Part of the ongoing series “High School Confidential: In the Trenches with Substance-Using Teenagers” by Dr. Peter Cohen

Read the first in the series here and the second here.

“There are no second acts in American lives.”-F. Scott Fitzgerald, author of The Great Gatsby

I would find one last opportunity to create an effective model of substance abuse intervention and treatment with teenagers–on a much smaller scale.

That’s not true. There are plenty of them. (And don’t blame Fitzgerald. His words were taken out of context). But when you bring your career to a close, it matters what you carry with you. Like a play or movie that starts off great, by the end credits, it could be a success, a failure, or something in-between.

My second act began three years ago when, at 64, I retired from a dream job as medical director of my state’s drug and alcohol administration. After nine years, I was proud of having initiated or collaborated on projects in three critical areas for improving substance abuse care for teenagers.

First, we created an ongoing series of training for counselors and therapists about treating teen substance use. Underlying that training was the goal of fostering four research-validated modalities for improving outcomes. Known by their acronyms, they are essential elements of how we help teenagers.

SBIRT (Screening, Brief Intervention, and Referral to Treatment)
MI (Motivational Interviewing)
ACRA (Assertive Community Reinforcement Approach)
SFT (Strategic Family Therapy)

Second, we took advantage of an influx of funds to create throughout the state after-school and weekend clubhouses for recovering teens.

Third, at a meeting of state substance abuse representatives, I advocated for the creation of a practice guide for treating adolescent substance use. I feared that if my fellow representatives didn’t define nationwide standards of care, teen substance abuse treatment might not be recognized or funded sufficiently as an essential part of the upcoming Affordability Care Act, what is now called Obamacare. And in September 2014, this document, The State Adolescent Substance Use Disorder Treatment and Recovery Practice Guide, was finally released to the public. (You can download the document at, website of The National Association of State Alcohol and Drug Abuse Directors).

Though I have had the privilege of taking clear steps forward, I also know that there are substantial forces that continue to compromise the quality of addiction treatment for teenagers.

Integration of Mental Health and Addiction Services

One recent reform among many states, counties and cities is the integration of “mental health” and “substance abuse” systems of care. Although a necessary and commonsense move, this integration can be unfocused and even naive, abolishing or neglecting essential policies, procedures, regulations and priorities. In addition, combining departments usually eliminates “duplicate positions” by reassigning specific employees or encouraging their retirement. This can lead to one serious unintended consequence: losing people with the talent and expertise to get the job done.

The mental health field has been traditionally weak in understanding the dynamics of addictions. It has also been too slow in establishing a unified electronic record to inform us about the needs of our consumers and families or measure clinical outcomes in a meaningful way. The substance abuse field, in contrast, has avoided or provided little training in understanding and treating the confounding aspects of mental disorders. And it has by history shied away from therapeutic work with families.

But having observed both disciplines at the clinical level, I think that they tend to share similar weaknesses. One is the practice of unsophisticated and ineffective group therapy. How often have you attended a conference, for example, that featured a session on effective methods of this potentially powerful treatment? And on a larger scale, both disciplines seem to have clung to therapies and treatments based more on tradition and ideology than on clinical effectiveness confirmed by research.

These two fields need each other. In my opinion, integrating mental health and substance use disorder treatment requires talent, an historical memory of what has and hasn’t worked, and the knowledge and ability to transform systems of care. This perspective is sorely needed, provided by professionals and administrators who are conversant with the practices and jargon of these historically distinct disciplines to help bridge these gaps and create true integration.

Inadequate Commitment to Adolescent Services

There is also a larger obstacle to providing effective care for teenagers. It still seems that compared to adults, federal, state and local budgets underfund prevention, treatment, and research of adolescent substance use disorders despite the need. Take a look at the current amount of devoted energy, resources, training, and administrative structures around the country and in your community. Witness the paucity of words and action on federal, state and local governmental websites concerning the problems of drug- and alcohol-using teens. It would make you think that we have already won the war against adolescent substance abuse, and all we have left to do is mop up the remaining problems with adults.

In other words, the raw truth about substance use disorders originating in adolescence has rarely resulted in a proportional and ongoing societal and governmental commitment to adolescent health and substance use intervention.

An Ideal Microcosm

There was too much work to be done. I knew that my retirement from state government was only semi-retirement. I would find one last opportunity to create an effective model of substance abuse intervention and treatment with teenagers–on a much smaller scale. I could put into practice all that I had learned, taught, and promoted about effectively integrating substance abuse and mental health treatment. And I could do it in an environment that recognized the importance of adolescent behavioral health and could devote sufficient resources to it. Lucky for me, I found an ideal microcosm, a therapeutic high school.

QIWYWA’s (Questions I Wish You Would Ask)

Sorry, only one question today.

Q: Are you nuts, working with teenagers in a therapeutic high school?

A: Let’s put the diagnosis of being nuts aside. I enjoy the tentative, ambivalent, turbulent, surprising and alternately charming and insulting energies of teenagers. But to do the job well and prevent burnout, I have had to learn to be more empathic and face up to, reconcile and forgive the excesses of my quirky adolescence. And there’s a story behind my commitment to troubled and troubling teenagers. I always have wished there had been someone there for me (other than my dear parents) who could guide me, shape me, and shape me up through the rough spots of my teenage years. I needed someone who didn’t get caught up in my angst and understood adolescence as a transition, a transition I didn’t asked for but had to live through to become an adult. So, giving to kids what you didn’t get as a kid could be a good thing, as long as you’re prepared to know what to do when the kid pushes you away.

Next time: How Do You Make Friends?

* (thanks to Tim O’Brien for inspiring the title, taken from his great novel The Things They Carried)


Peter Cohen headshotPeter R. Cohen is a board certified child and adolescent psychiatrist with additional certification in addiction medicine. For the past 34 years, he has worked in hospitals, residential programs, and outpatient clinics. For almost twenty years, he served as the medical director at the county and state level, focusing on policy and quality assurance for behavioral health programs. Now semi-retired, Dr. Cohen works part-time at a therapeutic high school in suburban Maryland.

Want to submit a question to Dr. Cohen? It may be answered in future blog posts! Email Jessica Williams at jessica at ireta dot org. If you submit a question, you will remain anonymous on our blog.