A model of recovery from substance abuse and dependence for korean adolescents
Hyun, Myung Sun
PROBLEM. There is a need for a model that illuminates the recovery process from substance abuse and dependence for Korean adolescents, identifies the stages and strategies of recovery, and directs interventions to specific stages.
METHODS. The model was developed from content analysis focused on the experiences during the recovery process of 8 Korean adolescents with substance abuse and dependence.
CONCLUSIONS. The stages in recovery include retracing, accepting, surrendering, and turning to change. The strategies of recovery involve a variety of activities and multidimensional domains. The model integrates the stages and strategies of recovery, and suggests nursing interventions to promote recovery of adolescents with a substance-related disorder.
Search terms: Korean adolescents, recovery model, stages of recovery, strategies of recovery, substance abuse, substance dependence Myung Sun Hyun, PhD, RN, is Assistant Professor, Ajou University, School of Medicine, Division of Nursing Science, Suwon, Korea; Susan Kools, PhD, RN, is Assistant Professor, University of California, San Francisco, School of Nursing, Department of Family Health Care Nursing, San Francisco, CA; and Sun Ah Kirn, PhD, RN, is Assistant Professor, University of Yonsei, School of Nursing, Seoul, Korea.
In Korea, substance abuse has increased dramatically with the rise of industrialization, technological innovations, and modernization. Thus, adolescent substance abuse is becoming a major social issue. Adolescents experience profound inner turmoil and are vulnerable to stress (Hauser & Bowlds, 1993). Particularly, competition for academic achievement is a major source of stress for adolescents in Korea. In addition, there are more influences in Korean society (e.g., mass media) that stimulate Korean adolescents to be curious about drugs and to use drugs rather than applying healthy coping methods to relieve stress. As with other age groups, once Korean adolescents start to use a substance, they rarely stop using it and they tend to become dependent on the substance (Chu, Kim, & Park, 1993).
As new laws have been enacted and enforcement of laws against illicit drug abuse in Korea has increased, the rates of abuse of legal substances among adolescents also have increased. Therefore, the use of cough remedies (e.g., lumina, lubiking) and industrial chemicals (e.g., glue, solvents, butane gas) is increasing among Korean adolescents. Their use is influenced by the fact that these substances are cheap and easy to buy.
In Korea, even though adolescent substance abuse and dependence have become a social problem, there are not sufficient treatment facilities focused on substance abuse; consequently, users are often hospitalized in a mental hospital. Moreover, there are no models and practical guidelines that can direct specific intervention in the Korean culture.
This article presents a comprehensive model of recovery derived from the experiences of Korean adolescents with substance abuse and dependence during the recovery process.
An epidemiological study of 965 middle- and high-school students found that 70.6% of them have used analgesics, 26% cigarettes, 7.9% inhalants, and 4.6% antitussives (Cha et al., 1993). The study also showed that the average ages for adolescents who are in reform school to have first used inhalants was before 12 years old (10.7%), before 14 years old (42.9%), or before 16 years old (32.1%).
Robinson and Greene (1988) stated that as adolescence is the period of transition from child to adult, there are major goals to be met: the development of a healthy self-image, meaningful relationships, a value system, separation from one’s parents, and education directed toward economic independence. They also stated if one becomes an abuser or dependent on substances during adolescence before one can develop a self-identity, one becomes vulnerable in normal development. Washton (1995) suggested that adolescents with substance abuse had not experienced negative consequences at first, so they rarely stopped using the substance, and then their addiction progressed very rapidly, causing developmental delays and negative effects on functioning. Presumably, their substance abuse and dependence has gradual negative effects on multiple dimensions, not only on one dimension, in their lives. Thus, in order for adolescents with substance abuse/dependence to recover, recovery should occur in multiple dimensions of their lives.
Several investigators have developed models to illuminate the behavior change involved in recovery from addiction. Prochaska, DiClemente, and Norcross (1992) developed a model that identifies five stages in recovery: precontemplation (not experiencing enough motivation to change habits), contemplation (thinking about stopping abusing), preparation (becoming determined to stop), action (actively modifying habits and/or environment), and maintenance (maintaining new habit of not abusing). They suggest these stages can delineate self-initiated and professionally facilitated change of addicted behaviors.
Other models of behavioral change include one developed by Horn (1976) for smoking reduction and cessation, and a cognitive-behavioral model by Marlatt and Gordon (1985). These models have proposed recovery as a process with characteristic, phase-specific behaviors and gradual behavioral change over time, and have improved our understanding of adult substance abuse recovery. These models are limited, however, when applied to adolescents who are affected in multiple dimensions by addiction to drugs, because these models are focused only on behavioral changes over time and do not regard the recovery process as multidimensional. Additionally, several researchers have pointed to the limitations in a simple measurement of recovery outcomes, because recovery from addiction should occur in multidimensional areas of one’s life (Lewis, Dana, & Blevins, 1994).
To address multidimensional areas, Beauvais (1992) developed a model for prevention and treatment of drug abuse among American-Indian youth that includes socialization factors, psychological variables, peer associations, and drug abuse. This model, however, does not suggest the comprehensive framework that can guide interventions for the addicted in clinical situations. The investigators in the present study developed a model of recovery for Korean adolescents with substance abuse and dependence that can incorporate the multiple dimensions and direct the interventions specifically.
Content analysis was used to develop a model of recovery from substance abuse and dependence for Korean adolescents. In the present study, it was assumed that adolescents who completed the 8-week treatment program went through the recovery process, so content analysis was focused on their experiences during the 8-week treatment program.
The study was conducted at a 25-bed urban alcohol-drug recovery clinic, one of the few facilities in Korea for those diagnosed with a substance-related disorder. Among the hospitalized patients in this clinic, most of the adolescents were diagnosed with a substance-related disorder, and most of the adults were diagnosed with alcoholism. The clinic provides patients with an inpatient treatment program lasting 8 weeks.
All patients received detoxification treatment when they were first hospitalized, and then received a program orientation. Next, they began to participate in treatment activities such as group therapy and educational intervention. Group therapy was conducted by a nurse and a social worker. The entire educational intervention consisted of lectures provided by a psychiatrist and group study. The group study was based on the Alcoholics Anonymous (AA) manual and guided by nonprofessional staff who had recovered from substance abuse.
Additionally, the programs included a diary, meditation notes, and an autobiography. The treatment program was based on the theoretical orientation of the Minnesota Model, known as the abstinence model. The key element of this approach was the blending of professional and trained nonprofessional (recovering) staff around the principles of Alcoholics Anonymous.
Adolescents diagnosed with a substance-related disorder hospitalized at this alcohol-drug recovery clinic were eligible to participate in the study. Some of them were diagnosed with substance abuse, others with substance dependence. Permission to contact the adolescents was obtained from the director of the clinic. In Korea, there is no social conception of written consent for research participation. When adolescents with a substance-related disorder were hospitalized at this clinic, the investigator explained the purpose of the study to the adolescents and verbal consent was obtained from each one. No adolescent declined to participate when asked. The adolescents were informed that their privacy and confidentiality would be protected.
The interviews were conducted weekly. Although the investigator interviewed 14 adolescents at the beginning, the final study sample was composed of 8 adolescents who completed the program. (Those who did not complete the 8-week treatment program refused to receive treatment and were discharged early.) Of the 8 who were included, 6 were male and 2 female; ages ranged from 15 to 21 (mean age 19.5 years). All were living at home, and most of them were forced by their parents to be hospitalized. They had used psychoactive substances for an average of 8.5 years and had histories of treatment at the local clinic or general hospital. Four adolescents had inhaled glue, 2 butane gas, and 2 were abusing antitussives. Sample demographics are shown in Table 1.
In-depth interviews, participant observations, and case records were used for data collection. The interviews were started close to the admission day and continued weekly until discharge. A semistructured interview guide was developed to elicit the adolescents’ experiences through the process of recovery from substance abuse. Questions of interest were “What are the experiences of adolescents through the recovery process?” and “How do adolescents in recovery change over time?” Additional questions evolved as data were collected and analyzed, providing opportunities to gather more data about the adolescents’ experiences of their recovery process.
According to the time when they were hospitalized and the treatment program provided, the interview theme was changed (Table 2). Interviews lasted between 20 minutes and 1 hour and were conducted in private treatment rooms at the clinic. Although the number of interviews varied, most adolescents were interviewed five times (range: 4-8). Interviews were recorded on audiotape and transcribed verbatim. To confirm and validate their experiences, two adolescents were interviewed again after their discharge.
Participant observations were conducted by attending group treatment sessions and focusing on the interactions among the adolescents. Field notes were made immediately after each interview and observation. These notes provided hints on things to look for and ask about in the next interview and observation.
Data analysis followed the procedures of content analysis, focusing on the experiences that adolescents passed through during the recovery process from admission to discharge. The following strategies were used in data analysis: (a) Audiotaped interviews were transcribed verbatim, (b) audiotapes were reviewed to find the experiences focusing on the recovery process, (c) significant statements were underlined and thematic contents focusing on the stages and strategies were extracted from the data, (d) key themes were identified and validated by comparing to other participants and field notes, and (e) themes were reviewed and checked by the research team and the psychiatrist and social worker in this clinic.
Stages of Recovery
Results indicated that recovering Korean adolescents pass through a series of four stages: retracing, accepting, surrendering, and turning to change.
Retracing. In the study, most adolescents engaging in substance abuse and dependence were forced by their parents to seek treatment. Therefore, they were angry at their parents and refused to accept their admission. Most resisted the treatment, and some intended to use substances continuously. A few suffered from withdrawal symptoms. As the period of detoxification passed and the adolescents were restored to physical well-being, they began to retrace their individual past lives. This was exemplified in this statement: “In the hospital, I feel refreshed . . . I can comfortably retrace my life from childhood . . . and I can have time to think comfortably about me. . . .”
Accepting. Through the stage of retracing their lives, the adolescents came to connect problems in their lives with the abuse of drugs. In this way, their denial was gradually broken down and they could acknowledge they were drug abusers. Because they accepted themselves as drug abusers, they could speak to other patients and therapists about how their lives had been destroyed by an addiction to drugs. One adolescent said, “I can accept the fact that I’m an abuser. I can have time to present my life in front of the group and it is a happy time for me. I’m trying to be satisfied with myself and to love myself. . . .”
Surrendering. Through the accepting stage, the adolescents could see that whenever they tried to abstain from drugs by themselves, they failed. Gradually, they surrendered the control of abstinence from themselves to others who were more powerful and healthier than they were. When they realized they had hit rock bottom due to substance abuse, then they could surrender. One adolescent shared this experience: “I realize now that I have already destroyed my life and hit rock bottom in my life . . . Now I’m not going to stop using drugs by myself . . . so I surrender my power to the others. . . .”
Turning to change. Through the surrendering stage, the adolescents began to change their lives, trying to fill their lives with healthy alternatives to drugs and live a drug-free life. One said, “I will relieve stresses through sports or recreational activities. I will go to church and I will make efforts so I will not be alone.”
Strategies of Recovery
Findings indicated that recovering adolescents used several strategies that involved a variety of activities and experiences: psychological, affective, cognitive, and social. These are strategies used by the adolescents in parallel with each stage.
Introspection. With introspection, adolescents had time to reflect and evaluate their problems and to consider the effects of their addictive behaviors on their own lives and the lives of their families. This was exemplified in this statement: “I began to realize that I destroyed myself-my relationship with my parents, my childhood, and my character. Now I can have time to think about myself, whereas I could not have such time in the past.”
Self-confrontation. With the ability to be introspective, adolescents reflectively turned inward, and gradually they could examine their problems and confront themselves. One said, “Some patients still inhale butane [gas] and suffer from toxic symptoms. Whenever I see them, I can visualize myself through their symptoms. . . . At those times, I can confront myself as a drug abuser.”
Self-disclosure. At this point, adolescents no longer needed to deny and defend their problems. Therefore, they could expose themselves honestly to others. One adolescent stated, “I can express my problems without concealment to therapists and other patients. I am happy that we can express our troubles with each other as if we are family.”
Experiencing an intimate relationship with others. In the process of self-disclosure, adolescents felt a hearty concern from other patients and therapists, and they could sympathize with other patients. Over time, as they became familiar with other patients, they experienced intimate relationships. One adolescent said, “Here, other patients and therapists are concerned about me, so I am happy. I’m so happy that other people love me like this.”
Recognizing the reality of drug abuse. From the first day of hospitalization, the adolescents began to receive several kinds of cognitive treatment interventions such as lectures, education, and manual study under a counselor’s guidance. They regarded these interventions as unhelpful, however, and they were bored with these programs. Over time, they realized that cognitive treatment interventions could help them recognize the reality of drug abuse. One said, AI learned with certainty the effects of drugs on people who abused drugs. I now have knowledge about the reality of drugs that had remained outside my awareness in the past.” Another adolescent said, “Yesterday, I saw other patients who had seizures due to drug intoxication. At that time, I was so afraid . . . and I could recognize the serious reality of drug abuse.”
Trying to substitute. As adolescents recognized the reality of drug abuse, they realized they could not abstain from drugs by themselves (without the help of treatment). Therefore, they began trying to find alternatives to drugs. By trying to discover healthy substitutes, they intended to learn to live without drugs. One said, “I will absorb myself in some objects that are not related to drugs-in sports, in my studies, and AA. . . . I will find something that can give me happiness.”
Integrating the Stages and Strategies of Recovery
Through integration of the stages and the strategies described above, a model was developed to illustrate recovery from substance abuse and dependence among Korean adolescents (Figure 1). During the recovery process, Korean adolescents in this study who had engaged in drug abuse and dependence appeared to pass through four stages: retracing, accepting, surrendering, and turning to change. They also appeared to use several strategies through each stage. These strategies involve a variety of activities: introspection, self-confrontation, self-disclosure, experiencing an intimate relationship with others, recognizing the reality of drug abuse, and trying to substitute. These strategies occur in multiple domains: intrapersonal (occurring within the individual’s mind), interpersonal (involving one-to-one communication), organizational (interactions in a small group), and social (relating to society or broader groupings of people in a social context).
At first, when adolescents were hospitalized, they appeared to pass through a retracing stage in which they retraced their life from childhood. The hospital provided external control by which they were isolated from drugs and placed in an environment in which they could comfortably engage in introspection. This strategy represents the intrapersonal domain in that introspection occurs in one’s mind.
The adolescents then moved into a stage in which they accepted their identity as drug abusers and could comfortably describe their experiences to others. During this stage, the adolescents saw other patients who suffered from intoxication symptoms and could visualize themselves through these patients. This helped them confront their identity as drug abusers. During this stage, they engaged in self-confrontation, self-disclosure, and intimate relationships with others. Self-confrontation is an intrapersonal process, self-disclosure occurs in an interpersonal domain, and intimate relationships with others exist within an organizational domain.
Subsequently, adolescents appeared to pass through a surrendering stage. During this stage, they realized how the drugs had destroyed their lives. As a result, they accepted the fact that they were powerless against the drugs and that they should surrender their power to others. In addition, in changing their perspectives on the reality of drug abuse, they could recognize the serious reality of it. This strategy represents the social domain, in that these perspectives on the reality of drug abuse become congruous with the conventional views about the negative consequences of drug abuse accepted in Korean society.
The last stage is the turning to change stage. After surrendering, adolescents tried to fill their lives with alternative activities, not drugs, and thus they were changing their lives. Substitution also represents the social domain, in that the alternatives they engage in are healthy and are accepted positively in their society.
The recovery was developed from content analysis focused on experiences among Korean adolescents who had engaged in substance abuse and dependence during the recovery process. This model is composed of stages and strategies that involve the multiple domains that adolescents recovering from drug abuse and dependence may experience.
This model also was developed on the assumptions that adolescents who completed the 8-week treatment program went through the recovery process. Some dropped out of treatment, and others relapsed after discharge. In the case of dropouts, the progress of the recovery process would be stopped, and if they relapsed and sought treatment, they would regress to an earlier stage in the recovery process.
This model is similar to the orientation in the 12 steps of AA and Narcotics Anonymous, in that both target acceptance of an addict’s identity, acknowledgment of powerlessness over the abused substance, and adherence to abstinence as a goal (Ouimette, Finney, & Moos, 1997). However, this model is different in that the 12 steps address spirituality as a means to sobriety and recovery (Smith, Buxton, Bilal, & Seymour, 1993). In addition, whereas the 12 steps direct a self-help approach, this model was developed from adolescents who participated in an inpatient treatment program at a clinic.
The model illustrates that adolescents’ recovery expands from the intrapersonal dimension to the social dimension-from the retracing stage to the turning to change stage. Prochaska et al. (1992) suggested precontemplation, contemplation, preparation, action, and maintenance in their model of change of addictive behaviors. This model is similar to their model in that both models begin with thinking and contemplation. While their model emphasizes the change of addictive behavior and maintenance of new behavior, however, our model emphasizes the gradual expanding of dimensions in change during the recovery process.
In the model developed for American-Indian youth with drug abuse, Beauvais (1992) suggested the understanding of drug use behavior must begin with a social structure, and the first step in treatment is to help users restructure their social lives. It is possible to assume that the emphasis on social structure in Beauvais’ model is due to the particularity of a tribe. In our model, it is suggested that the recovery process should begin with introspection-an intrapersonal domain. That is, the recovery process begins by way of the individual getting in touch with him/herself.
Adolescents, who are in the process of separating from their parents and moving toward adulthood, have critical tasks that need to be achieved during adolescence-they need to learn social skills and have intimate relationships with peers. Therefore, if adolescents abuse drugs or alcohol, those learning processes that are required of them to deal successfully with various challenges and to grow toward an adult may stagnate. In this model, one of the strategies in the surrendering stage is indicated as an intimate relationship with others to reflect this point.
It is not certain that the changes described in this model will continue throughout life or whether there are additional later stages. It is possible to suggest that the recovery process proceeds toward, but does not end with, abstinence. It is certain, however, that the recovery process exists on a continuum and requires a lifelong commitment (Chappel, 1995). Relapse is possible when considering a patient’s recovery because adolescents may repeat the stages described in the model several times before full recovery. Schachter (1982) suggested that relapse can be helpful because relapse can help an individual realize his or her weaknesses.
While this model is based on Korean adolescents’ experiences during recovery, it can be applied to other culture groups. Also, the stages and strategies included in this model should be tested, revised, and refined by further empirical research.
The model delineated in the present study provides a comprehensive framework that can be applied in clinical practice for Korean adolescents engaged in drug abuse and dependence. This model particularly provides a framework for nurses to work with them in assessing them and developing interventions. It is important for nurses to assess what stage adolescents are passing through and what strategies they are using during each stage. Based on this assessment, nurses can develop interventions to specific stages and strategies. Some adolescents may stay in some stages for a long time, depending on their readiness or resistance to change (Prochaska et al., 1992).
During the retracing stage, physical recovery from withdrawal symptoms promotes introspection. There-fore, when adolescents are hospitalized at the clinic, prompt management of the physical problems of withdrawal is essential, and it is important to provide adolescents with a nonjudgmental environment in which they are supported to become introspective. During the accepting stage, they can speak to other patients and therapists about how their lives have been destroyed by their addiction to drugs. It is important to provide a nonpunitive and supportive setting in which they can become more open and honest with themselves and others. Then, interventions that are more instructional and direct are helpful, encouraging them to confront the discrepancies between their perceptions of problems and realities of the problems. In addition, an environment in which staff and peer alliances can be developed is beneficial (Belding, Iguchi, Morral, & McLellan, 1997; Tunis, Delucchi, Schwartz, Banys, & Sees, 1995).
During the surrendering stage, it is hard for many adolescents to acknowledge their powerlessness in the face of drugs because to them this acknowledgment can be equal to giving up control over their addiction to drugs. This acknowledgment also is more critical because they are adolescents-young. Therefore, it is important to maintain the therapeutic alliance and listen with compassion to adolescents’ stories. During this stage, cognitive nursing interventions can be effective in helping them realize the seriousness and dangers of drug abuse and dependence. During the turning to change stage, they try to fill their lives with healthy alternatives to drugs. Nurses need to provide adolescents with information about alternatives that can replace drugs and opportunities to practice these alternatives in a safe, supportive environment (Compton, 1989; Peels, 1987).
When adolescents begin to abuse drugs, normal maturation and growth processes are delayed and learning to socialize becomes maladaptive (Washton, 1995). Particularly during the accepting stage, it is important for nurses to provide the environment in which patients can interact with others intimately and openly. Experiencing an intimate relationship with others is important in the recovery process, because intimacy is one of the tasks that should be accomplished in the development of adolescents and young adults (Hauser & Bowlds, 1993).
Several limitations of the present study should be noted. This model cannot adequately illuminate the recovery process of Korean adolescents engaged in substance-related disorders because only individuals in inpatient programs were involved in the present study, with the assumption that adolescents who completed the 8-week treatment program went through the recovery process. Therefore, future studies on others who maintain their sobriety or participate in self-help groups should be conducted to discover whether this model can be applicable to them. Additionally, because the participants who abused legal drugs such as glue or butane gas were included in this study, this model may have limitations to other adolescents who abuse illegal drugs.
Prochaska et al. (1992) suggested motivation, resistance to therapy, and defensiveness as individual factors; these factors can affect the recovery process suggested in our model. Since it was not delineated how these individual factors affected the recovery process, this model is focused on positive experiences rather than negative experiences among adolescents during the recovery process. This model should be refined by further studies that can delineate how negative individual factors such as resistance and defensiveness can affect the recovery process.
This study suggests a model that illuminates the recovery process from substance abuse and dependence for Korean adolescents. The model was developed by integrating the stages and strategies of recovery. The strategies of recovery involve a variety of activities and multi-dimensional domains. This model provides a framework that can be applied in clinical practice for Korean adolescents with substance abuse and dependence, and can direct nurses to assess this population and develop interventions for their recovery.
Author contact: firstname.lastname@example.org, with a copy to the Editor: Poster@uta.edu
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Myung Sun Hyun, PhD, RN, Susan Kools, PhD, RN, and Sun Ah Kim, PhD, RN
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