As more opioid-addicted young adults are entering treatment facilities, many addiction professionals are seeking alternative ways to guide this demographic into recovery. Marworth Alcohol and Chemical Dependency Treatment Center’s young adult population (ages 18-25) doubled from 159 in 2009 to 319 in 2014. Today, young adults account for a quarter of all our inpatient admissions, and the majority claim opioids as their former drug of choice.
As our young adult population grew, we noticed a related increase in non-routine discharges from our facility. We convened a multi-disciplinary team of counseling, recreation therapy, medical, nursing, disease management, quality and support staff to investigate this trend and determine why this population was struggling to make a full commitment to the treatment process.
We discovered that young adults think and act differently than our older patients and haven’t had the time to develop as many coping skills. When considering the perspective of Prochaska and DiClemente’s Stages of Change model—pre-contemplation, contemplation, preparation, action, maintenance, termination—we found that most young adults enter treatment in the pre-contemplation or contemplation stage. However, our staff had grown accustomed to working with older adults who enter treatment in the preparation or action stages. Essentially, we were treating our young adult patients as though they were further along in the recovery process. Recognizing that each stage of change requires different types of interventions, our treatment team set out to adopt treatment approaches that will better meet the needs of our growing young adult population.
Several staff members expressed interest in working with the young adult population, and we encouraged them to trust their clinical intuition to tailor creative treatment interventions. We regularly evaluated new treatment modalities to see what worked and what didn’t.
The treatment modalities that have proven to resonate most with young adults include acupuncture, sand tray therapy and recreation therapy. Over the course of a year we developed a successful program that resulted in an eight percent decrease in non-routine discharges of patients in the 18-25 age range.
The detoxification phase of treatment is physically uncomfortable for those withdrawing from opiates. For young adults who often have low frustration tolerance, this process is especially painful and distressing despite medical interventions such as suboxone therapy.
To ease the discomforts of detox, an acupuncture protocol was implemented to complement the detoxification phase of treatment for those withdrawing from opioids. The National Acupuncture Detoxification Association (NADA) ear protocol was specifically developed to be used in addiction treatment settings. A licensed acupuncturist uses 10 needles placed in key spots on the patient’s outer ear to correspond with organs that are negatively affected by substance abuse, such as the kidneys, liver and lungs. The procedure releases hormones, including endorphins and cortisol, which can aid in pain relief and stress reduction.
Eighty-nine percent of patients who experienced the acupuncture protocol reported that it improved their sense of well-being, improved the quality of sleep, improved their mood, and helped make their detoxification more comfortable.
Sand Tray Therapy
Sand tray therapy is one of the most recent techniques added at Marworth and it has been especially therapeutic for young adults. By manipulating sand and figurines in a tray to build miniature scenes, or “worlds,” patients have the opportunity to visually portray feelings and experiences that are difficult to verbalize.
Sand tray sessions include four to five patients and two counselors. Patients spend about 25 minutes creating two worlds—one representing their life in addiction and one representing their aspirations for a life in recovery. The counselors offer directive guidance as needed and observe the patients to see how they are interacting with their worlds as well as the other group members. When the worlds are complete, the lead counselor uses Socratic questioning to help each patient process the experience. Describing their worlds helps the patients find the words to verbalize their history. The second counselor keeps detailed notes.
After patients leave a sand tray session, the counselors review the notes and pass along key observations to each patient’s primary counselor. For example, a patient’s world might depict himself or her -self standing on a bridge between the past and future worlds. This might indicate to the counselors that the patient is still in the contemplation stage of behavior change.
Sand tray therapy, which is also known as sand play or the world technique, has been shown to promote communication, anxiety reduction, emotional release, safety and containment, self-control, and therapeutic metaphors. Since introducing the technique at Marworth in 2014, 96 percent of patients cited that they had a positive experience with it in their discharge evaluation. The majority found it helpful in improving their abilities to talk about their addictions; improving their insights into the impact of the disease on their lives; uncovering ideas for what life in recovery can look like; expressing themselves in a creative manner; and relating to others through discussion of the meanings of the sand trays.
Our investigation into how to better work with young adults revealed challenges that results from interactions with older adults. The age gap creates significant personality differences that can be disruptive to everyone. For example, young adults often have lower self-motivation levels and less coping skills to manage stress, so they require supplemental guidance and encouragement that takes focus away from other group members. Also, transference between patients is common. Specifically, many young adult patients regard the older patients as parental or authority figures, and the older adults consider the younger patients as children. While these roles may be beneficial in some situations, it is important for all patients to be equal when in treatment.
To address these issues, we now offer some recreation therapy sessions for young adults only. By grouping peers together in treatment, we create social settings that are similar to what they’ll experience after discharge from the inpatient program. This also reduces disruptions to patients in other age groups.
Young adults usually have higher energy levels and different interests than their older counterparts. We provide them with additional physical activities in the form of fitness center groups and team sports, like disc golf, flag football, or ultimate Frisbee. Aside from burning energy, these activities promote support, trust and asking for help.
Also, boredom is a top relapse trigger for most young adults. By learning to fill their free time with positive leisure choices, they can avoid filling it with using or other destructive activities. Indeed, these are important coping skills that will be useful in their daily lives.
Another successful recreation therapy activity is music and film appreciation, in which young adults listen to songs or watch movies together. Afterward, the group members analyze the lyrics or scenes and discuss themes that relate to addiction and recovery.
Other recreation therapy activities include facilitating a “circle of identities” project that promotes self-awareness and self-acceptance. We also ask patients to create their own coat of arms to express special memories, achievements, and dreams to aid in values clarification.
To culminate the recreation therapy experience, we created a yearbook for young adult patients to help illustrate they are not alone in the journey of recovery. At the last recreation therapy session, each patient has the opportunity to leave a message or draw a picture in the yearbook for future young adults to view.
Another important part of our treatment program for opiate-addicted patients, including young adults, is relapse prevention. As with any addiction, relapse is always a possibility. In the case of opiates, a relapse that results in an overdose can be fatal. To this end, we provide a prescription for Naloxone (Narcan®), an overdose reversal agent, to patients before discharge to be kept on hand in the event of an overdose. As part of their participation in the family program, family members learn how to identify an overdose and how to use the injection on their loved one.
The emphasis of our relapse prevention program continues to be on education and coping skills to help prevent patients from returning to drugs. However, the naloxone can be used as a life-saving tool in an emergency situation.
Marworth Alcohol and Chemical Dependency Treatment Center is located in Waverly, Penn. Valerie Noel, MEd, is a Drug and Alcohol Counselor, Lori Pilosi, MS, CTRS, is the Lead Recreation Therapist, and Dominic Vangarelli, MA, CAC, is Director of Counseling. Visit us online at www.marworth.org.