Gonzales, R., Anglin, M., Beattie, R., Ong, C., & Glik, D. C. (2012). Understanding recovery barriers: Youth perceptions about substance use relapse. American Journal Of Health Behavior, 36(5), 60

Douglas Anglin, Professor in Residence, Associ- ate Director; Rebecca Beattie, Staff Research As- sociate; Chris Angelo Ong, Staff Research Asso- ciate, Integrated Substance Abuse Programs, Uni- versity of California, Los Angeles, CA, Semel In- stitute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA. Deborah C. Glik, Professor, School of Public Health, University of California, Los Angeles, CA.

Contact Dr Gonzales; [email protected] Objective: To qualitatively explore how treatment-involved youth ret- rospectively contextualize relapse from substance use. Methods: Four- teen focus groups were conducted with 118 youth (78.3% male; 66.1% Latino) enrolled in participating substance abuse treatment pro- grams (4 young adult and 10 ado- lescent) throughout Los Angeles County. Transcripts were analyzed for relapse perception themes. Re- sults: Dominant relapse themes include emotional reasons (90%),life stressors (85%), cognitive fac- tors (75%), socialization processes (65%), and environmental issues (55%). Conclusions: Youth percep- tions about relapse during treat- ment should be used to better in- form clinical approaches and shape early-intervention recovery agen- das for substance-abusing youth.

Key words: substance abuse treatment, relapse, youth percep- tions, adolescents, young adults Am J Health Behav. 2012;36(5):602-614 DOI: http://dx.doi.org/10.5993/AJHB.36.5.3 S ubstance use problems among youth under 25 represent one of the major prevention and treatment issues in the United States: nearly 70% of all youth mortality (ages 15-24) has been attrib- uted to unintended injuries, homicide, and suicide, 1 all of which are highly corre- lated with substance use behaviors. 2,3 Moreover, statistics from general popula- tion US-based prevalence surveys, na- tional treatment admission data, and ju- venile justice drug offense cases supportthe extent of problem. National (US) sur- vey studies show that illicit substance use and binge drinking trends for youth are up from previous years: 10.0% of 12- to 17-year-olds and 21.2% of 18- to 25- year- olds report past-month use of illicit sub- stances, and past-month binge drinking rates were 8.8% and 41.7% for 12- to 17- and 18-to-25-year-olds, respectively. 4 Publicly funded treatment admissions are also high: 7.6% of admissions are under 18 and increase to 21.6% for those 18 to 25. 5 Substance use-related juvenile/ criminal court cases are common as well:

44.2% of all cases ages 10-24 were for drug offenses, 15.1% for juveniles 10-17 years of age. 6 Given such public health complexities, much of the attention regarding address- ing substance use issues among youth has been directed at interrupting drug use through treatment settings, where the main goals are to “effectively reduce substance use behaviors and improve critical areas of life functioning that are expected to be positively influenced by Gonzales et al Am J Health Behav.

™ ™™ ™ ™ 2012;36(5):602-614DOI: http://dx.doi.org/10.5993/AJHB.36.5.3 603 treatment.” 7 Large-scale treatment out- come studies with youth demonstrate that treatment (in general) produces posi- tive changes in substance use and other psychosocial outcomes; 8-11 however, treat- ment benefits tend to diminish over time. 12 Substance use “relapse” is of primary concern, which is typically about 65% in the first 90 days after treatment and increases to rates of about 85% during the post-year follow-up period. 11,13-20 Relapse has been contextualized both as a “discrete outcome” or “a process.” 21 Definitions of relapse also differ and typi- cally have been either operationalized as “a return to any use” or “a return to original problematic use” before treat- ment. 22,23 There have been several at- tempts to establish specific conceptual models for relapse among adult popula- tions. 23-33 To date, conceptual models tend to cat- egorize relapse using 4 major precur- sors/antecedents, 34,35 including the spe- cific drug (agent), characteristics of the user (personal), characteristics of the user’s social relationships/setting (in- terpersonal), and environmental (situ- ational) factors. Relapse precursors that have received the most support include negative affective emotional states, 34,36,37 cognitive-behavioral factors including self- efficacy/confidence, 38 outcome expectan- cies, 39 urges/temptations, 40 coping, 41,42 and motivation/readiness to change. 34,44,45 Interpersonal determinants include relationship conflict, 46-48 social pres- sures, 49 social support, and life stres- sors. 50-53 Environmental determinants include cue-situational exposures and geographic disadvantage, ie, high avail- ability of drugs, crime and poverty. 27,54-57 Despite these findings, many studies conclude that relapse is often random, complex, and dynamic, 58-60 determined by an interaction of diverse physiological, individual, and situational factors, 32,61 and cannot be solely captured by a single process model. 62 Research on substance use relapse among youth is less extensive. Existing youth-based studies have identified simi- lar relapse determinants as are found among adult samples 63-66 ; however, it is considered to be particularly more com- plex for several reasons: adolescents are still undergoing brain maturation and are in the midst of greater cognitive and social-emotional development pro-cesses; 67-69 have higher co-occurring men- tal health and psychosocial dysfunctions within family, school, and legal settings; 70- 73 have greater influence from social agents/events; 74-76 have different clinical courses of substance use severity/diag- nosis 77-80 and lower levels of treatment motivation. 80,81 Although the literature is growing in the area of substance use relapse among youth populations, retrospective accounts of the relapse process are limited, and many substantive questions remain. This study employed a qualitative approach to examine the following research ques- tions: (1) How do youth in treatment per- ceive their risk for substance use after treatment? (2) What are some major fac- tors that are associated with relapse risk among treatment-involved youth? This study seeks to address these questions to identify some of the early warning signals indicating potential relapse for youth 24 years and younger to better inform clini- cal approaches to better meet the needs of substance-abusing youth as well as shape early-intervention recovery agendas.

METHODS A convenience sample of youth aged 12-24 was drawn from participating sub- stance abuse treatment programs (10 adolescent specific and 4 adult) in diverse Los Angeles areas (San Gabriel Valley, North Hollywood, West Los Angeles, San Fernando Valley, and Antelope Valley).

Unlike the adolescent-specific programs used, this sample does not include young adult-specific programs, but rather a se- lect set of participating adult programs that had designated young adult groups to capture youth 18-24. Hence, due to the participating treatment sites availability of young adults, there are fewer young adults groups available. Research proce- dures were approved by the Institutional Review Board of the University of Califor- nia Los Angeles.

Participants One-hundred eighteen youth between 12 and 24 constitute the study sample:

average age was 17.4 + 2.9 years; 78.3% male; 66.1% Latino and 25.2% white (25.2%); 69.5% were in outpatient treat- ment; and most reported marijuana (40.9%) or methamphetamine (30.4%) as their primary substances of abuse. Sample characteristics are representative of Understanding Recovery Barriers 604 youth based on wide-scale California treat- ment evalautions: average age of youth admissions is 17, 68% male, and 59% Latino. 84 Procedure A total of 14 focus groups were con- ducted with 118 youth in participating substance abuse treatment programs between September 2010 and December 2010. Focus groups were 90 minutes in length and digitally audio-recorded. Each participant received a $10 gift card for incentive. The principal investigator (PI) moderated each group using scripted ques- tions. 34 A research assistant (RA) trained in focus group procedures assisted with moderating the focus groups.

The scripted questions covered youth perceptions and attitudes around sub- stance use behaviors, substance use re- lapse, and substance use recovery. The focus group leader (PI) used a standard- ized script to discuss the relapse concept and provide a common level of under- standing of relapse. For this, participants were asked to think about life after treat- ment and consider the most common situations or reasons that caused them to relapse (defined as both (1) using any alcohol or drugs again and (2) reverting back to their pretreatment pattern of drug use). Using the following scenario: “Jane/ John went through treatment for sub- stance use problems. After treatment (within the next 3 months), he/she re- lapsed. Finish my statement: ‘He/she relapsed because…?’ ” After general re- sponses to the relapse scenario were noted (ie, stress), specific reasons related to each response were assessed (ie, fam-ily, school, legal, etc). In addition to par- ticipating in the focus group discussion, all participants anonymously completed a demographic questionnaire collecting age, gender, race/ethnicity, primary sub- stances used, and treatment history in- formation for descriptive purposes.

Data Analysis Audio recordings for 14 focus groups were transcribed by 2 research assistants and edited and re-reviewed by the research team for accuracy and fidelity. Transcripts were coded using a systematic set of proce- dures based on grounded theory 84 to induc- tively develop themes around relapse per- ceptions among youth. To ensure com- pleteness and accuracy, 2 reviewers coded each transcript, and a third coder was used to resolve any discrepant coding by a con- sensus approach with the research team. 85 Using ATLAS.Ti, a qualitative statistical software program for content and text analy- sis, 86 focus group responses from all youth participants (N=118; 92 adolescents and 24 young adults) were assessed to obtain overall percentages for each theme identi- fied and unique responses per theme by age-group. Responses to the brief demo- graphic questionnaire were quantitatively analyzed using SPSS, version 18; however, Table 1 General Themes of Substance Use Relapse Among Youth 12-24 (N=118) % Overall Group Response Emotional Reasons90% Life Stressors85% Cognitive Factors75% Socialization Processes65% Environmental Issues55% Table 2 Combined Qualitative Youth (12-24) Statements of “Emotional Reasons” “To cope or take the edge off of problems” “To feel better about all the drama in our life” “To cope with negative feelings, anger, sadness, loneliness, guilt, fear, pain, and anxiety” “To escape or just to get away from reality” “They don’t want to face their fears” “They know there is a better feeling than being sober where life sucks” “Because it helps you break those internal barriers” Gonzales et al Am J Health Behav.

™ ™™ ™ ™ 2012;36(5):602-614DOI: http://dx.doi.org/10.5993/AJHB.36.5.3 605 because of the assured anonymity, demo- graphic questionnaire data could not be linked to focus group responses; hence, these results are presented descriptively.

Overall, themes reported in results are based on analysis of open-ended responses to focus group scripted questions. Where appropriate, focus group (age) differences (ie, adolescent versus young adult) are reported.

RESULTS Table 1 provides 5 major themes that emerged in response to qualitative youth responses to the relapse scenario “He/ She Relapsed Because…” This table is followed by examples of youth statements supporting each theme. It is important to note that some youth (from 10 adolescent focus groups, n=92) did not even know what relapse meant (10%). For these youth, they were asked to consider re- sponding to the questions based on the definitions of relapse used in the field [defined as (1) using any alcohol or drugs again or (2) reverting back to their pre- treatment pattern of drug use].

Emotional Reasons The dominant relapse theme for youth,including both adolescents (ages 12 through 17) and young adults (ages 18 through 24) was emotional reasons (90%), feeling unable to cope with negative emo- tions without drugs. Table 2 displays com- bined statements from youth supporting this theme.

Life Stressors The second theme identified was life stressors (85%) for both adolescent and young adults as supported by statements such as “To take the stress away,” “To get away from life stressors,” “Because life and everything that comes with it – sucks.” However, when questioned more deeply about the reasons for stress, responses greatly differed for adolescent and young adult participants worth noting. For ado- lescents (12-17), stress was referred to more so because of parents (criticizing, nagging, mistrust, conflict, put-downs, no faith/confidence in us, not being around), school (failing classes, getting in trouble), and peer pressure (fitting in); whereas older-aged youth (18-24) were more likely express stress in terms of realities of life that had to do with intimate relationships (commitment), financial responsibility (debt, employment issues) and housing Table 3 Qualitative Statements of Life Stressors by Youth Group Adolescents (12-17) “Still, after treatment, parents continue to just criticize us all the time and put us down…we’re no good, failures. They constantly complain and nag about how we do everything wrong. They don’t trust us, where we go, who we talk to. Basically they have no faith or confidence in us.” “School is hard, all the homework, tests, and class things you have to keep up with…it never ends.” “Relapsing has to do with the stress of hanging out with your friends and fitting in.” “Using starts as a social thing, and then after a while, it becomes all you do with your friends…You wouldn’t know what else to do.” Young Adults (18-24) “Well coming out of treatment you’re on a pink cloud, telling everyone you’re gonna do hella f’ing well….

And then life kicks in … just reality is a bitch… the stress is overwhelming and makes me, feel like stuck.

Cuz I’ve gotten myself in a hole and that makes me want to use you know.” “Relapse happens because relationships go bad, break-ups and being lonely, sex becomes an issue, or just commitment issues.” “Drugs and alcohol become an easy solution for fears about your financial and life stressors…having a job or a place to live.” Understanding Recovery Barriers 606 stress (rent and bills). Table 3 displays statements from both youth groups sup- porting this theme.

Cognitive Factors The third theme in response to “He/ She Relapsed Because…” was cognitive (75%), with the dominant reasons for both adolescents and young adults alike being poor motivation, craving/urges, and low confidence. Table 4 displays combined statements from youth supporting this theme.

Socialization Processes The fourth theme had to do with social- ization processes (65%); however, re- sponses regarding the type of social pro- cesses differed between adolescents and young adults. Specifically, adolescents were more likely to note peer pressure and media influence whereas young adults discussed issues related to social net- works and social norms. Table 5 displaysstatements from both youth groups sup- porting this theme.

Environmental Issues The final theme identified among both youth groups was environmental issues (55%), which included responses about access/availability and cues/triggers (55%). Table 6 displays statements from both youth groups supporting this theme.

Discussion Considering the relapse ecology of youth, our data highlight 5 major reasons for youth relapse: negative emotions, stress, cognitive factors, socialization pro- cesses, and environmental issues. Al- though this study contributes a qualita- tive assessment of the relapse process among treatment-involved youth, there is still significant complexity in under- standing the developmental pathways to relapse.

As supported by our results, such path- ways are best conceptualized as multifac- Table 4 Combined Qualitative Youth (12-24) Statements of Cognitive Factors Poor Motivation “They weren’t ready or willing to do what it takes to stay clean.” “There are some who choose to be here, but most are here because of parents or court-ordered, so they’re gonna relapse because they have to want to stop on their own” “Because motivation is the biggest issue for most of us – and it’s not there…everything told to us in treatment just comes in one ear and out the other” “No more testing, they’re finally out of treatment” Cravings/Urges “Having positive feelings that make you want to celebrate - have a drink or use” “They had cravings because you are either in the presence of drugs or alcohol, drug or alcohol users, or at places where you used or bought drugs before” “Because that’s what typically happens after treatment – we all go back to craving or chasing that first high” Low Confidence (Self-efficacy) “Because they were scared to take on the challenge of quitting… they didn’t have the strength to not use again” “Not having confidence to manage their life on their own” Gonzales et al Am J Health Behav.

™ ™™ ™ ™ 2012;36(5):602-614DOI: http://dx.doi.org/10.5993/AJHB.36.5.3 607 Table 5 Qualitative Statements of Socialization Processes by Youth Group Adolescents (12-17) Peer Pressure “Because my friends are negative influences…they keep asking – you want to get high” “For me, it’s not really about the place or situation - like a party, but about the people there – friends have a strong influence on what we do – they can turn any place into a bad place” Media Influence “Because they saw it glorified on TV or heard about how fun it is on the radio, so it reminds them of how it feels and how it’s good, and how happy they will feel” “I think because of the media influence. All types, TV, radio, film, internet, video games show alcohol, cigarettes, marijuana, prescription pills, other drugs, in a positive light and make using/drinking normal.

So we start to believe it and think it’s normal part of life” Young Adults (12-24) Social Networks “They continued to want to party and connect with old drug use networks” Social Norms “Like seriously? Like if you’ve never tried pot. Like, I mean, you don’t have to be a black tar heroin user, but I mean it’s just what’s in our social culture and expected” “Because of the social standards or whatever you want to call them about using alcohol and drugs in our age group – young people just use a lot of drugs…and they think it’s normal and being sober is not normal” Table 6 Combined Qualitative Youth (12-24) Statements of Environmental Issues Access/Availability “We just have to walk down the street in our neighborhood…dope dealers and drugs are everywhere” “We just have to walk down the street in our neighborhood…dope dealers and drugs are everywhere” Cues/Triggers “Just triggers – the day-to-day things we hear, see, do,” “It’s always around – in your face…and when you see it or smell it you’re like damn, pass that - you might contemplate it little bit, but in the end, you just say, ok” torial, 87,88 which fall into 3 general theo- retical streams of influences: individual- level factors, socialization influences, and broader environmental influences. Spe- cifically, individual-level influences in- cluded negative emotions, stress, andcognitive factors; socialization influences included peer pressure, social network/ social norms, and media influence; and broader environmental influences in- cluded access/availability and cues/trig- gers, which merit separate discussions Understanding Recovery Barriers 608 for each. It is important to note that, as discussed in the introduction, these re- lapse determinants are fairly similar to relapse factors observed among adult samples; 63-66 however, such relapse pro- cesses have more emphasis around so- cial-emotional and environmental devel- opment processes, rather than personal clinical orientations around substance use severity.

Negative emotions. Research supports that the majority of youth with substance use problems also have one or more co- occurring problems such as depression, anxiety, traumatic stress, self-mutila- tion or suicidal thoughts, hyperactivity and conduct disorder, criminal or violent tendencies, etc. Prevailing beliefs under the psychoanalytic framework is that drug use is a symptom of an underlying psy- chological disorder. 89 Accordingly, sub- stance use is a secondary condition caused by underlying mental disturbances, known as the self-medication model, whereby individuals use drugs to self- medicate or relieve symptoms of psycho- logical distress. 90 Because relapse is likely to occur if these symptoms are not ad- equately addressed during treatment, a major goal of treatment programs is to include care and services (counseling interventions) that uncover and treat the underlying psychopathology feeding drug abuse behaviors.

91,92 Although treatment programs are working to effectively ad- dress such multiple problems simulta- neously (eg, standardized assessment for other problems and provision/coordina- tion of case management services), 16 ex- tending these efforts beyond formal treat- ment is not a common practice. 95 It is possible that the positive outcomes ob- served in treatment could be better sus- tained if posttreatment recovery mainte- nance services (ie, continuing care mod- els) included emotion regulation and cop- ing skills for dealing with negative emo- tions.

Stress. Stress has been well estab- lished as a significant risk factor for re- lapse. 96-101 We found developmental differ- ences in relapse-associated stress that support the conceptualization of stress “as a relationship between an individual and his/her environment.” 102 For adoles- cents, parental issues, peer pressure, and school problems were dominant stres- sors, whereas for young adults, stress was described more in terms of life circum-stances, emerging adult responsibilities, and interpersonal romantic relationships that coincide with their current develop- mental period: “gaining greater indepen- dence” and “leaving the parent nest or family environment.” 103 Many studies con- sistently show that parents, peers, and school serve as major socialization fac- tors in predicting the initiation, mainte- nance, and exacerbation of substance abuse in adolescents; and the stress- related findings specific to young adults are similar to what is typically found with older adults in treatment, which is linked to pretreatment problems of legal issues, relationships, job loss, and financial debt. 104,105 From a clinical and recovery support perspective, these results high- light the importance of integrating stress management efforts into programs rather than simply focusing on parental, school, or employment problems specifically as is done in most programs. 76,106,107 Cognitive factors. Three important cognitive factors warrant further consid- eration in terms of understanding re- lapse among youth: motivation, cravings/ urges, and confidence, ie, self-efficacy.

As other studies have found, relapse or continued use of alcohol and drugs, is related to the fact that few youth with substance use problems are motivated to be in treatment as they rarely express desires to quit or any strong commit- ments to maintain abstinence. 81,108,109 Fur- ther, most youth presenting for treat- ment are not self-referred. Instead, they are coerced by a parent, juvenile justice system official (judge, probation or parole officer), school official, child welfare worker, or representative of some other community institution. 8,10 These findings highlight the need for relapse prevention models in both clinical and recovery sup- port settings to take into account the extent to which youth are motivated or ready to change their substance use be- haviors. 44,110 Future research on youth relapse needs to consider the potential differences in perceptions among youth mandated to treatment versus youth vol- untarily in treatment. By ignoring moti- vation at treatment admission, assess- ments of outcomes become complicated and often limit interpretation of relapse prevention models.

Confidence (self-efficacy) was also cited as an important cognitive factor related to relapse as has been found in other stud- Gonzales et al Am J Health Behav.

™ ™™ ™ ™ 2012;36(5):602-614DOI: http://dx.doi.org/10.5993/AJHB.36.5.3 609 ies. 111 However, the confidence expressed by youth had more to do with one’s ability to abstain from drugs in the face of life stressors or internal/social cues/trig- gers, such as the stress of fitting in, rather than on peer pressure associated with being “forced” to use drugs. This result highlights the importance of inte- grating stress management skills (in ad- dition to peer resistance skills) into youth relapse-prevention models. Lastly, an interesting area of research worthy of further inquiry has to do with continued substance use after treatment that is not related to one’s primary drug of choice, particularly tobacco use. As others have noted, a major issue facing individuals in treatment (in general) is a drug-use re- covery environment that far too often facilitates tobacco use. 112 Socialization processes. All youth sup- port the view that relapse is a byproduct or function of socialization processes that influence developmental vulnerability for relapse. Although we observed differences in socialization processes between ado- lescent and young adults, the circum- stances and extent to which relapse oc- curs is largely regulated by peer/social norms, customs, traditions, and stan- dards. 113 In general, adolescents reported friendships and peer pressure along with media influence as important relapse triggers; whereas young adults tended to highlight social networks and social norms as dominant features of their so- cial surrounding that influenced relapse.

Numerous studies have established that peer-group and social norm processes are strong influencers of drug use behav- iors, 86,115,116 as they foster positive expect- ancies about drug use and create prosocial norms, and both serve to encourage drug use behavior. 117,118 It is important to point out that for most adolescents, cliques or friendship bonds are an important and a common feature during social/emotional development contributing to substance use risk behaviors.

114,115,120,121 However, as our data indicate, the peer/friendship clique might not be as important for young adults as they have “developed and ma- tured” over time into a web of social rela- tionships and social networks more asso- ciated with larger social processes oper- ating. 122 Moreover, although not as apparent for older youth, media depictions of drugs were noted as important determinants ofrelapse by many adolescents. Other re- search supports this view, such that the tobacco and alcohol industries alone spend billions of dollars each year aggressively marketing their products to adolescents through depicting images of glamour, success, and independence – all highly esteemed social values within American society. 123 Such marketing strategies have paid off as noted by several studies show- ing a positive impact on youth decisions to smoke or drink. 124,125 Overall, such so- cialization processes that youth experi- ence are complex issues that create ob- stacles for those attempting to develop a drug-free recovery lifestyle (ie, break free from peer pressure and extant social norms that promote and normalize sub- stance use).

Environmental issues. As reflected by our data, environmental factors of ac- cess/availability and cues/triggers also play a critical role in facilitating relapse for youth. According to most, drugs are readily available and accessible to them.

National survey data from Monitoring the Future highlight the importance of the positive relationship between perceived availability of drugs and trends in use among adolescent youth.

126 To date, most attention on relapse de- terminants has been directed at indi- vidual-level factors, promoting the view that the responsibility for one’s relapse ultimately falls on oneself and shifting attention away from larger environmen- tal forces that also may be influencing relapse behavior. However, such envi- ronmental influences on relapse are im- portant to consider as “the individual can- not be conceptualized as an autonomous actor making self-governing decisions in a social vacuum.” 129 For clinical and re- covery support programs to be effective, they must also address such structural influences.

Limitations The present study must be considered in light of its limitations. The accuracy of relapse descriptions or circumstances among this clinical sample must be ques- tioned as they are retrospectively provid- ing aggregate perceptions of relapse rather than any specific experiences. Also, the data were from a single time point, thereby limiting conclusions regarding the pro- cess of posttreatment relapse. Addition- ally, the results cannot be overgeneralized Understanding Recovery Barriers 610 to treatment-involved youth in other treatment settings given the variability between the treatment sites used to con- duct the qualitative work as well as the nature of the sample used (convenience).

Finally, focus group thematic results are only presented descriptively. Although it may be that the general risk for sub- stance use relapse among youth as a whole may be similar, with some general differences noted among age-groups, there may be important gender or other differ- ences in relapse risk factors among treat- ment-involved youth that this study did not consider due to confidentiality limita- tions associated with anonymous data collection. Further research should find procedures to remedy such deficiencies.

Conclusion This study contributes to the extant literature on relapse specific to youth populations. Results add clarity to the dynamic process of relapse in youth as they explicate the actual experiences and perceptions of treatment-involved youth.

Overall, there is no single variable suffi- cient to predict relapse among youth alone.

Although individual(personal)-level fac- tors have been shown to account for much of the variance explaining proneness to youth initiation and maintenance of sub- stance use, 84,108 there is still a wide array of social and environmental forces that contribute to the progression of substance use behavior.

128,129 Hence, the interrela- tions among key individual, socializa- tion, and broader environmental vari- ables are likely to be of increasing impor- tance for understanding the developmen- tal relapse trajectories of treatment-in- volved youth.

Furthermore, because treatment for substance use and related problems tends to be treated acutely and for a relatively short period (less than 3 months), 130 a systems issue to consider is the need for ongoing interventions (continuing care) to promote the necessary skills acquired during treatment, as they may not carry over or be sustainable posttreatment. It needs to be recognized that most treat- ment-involved youth are in a structured clinical environment and when it is re- moved they struggle with the loss of struc- ture as they transition into a less un- structured world. In the transition they continue to experience co-occurring is- sues that can hijack emotions, be ex-posed to drug using friends, encounter repeated life stressors, face competing social norms that reinforce drug use, enter into a broader environment where drugs and alcohol are frequently avail- able, and continue to be triggered or cued to drug use. To minimize adverse effects, continuing care models must be devel- oped addressing such complex, interre- lated issues.

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