Underage drinking treatment evolves with better understanding

Barack Obama stood inside a 9-by-10-foot prison cell meant to hold three men. It was July 2015, and he had just become the first United States president to visit a federal prison. As he stood in the small cell, he reflected that it was only “by the grace of God” he was standing there as the president and not as the prisoner.

“What is normal is young people making mistakes,” Obama said later that day during the annual national convention of the NAACP. “These are young people who make mistakes that aren’t that different than the mistakes I made and the mistakes that a lot of you guys made.”

As a public figure, Obama has been open about his history with drugs, stating that as a young man, he drank alcohol, smoked marijuana and tried cocaine while in school. As he pointed out in July, he was lucky to avoid an arrest and the possible juvenile detention that may have come with it when he was underage.

For many young people who come into contact with the court system, the services provided once incarcerated can make a significant impact on their odds of re-offending.

According to Jillian Saxton-Moody, a mental health clinician who works with incarcerated teens at the Fairbanks Youth Facility, many kids never see any form of substance abuse treatment until they’re already in a correctional facility.

“For some of them, this is the first social service they’ve ever been involved in. We’re sometimes the first person to see anything wrong at home,” Saxton-Moody said.

Obama sat down with six men there on drug convictions during his visit to El Reno Correctional Facility in Oklahoma. “They expressed huge appreciation for the educational opportunities and drug counseling that they had here in prison,” he said afterward.

Resources in correctional facilities, whether for adults or young offenders, haven’t always been what they are today. Even now, access to support services can vary depending on where a person is incarcerated.

If counselors can reach kids while they’re in juvenile detention, those kids have a much better chance of avoiding a 9-by-10-foot prison cell as an adult.

Methods of treating alcohol use disorders in adolescents have evolved during the last several decades. Dr. Charles Herndon, the medical director of Providence Breakthrough, a treatment program in Anchorage, has been working in addiction medicine for decades.

Herndon said, when he first began his career, the research on addiction medicine was a fraction of what it is today, as evidenced by the copy of the book “Principles of Addiction Medicine” he has on his desk.

“It is huge. When I first got into addiction medicine it was a modest-sized textbook,” he said. “The research has just exploded.”

With advances in research, physicians and clinicians also have begun to shift the way they treat adolescents with substance abuse disorders, particularly by dealing with substance abuse not as something people have done wrong but rather as an illness that’s affecting their lives.

“I think we’re ahead, Alaska as a whole, DJJ (the Department of Juvenile Justice), they’re really ahead of the game when it comes to this approach,” Saxton-Moody said. “It’s kind of exciting because our numbers, over the last 12 years, they’ve halved the number of referrals.”

During the last 12 years, the number of minors in Alaska sentenced to time in correctional facilities because of drug or alcohol charges has been steadily reduced, from 730 in 2003 to 395 in 2014.

That number, provided by Juvenile Justice, only counts cases where a drug or alcohol offense was the most serious charge committed by the individual being referred.

However, most of the more serious charge types also have gone down significantly.

A big contributing factor behind that improvement in Saxton-Moody’s mind has come with the department’s progress in, firstly, assessing what kids need treatment and, secondly, getting them into the right treatment programs.

That has come in part because the system has better assessment tools and because facilities are now required by law to perform a psychiatric assessment of every person who enters the facility. That federal law was passed in 2003 to help reduce instances of sexual violence among inmates.

Some youth detention facilities in Alaska do more than just provide referrals. At the Fairbanks Youth Facility, clinicians work directly with young people who struggle with substance abuse or mental health issues while they are incarcerated.

For many years, the primary program used at the Fairbanks Youth Facility for combating substance abuse was the traditional 12-step program. Recently, however, the department as a whole began implementing a new program called Seven Challenges in each of its facilities that offer treatment. The department has eight facilities throughout the state, and about half of them include treatment centers.

Like the 12-step model, Seven Challenges isn’t focused only at people who are incarcerated. Unlike the 12-step program, Seven Challenges was designed specifically for adolescents. It uses data on successes and shortcomings of adolescent treatment, making it an evidence-based program.

The biggest difference between the 12-step program and Seven Challenges comes in the way the two practices ask participants to think about their addiction, a key distinction when it comes to treating young people, according to Saxton-Moody.

“It’s letting them make their own decisions, not telling them they have to have their sobriety,” she said. “It kind of goes along with our trauma-informed care approach. Instead of asking ‘What did you do wrong?’ it’s ‘What happened to you?’”

Whereas a key part of 12-step programs revolves around admitting faults and focusing on the ways a person has wronged others, Seven Challenges attempts to empower young people to see their substance abuse as a coping mechanism and to replace it with healthier lifestyle choices.

“If I tell you right off that you’re a bad person for using heroin, you’re just going to feel shame. Shame does not get anybody anywhere,” Saxton-Moody said. “We know that most of these kids come with a huge amount of baggage. Most of them have been abused.”

The goal of Seven Challenges is to help adolescents make the decision of sobriety themselves.

“Traditional approaches to working with adolescents with drug problems have produced high drop out rates and disappointing outcomes,” the program’s overview states. “The mad rush to get youth to immediately say ‘I will quit’ often leads to either increased defiance or increased dishonesty, with young people telling adults what they ‘want to hear.’”

Herndon, the doctor in Anchorage, said it’s not always realistic to expect 100 percent alcohol abstinence during treatment.

“The old philosophic model was treatment was only effective if you were able 100 percent of the time to maintain abstinence,” Herndon said. “That’s something that’s evolved. I still think that’s a good ideal, but it may not be true for everybody.”

The youth facility in Fairbanksstill uses 12-step programs, the success of which have been backed up by several well-regarded studies looking into adolescent alcohol treatment. But the 12-step program is now tempered with the use of Seven Challenges.

For some adolescents, one program may work better than the other. According to Herndon, while the 12-step program has been proven to be exceptionally successful for many people, some people don’t take to the method.

“The more options you can have … if one approach isn’t effective or it’s met with resistance, if you can switch them into something else you can find a better fit sometimes,” Herndon said.

Seven Challenges’ success in Alaska’s youth correctional facilities has yet to produce measurable results since the program just debuted this year, but Saxton-Moody said she has already noticed an anecdotal difference in her own work with kids.

“That is much more effective than the whole kind of old school … you need to get clean, you need to do what you need to do, this is all your fault,” she said.

While the Department of Juvenile Justice plays a significant role in public health, the majority of young people with substance abuse disorders will never end up in a correctional facility.

Roughly one-third of people experiencing mental illness are also dealing with substance abuse, and about half of all people experiencing a serious mental illness are also dealing with substance abuse, according to the National Alliance on Mental Illness.

This realization has led to a shift in the way providers think about treatment.

A decade ago when Saxton-Moody began working as a clinician, the standard method of behavioral health treatment was to focus on mental health and substance abuse separately. Once one area had been taken care of, you could move on to the other.

“When I first got into the field, it was you’ve got to deal with addiction first and then we can go worry about this, which is ridiculous,” she said. “We know better now. We have to treat them concurrently.”

Gunnar Ebbesson, the clinical director of Turning Point Counseling Services in Fairbanks, agrees that treating just one of multiple problems is a self-defeating, Sisyphean endeavor.

“They let these kids go home and their substance abuse disorder problems aren’t addressed,” Ebbesson said.

A study published in 1999 in the Journal of Family Practice found that, at the time, about 30 percent of physicians surveyed treated patients with depression and substance abuse disorders in partnership with a mental health provider. Even then, the treatment “seldom included joint treatment planning,” according to the study, leading its authors to conclude that “if concurrent treatments are to become more collaborative — with regular contact and effective communication, co-location of practices appears important.”

During the last decade, concurrent treatment of mental health and substance abuse disorders has become increasingly common, but in many cases resources have yet to fully catch up. In Fairbanks, for instance, Turning Point is the only dual-diagnosis outpatient program, according to Ebbesson.

Family Centered Services offers a dual-diagnosis residential program in Fairbanks, according to Marjorie Risner, the organization’s Substance Abuse Program Director. Beyond those programs, though, there isn’t much by way of concurrent treatment.

“Unfortunately, there’s still a big divide between agencies that will treat both,” Risner said.

In many cases, programs will treat a patient’s substance abuse disorder but refer the patient to a different agency for mental health services. A 1995 study performed by researchers at Brown University found that locating both a patient’s behavioral health and substance abuse counselors in the same facility was linked to better outcomes than when patients were referred to another facility for one or the other.

In rural communities, the options are even more limited or in some cases non-existent. A young person living in one of the larger rural communities, such as Barrow or Bethel or Nome, may have access to treatment options similar to those in Fairbanks. Options for adolescents living in a smaller community quickly reduce to one: leave for the city.

For young people especially, leaving their home, school and family and heading to an unknown city can make for a difficult transition.

“It’s a huge problem because people get referred out to different treatment programs in the Lower 48 or around Alaska,” Ebbesson said, “and then they come back to their community and there’s no resources at all, and their transfer success is just so limited.”

In the last couple years, one rural community in particular has been working to address this shortage, with little to no resources. In the Interior village of Tanana, Cynthia Erickson has attempted to rally the youth of the community.

In a village with 200 people, there’s no such thing as Alcoholics Anonymous — or anything anonymous. Through the Tanana group, Erickson has essentially created a group environment where the teenagers in Tanana can express their concerns about the things that have happened around and to them.

“I just don’t understand why we’re pussyfooting around the issues; 6-, 7-, 8-year-olds can tell you (what’s going on),” Erickson said.

Many of the primary methods of treatment for adolescent substance abuse and mental health disorders revolve around the use of group therapy. And while it may not be financially feasible to put clinicians in every rural Alaska community, it may be possible to create effective group therapy curricula that can be replicated by small towns.

This year, Erickson created a nonprofit organization called My Grandma’s House, through which she hopes to begin applying for grants. With My Grandma’s House, Erickson hopes to spread education about issues like suicide and alcohol misuse to adolescents all over Alaska, while also providing peer support for young people in rural communities like Tanana.

Since bursting onto the state scene at 2014’s Elders and Youth Conference, her group of kids has traveled all over the state, speaking with adults and kids alike.

For those with alcohol use disorders, peer support can be as important in treatment as any other concurrent methods, according to Herndon.

“Peer support means so much to an adolescent,” Herndon said. “That type of support for each other is just as important in my opinion as the bonds they form with their own counselor.

Reporting for the Daily News-Miner’s expanded coverage of efforts to reduce alcohol misuse in Alaska is supported financially by the Recover Alaska Media Project fund at the Alaska Community Foundation. Contributors to the fund are the Alaska Mental Health Trust Authority, Mat-Su Health Foundation, Southcentral Foundation, Rasmuson Foundation, Providence Health & Services Alaska, and Doyon, Limited. The News-Miner has sole responsibility for the selection and execution of the stories produced for this project.

Contact staff writer Weston Morrow at 459-7520. Follow him on Twitter: @FDNMschools.

Originally published March 30, 2016 by Weston Morrow in Fairbanks Daily News-Miner.