A systems approach to substance abuse identification and intervention for school counselors.
He worked with a 15-year-old male, Anthony, who was having academic and behavioral difficulties at school, but whose aptitudes were high in all academic areas. Anthony had a history of erratic mood swings; teachers would report that he was a nice and polite young man one day but then would tell them to "go to hell" the next day. After further interactions, a complicated family history of substance abuse and discord emerged. As he built rapport with Anthony, the counselor gained a better understanding of his personal history of alcohol and drug misuse or abuse. Anthony's drugs of choice were alcohol and marijuana, with occasional use of hallucinogens and cocaine. A meeting with Anthony and both of his parents was arranged, and Anthony's problems and possible interventions outside of the school system were discussed. During this meeting the complexity of the situation became more apparent.
This new perspective of the intricacy of this young person's problem revealed that his issues were not only intrapersonal but also interpersonal. The school counselor felt unprepared by his education to assist this young man and his family concerning substance abuse and a systems perspective. The purpose of this article is to provide school counselors a systems perspective of substance abuse. The following four topics will be addressed: (a) identification of the symptomatology of adolescent substance abuse, (b) a systemic perspective on adolescent substance abuse, (c) the role of the family in the perpetuation and healing of this dysfunction, and (d) the role of the school counselor in working with adolescent substance abuse issues from a systems perspective.
The Complexity of Substance Abuse and the Challenge of Counseling Adolescents
Substance abuse problems are serious, often recurring, complex, biopsychosocial disorders that generate systems problems at many levels, from the cell and organ, to family, to schools, to workplaces, and to society at large (Alexander & Gwyther, 1995). Data collected in 1997 suggested that substance use among 12- to 17-year-old adolescents rose to 11.4%, while increasing from 2.2% to 3.8% in young persons between the ages of 12 and 13 (Substance Abuse and Mental Health Services Administration, 1999). The onset of substance use is occurring at younger ages. This results in increased numbers of adolescents entering treatment for substance abuse with greater social and emotional developmental deficits (Fisher & Harrison, 2000). In addition, many adult alcoholics begin abusing substances in adolescence (Robins & Price, 1991).
Adolescents can be challenging to work with in a therapeutic relationship, amplifying the problem for helping professionals. Some studies have maintained that adolescents are the most challenging of clients to work with in counseling (Church, 1994; Hanna, Hanna, & Keys, 1999). Adolescents may be reluctant to engage in a helping relationship with adults and often are poorly motivated for change (Rutter & Rutter, 1993; Sommers-Flanagan & Sommers-Flanagan, 1995). An adolescent's resistance to counseling may be a part of his or her normal developmental process of autonomy and a reaction to a directive and confrontational therapist (Miller & Rollnick, 1991). As Church (1994) stated, "because of their desire for autonomy, adolescents may be very sensitive to situations where they believe others are asserting their power or authority" (p. 105). Counselors need to have a clear conceptual understanding of adolescence and developmental theory in order to establish and maintain a therapeutic relationship.
All counselors encounter clients with presenting or related problems of substance abuse (Fisher & Harrison, 2000; Sales, 1999). However, many school counselors receive no specific preparation in the area of substance abuse in their graduate programs. In the field of counselor education, few programs offer course work in the specific area of substance abuse (Lenhardt, 1994). The Council for Accreditation of Counseling and Related Educational Programs (CACREP 1994) standards for curriculum and clinical training do not specify course work in substance abuse or family systems in school counseling curricula (Sales, 1999). However, such preparation is necessary for school counselors to assist young people at risk (Hershenson & Strein, 1991; Lenhardt, 1994; Lewis & Lewis, 1981).
Contributing to the problem of lack of education and instruction in the identification of substance abuse for school counselors is the reality that counselor-student ratios are a factor that limits the amount of time that counselors have to address these issues (Stickel, 1991). Olsen and Dilley (1988) confirmed that there is considerable evidence to support the contention that school counselors cannot meet all of the demands placed on them. Other studies have also found that school counselors are concerned about being required to perform increasingly nonprofessional duties in a limited amount of time (Burnham & Jackson, 2000; Hutchinson, Barrick, & Grove, 1986; Stickel, 1991).
Identification of Adolescent Substance Abuse
For the purposes of this article, the term adolescent substance abuse will be used to encompass substance abuse, dependence, and addiction. The symptomatology of adolescent substance abuse is varied, and the assessment criteria are subjective (Doweiko, 1999). Research suggests that some counselors are unsure of the symptoms of adolescent drug abuse; therefore, they rely on the same diagnostic signs used with adult substance abusers (Bukstein, 1995; Greenbaum, Foster-Johnson, & Petrilia, 1996). Owen and Nyberg (1983) surveyed more than 70 adolescent chemical dependency programs and found that current assessment practices are often based on adult models of addiction and substance abuse with great variability from facility to facility. Substance abuse is viewed ambivalently in society; thus, parents and helping professionals may have difficulty differentiating nonproblematic from problematic substance use (Nunes & Parson, 1995).
Drug use may have different meanings for adolescents at different stages of psychological development (Schaefer, 1999). Specific risk taking or exploratory substance use may be extreme in early adolescence, when social interaction and biological drive interact as teenagers strive for competence in unfamiliar domains. Unlike older substance abusers, the adolescent will not have had time to "hit bottom" and may have a rather egocentric view of life (Doweiko, 1999). Complicating this process further, stereotypical descriptors of adolescents such as moodiness, narcissism, and social and interpersonal problems are similar to substance abuse symptomatology.
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000), substance abuse refers to
a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: (1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home ... (2) recurrent substance use in situations in which it is physically hazardous ... (3) recurrent substance-related legal problems ... (4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. (p. 199)
Research has been conducted by Martin, Kaczynski, Maisto, Bukstein, and Moss (1995) in which they concluded that the current DSM-IV-TR symptoms are too broad to address adolescent substance abuse. Other researchers have developed specific symptomatology for adolescent substance abuse. Nunes and Parson (1995) presented characteristics that may indicate adolescent substance use and possible abuse. Risk attributes, if unopposed by protective factors, that predict or precipitate substance abuse included: (a) poor parent-child relationship; (b) psychiatric disorders, especially depression; (c) a tendency to seek novel experiences or take risks; (d) family members and peers who use substances; (e) low academic motivation; (f) absence of religion/religiosity; (g) early cigarette use; (h) low self-esteem; (i) being raised in a single-parent or blended family; and (j) engaging in health-compromising behaviors. Adolescents who concurrently possess five or more of these qualities are at extremely high risk for substance use problems.
Other researchers have contributed other variables that may be specific to adolescent substance abuse. Martin et al. (1995) concluded that alcohol-related black-outs, craving, and risky sexual behavior are common among adolescents with alcohol abuse issues. The Johnson Institute Community Project (1985) identified six characteristics as indicators of adolescent drug abuse: (a) the use of chemicals to get "smashed"; (b) going to parties where drugs other than alcohol are in use; (c) refusing to attend parties where drugs are not present; (d) drinking liquor, as opposed to beer and wine; (e) using marijuana; and (f) being drunk at school. Within the context of the school environment, deterioration in academic performance, increased absenteeism and truancy, fighting, verbal abuse, defiance, or withdrawal are visible indicators (Fisher & Harrison, 2000). Additionally, adolescents who have substance abuse problems are likely to be enrolled in school but encountering school behavior problems such as being sent to the principal and skipping classes (Zarek, Hawkins, & Rogers, 1987).
School counselors need to be able to recognize the warning signs of adolescent substance abuse. Identification leading to interventions has been found successful at early stages of substance use, before the adolescent becomes more emotionally involved with his or her drug of choice (Palmer & Paisley, 1991). School counselors may have the opportunity to identify and intervene with the young person and his or her family before the substance abuse becomes more severe.
A Systems Perspective of Adolescent Substance Abuse
People do not exist in isolation; they are a part of larger systems. Systems thinking is a way of conceptualizing a problem that uses circular reasoning to evaluate interaction patterns within a system and between systems (Doerries & Foster, in press; Sontag, 1996). Systems theory postulates that people in the family unit play a part in the way family members function in relation to each other and in the surfacing of problem behavior (Bowen, 1974). A systems view allows for a new and expanded definition of intervention, moving away from the individual as the sole form of treatment and supporting the adoption of a proactive, positive stance while promoting growth-producing behavior in families and related systems. Within this conceptualization, substance abuse is viewed as maladaptive behaviors expressed by a family member(s), and is an indication of the dysfunction of the entire system (Stanton, Todd, & Associates, 1982). Therefore, to gain a comprehensive understanding of a dysfunction, it is important for a school counselor to consider the whole family system and its relationships to other larger external systems such as the school, the workplace, and legal systems.
The systems perspective views substance abuse as potentially serving a function within the family. The adolescent abusing drugs may be seen as the symptom bearer for an unbalanced family system. Haley (1980) suggested that the substance abusing family has become "stuck" at one stage of development in the normal family life cycle; therefore, the problem lies not within the teen drug abuser but rather in the failure of the family system to successfully negotiate the stage requiring mutual disengagement of parent and young person. The adolescent drug abuser serves as a focus of attention for the family to preserve family stability by detouring conflict away from other subsystems (Anderson & Henry, 1994; Levine, 1985). For example, the youth's problematic behavior can draw the family members together to focus on the substance abuse, directing attention away from other family problems such as marital conflict. This dysfunctional coping style may be passed from generation to generation through interaction patterns (Kaufman & Kaufman, 1979, Kerr & Bowen, 1988) and genetics (Doweiko, 1999). Therefore, a family system with similar characteristics and patterns that includes a substance-abusing member may have been evident in previous generations.
Genetics and the family environment, structure, and processes are the primary sources for human development. Parents influence their children's behavior by modeling actions, by defining norms, by controlling the youngster's vulnerability to the influences of others, and by providing positive attachment (Kandel & Andrews, 1987). Family factors such as degree of parental nurturance and support, parent-child communications, and parental relationships have been found repeatedly to have a relationship to adolescent substance abuse (Glynn & Haenlein, 1988; Piercy & Frankl, 1989; Piercy; Volk, Trepper, Sprenkle, & Lewis, 1991; Stanton et al., 1982).
Specific variables of family patterns and interactions have also been identified as influences on adolescent substance abuse. Parental substance abuse has been positively related to adolescent substance use, while family bonding and parental support appears negatively related to misuse and abuse (Piercy et al., 1991). Parental support in the form of acceptance, warmth, and personal value is consistently linked to positive development in youth and negatively related to substance abuse (Anderson & Henry, 1994; Piercy et al., 1991). Families of adolescent substance abusers tend to be rigid and have difficulty adapting to change (Bartle & Sabatelli, 1989; Levine, 1985). A relationship between low bonding to family and problematic alcohol and substance use among adolescents supports Bowlby's Attachment Theory (Hawkins, Catalano, & Miller, 1992). Other research has indicated that the parental subsystem of adolescent substance abusing families is more controlling, provides little opportunity for independence and expressiveness, promotes a high degree of conflict in the family, and produces a low degree of cohesion and closeness in the family (Baumrind, 1991; Friedman & Utada, 1992). Based on this research, adolescent substance abuse appears to have a strong relationship to family structure and interpersonal relationships within the family. It is therefore important for school counselors to consider potential adolescent substance abuse from a systems perspective.
Systems theory postulates that a change in the function of an individual is followed by compensatory change in other family members (Bowen, 1974; Goldenberg & Goldenberg, 2000). Based on this theoretical premise, an adolescent substance abuser has an influence on every member of the family system. An example of this is the "family secret" of an abusing family, which in time becomes the dominating force around which the family's rules and rituals are centered (Brown, 1985). Preservation of this unhealthy system supersedes the healthy development of any individuals within this system and can cause developmental retardation of the family members (Brown & Lewis, 1999).
Intervening with the adolescent who is abusing substances addresses only one piece of the powerful influence of this systemic dysfunction and misses the needs of the overall system. It is important for school counselors to understand the principles of systems perspective when addressing adolescent substance abuse. The perspective allows for an expanded view of identification and intervention. In addition to considering a systems perspective, there are a number of ways in which a school counselor can assist an adolescent with substance abuse issues. The next section identifies specific strategies school counselors can employ to support change.
The School Counselor's Role in Supporting Change
School counselors can be the first line of defense in detecting student troubles that may require specialized treatment not offered in the school setting (Ponec, Poggi, & Dickel, 1998; Ritchie & Partin, 1994; Whiteside, 1993). School counselors have four functions within a systemic perspective for working with students with possible substance abuse issues. The four tasks are:
* Identify the possible warning signs of student substance abuse
* Work with the young person to establish a therapeutic relationship
* Support the family system to promote change
* Be a resource and liaison between the student, the family, the school, and community agencies and treatment programs
School counselors are well positioned to assist in substance abuse prevention and intervention efforts because of their continual work with students and school personnel (Hayes, 1997; McClanahan et al., 1998; Thomas & Texidor, 1987). School counselors are visible and accessible to young people. One survey conducted in North Carolina with 7th through 12th grade students indicated that the students were most likely to talk with a school counselor or teacher about their drug or alcohol problems (Alcohol and Drug Defense Program, 1987). The adolescent's first interaction with an adult about his or her possible problem may be with the school counselor (Sales, 1999). The school counselor's contact with the adolescent's teachers, peers, parents, and coaches, and the young person can facilitate the identification of the warning signs of substance abuse. This close proximity can also facilitate early intervention. An example would be discovering incongruences and changes in a student's behaviors and moods. This may come in the form of a drop in grades, increased absences, and comments by teachers and other school personnel about changes in the young person. These are all indicators that some change is occurring with the student and that further exploration is needed. It is therefore vitally important that school counselors are familiar with the early warning signs and symptoms of substance abuse.
School counselors are also in the unique position of being able to follow a young person over the course of several years. In substance abuse intervention, treatment, and follow-up, it is important to establish a relationship in order to provide ongoing support. Despite the dilemmas posed by lack of time, other responsibilities, high caseloads, and innumerable demands, if a school counselor is committed to counseling, then he or she can maintain a foundation of support and a linkage between the adolescent and the systems in which he or she functions. Carl Rogers' (1995) conditions of unconditional positive regard and empathic understanding can support future work with the young person within the systemic contexts of the individual, the family, the school, and possible community agencies. If a therapeutic relationship is not established, the counselor's likelihood of encountering future resistance in interactions and/or interventions is increased (Miller & Rollnick, 1991; Miller, Zweben, DiClemente, & Rychtarik, 1995; Sommers-Flanagan & Sommers-Flanagan, 1997).
School counselors are in a position to support families and to encourage parents to become more involved in their son's or daughter's school lives. Studies have linked a relationship between low parental involvement in the schools and students' poor academic achievement and at-risk behaviors (Dornbusch, Ritter, & Liederman, 1987; McLaughlin & Vacha, 1992). Parents need increased contact with the school and with other parents to expand their understanding of how the school system works, what the school is trying to accomplish, and what resources are available to them to assist their child and themselves through the school system and community (McLaughlin & Vacha, 1993; Simons & Robertson, 1989). School counselors are able to provide this connection for parents through parent education classes in substance abuse prevention and the identification of signs and symptoms of substance abuse. School counselors can also facilitate early intervention with families of students who exhibit early warning signs of substance abuse. Another connection for school counselors is to provide crisis intervention and referrals. Some approaches that provide this connection include providing parent education classes at the school where the school counselor is engaged, offering parent-child-teacher-school counselor conferences during hours that match parents' work schedules, school counselors being visible and available at after-school activities, and coordination of other activities designed to increase parental involvement.
It is especially important for the school counselor consider the family system when considering the early identification of substance abuse. Consulting the parents about behavior in systems outside the school setting can provide valuable information. Inviting the parents for a consultation also enables the school counselor to observe some of the interactions within the family system, alerting him or her to some of the signs and symptoms mentioned.
School counselors are also in a unique position to bridge the gap between families, community institutions and programs, the school, and students by functioning both as a resource and liaison (McLaughlin & Vacha, 1993). The most central individual to initiate student referral is the school counselor (Mulherm, 1995; Ritchie & Partin, 1994; Whiteside, 1993). Research has indicated positive outcomes from a collaborative relationship between school counselors and community agencies (Hobbs & Collison, 1995). To establish this collaborative relationship, communication between institutions is paramount. School counselors need to understand the community agencies' goals, objectives, and limitations. An approach that can facilitate this understanding and interaction is for school counselors to make a personal visit to the community agency to meet staff and develop collaborative working relationships. It is also helpful for the community agency personnel to visit the schools and meet with administrators, counselors, and faculty where they can discuss their agency's goals and processes (Ponec et al., 1998).
School counselors also can serve as the liaisons between the school, the outside agency, and the family. Parents often blind themselves to their children's markedly altered behavior; therefore, counselors need to approach the possibility in a nonconfrontational manner, without blaming the parents. One method of managing this difficult interaction is to emphasize the positive. Reframing or relabeling the adolescent's behavior in a positive fashion may make the uncomfortable topic of substance abuse less threatening for the parents to hear (Haley, 1976). The focus needs to be on facilitating future change, rather than on past behaviors or experiences. The systemic perspective can assist the school counselor in understanding the complexity of the student's substance abuse and his or her work with the family to get them the necessary support they may need to change the family's current homeostasis.
Liaison services can also be paramount when a student returns to school following substance abuse treatment. The school counselor can be integral in providing continuing liaison services between the treatment program, aftercare services, the family, the school, and other professionals and systems that may be involved (e.g., the courts and legal system).
School counselors are in a unique position to intervene early in adolescent substance abuse. However, school counselors need to understand the scope of the problems of the adolescent. An adolescent's substance abuse difficulties are not his or hers alone; they are a part of and a product of a larger system that continuously plays a role in his or her development and maintenance. Therefore, treating the individual addresses only one piece of the powerful influence of this systemic dysfunction, and can miss the overall extent of the problem.
As the first author continued to meet with Anthony, he learned that Anthony's parents were divorced, and he lived with his mother and visited his father every other weekend. His mother appeared to be emotionally over-attached to Anthony, while his father seemed disconnected from his son. The father had a history of alcohol abuse, as reported by Anthony and his mother. Anthony spoke of fishing as a favorite activity with his father, and also related how his father would sit on the boat and get drunk every time they were together. The situation became more and more complex. The school counselor found that he could not focus on Anthony alone; he could not provide family counseling in the school setting. He could not change Anthony, but needed to expand the system and find resources to support Anthony and his family. Anthony taught him to look at substance abuse from a broader systemic perspective.
This systems perspective on adolescent substance abuse offered a broader understanding of a complex situation. School counselors need to recognize that many forces interact in the young person's alcohol or drug abuse and that multiple interventions may be necessary to facilitate change. According to Bowen (1974), "family systems therapy offers no magic solution for the total problem, but the theory does provide a different way to conceptualize the problem" (p. 120). It is important that school counselors understand both substance abuse and a conceptualization of family systems to best assist their students. As a result of this understanding, school counselors are prepared to support the family system to change and to be liaisons between the student, the family, the school, and community agencies and systems.
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Glenn W. Lambie, Ph.D., NCC, NCSC, is an assistant professor in the Department of Human Development and Psychological Counseling at Appalachian State University, Boone, NC. E-mail: spider@ widowmaker.com
Laurie J. Rokutani is prevention director, School of Psychology and Counselor Education, The College of William and Mary, Williamsburg, VA.