
The development of these new addictive behaviors can be
explained by Shorter’s (1993) concept of a “symptom pool.” Many
symptom...
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