MARA GOVERMAN: A teen is using substances. How do you decide what kind of treatment makes sense? Outpatient therapy, a more structured program? We are breaking it down.

JOSH FEDER: Welcome to The Carlat Psychiatry Podcast. I am your host, Dr. Josh Feder, the editor-in-chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice, Second Edition (2023).

MARA GOVERMAN: And I'm Mara Goverman, a licensed clinical social worker in Southern California with a private practice and an avid reader of The Carlat Psychiatry Reports. Today, we are discussing how to determine the appropriate level of care for teens with substance use disorders. Deciding on the right level of care involves looking at substance abuse severity, co-occurring conditions, family support, and the teen's engagement in treatment. So, Dr. Feder, when working with teens, how do you start thinking about treatment options?

JOSH FEDER: One option is to start with outpatient care if the substance use is mild and the teen has strong family support. That typically involves weekly therapy, often family-based, and sometimes medications that treat co-occurring conditions like depression, anxiety, or ADHD, or medicines that can reduce craving for substances. But when kids need more time in structured care, intensive outpatient programs or IOPs are a good option to think about. These involve three to five sessions per week while allowing the teen to stay in school and at home. So, I have had lots of kids in IOPs, and I am so grateful for them because the kid can stay in school, they don't have to sleep somewhere outside of the home, and they're getting several days a week, you know, multiple hours in those afternoons...

MARA GOVERMAN: And the family is getting support.

JOSH FEDER: And the family is getting support. So, to me, so many times I see kids who were trying to do motivational interviewing, something like that—we will talk a little bit more about that later—and if it is just not working, IOPs are a great next step.

MARA GOVERMAN: One of the challenges I recall over the years in co-treating with you are the teens who are using marijuana and not wanting to stop, and yet it is a problematic issue for the family and their lifestyle. And as a psychiatrist who works in private practice, I wonder if you could comment for our listeners. How do you begin that discussion?

JOSH FEDER: Oh my God, weed is everywhere, right? And there are other substances, right? But in our practice, weed, alcohol, and nicotine (which is like even more addictive than about anything else we have going) is a problem. And honestly, the thing that haunts me the most is fentanyl. So, it is the risk of getting whatever it is, weed or some other pills, that you get off the street. And so many of them contain fentanyl, and it is like one and done, I mean literally dead. And then the everyday worry is the kids who love their weed, and that is ubiquitous, and they don't want to stop using it. And so, all our work on motivational interviewing can work if you are pretty good at it, and it can work overtime. You and I have shared cases where people have been using, for like years, and they come to us, then it takes another couple years, and then they are not using. I just had another kid do this. Three weeks clean this week, and feeling a little bit better, but I have been working with this guy for four years, and finally, we are at that point. So, it's a long-term process, really challenging, and getting somebody like that to IOP when they're not actually malfunctioning enough...

MARA GOVERMAN: Or not available.

JOSH FEDER: Or not available. So, the IOPS might not be available, and the person might be, just not wanting to go—it is hard to push them. So, you're right; there are a lot of challenges with it, but honestly, when you can get somebody to an IOP, it is a godsend because it takes a weight off my shoulders for a while. I mean, they come back right from the IOP after about three or four weeks, but it is still a very useful approach.

MARA GOVERMAN: I just wanted to touch base on one thing that became an issue many times for you as a private practice doctor: when do you begin medication if someone is continuing to use substances?

JOSH FEDER: So, there was a time in my practice where if someone was using, I wouldn't treat their ADHD, whatever it was. I would say, Well, why are we doing this if you are not clean? Because weed is a great example of one where the withdrawal makes you depressed, and you are going to keep smoking, and I am going to be treating your depression. I understand dual diagnosis, right? I mean, we have been talking about that for decades, and I have been around for decades. But why bother? I mean, why am I wasting your money and my time in a private practice where a million people want to get in, but I don't think I am going to get anywhere? I shifted that because I wasn't winning those battles at all, right? And people were just continuing to use it.

MARA GOVERMAN: And suffering.

JOSH FEDER: And now, I am more assertive about trying to treat co-occurring conditions. But honestly, that came with the advent of my increasing skill, I would like to say, in motivational interviewing because if I can get someone to think about what are the things that they get from using and what are the things that they're trying to get in their life, and how might the substance be getting in the way, that conversation goes better. When you are co-treating whatever, it is, and some of these medicines can then reduce some of the craving— that is for another, a more extensive discussion.

MARA GOVERMAN: If substance use is more severe or there are acute mental health concerns, a partial hospitalization program (or PHP) might be more effective. These provide daily structured treatment while the team continues living at home.

JOSH FEDER: IOP is usually a few weeks, and then insurance is like, Eh, they can go back to outpatient. Same thing with PHP, although the step down from PHP is often IOP, right? With a PHP they are missing school. Usually, it is four or five days a week. But then they cut it down to like three days—which is weird because then what's the kid doing when they're just at home? To me, it feels a little bit at risk, but in any case, there's a place where they don't have to be sleeping in a hospital, and they do bring schoolwork in, so you don't always get totally behind. But if it's a choice between residential and trying to do a PHP first, I would totally try to do a PHP first. Again, no program is perfect, and you always get kids complaining, Oh, I'm bored, we're not doing anything. But the truth is that the outcomes that I see in my practice are generally pretty good. Where people are more likely to be clean for those few weeks and more likely to be more amenable to whether it is IOP or outpatient afterward and continuing to work because it does give some time to the process of that motivational interviewing, meaning understanding where are you in your life, where are you going with this, and where's it going to lead you if this doesn't work? That sort of thing. So, it is a bit of a come to Moses moment.

MARA GOVERMAN: In your experience, do you anticipate that you have to go through PHP programs more than once?

JOSH FEDER: Like with adults, you usually need several cycles of inpatient, maybe for a month or two, sometimes before it takes. I see substances as having almost a life of their own in the psyche of the person they make you want to use them. It's like an imp or a, you know, some other kind of demonic...

MARA GOVERMAN: Or an alter ego.

JOSH FEDER: Something, but anyway, it makes you want to do it, and it takes a long time to get to a place of fortitude to be able to say, Okay, well, maybe this isn't so good for me, maybe I can step away. I mean, there are some people who just step away, but that's not the majority about a long shot. So, it is challenging, and people do sometimes run through PHP a couple of times before they have effects, and similarly, if you fail PHP a few times, well then, we're starting to talk residential treatment. So, when a teen's home environment is kind of part of the problem, if it is kind of disruptive if people have mixed feelings about using, because a lot of parents are using, right? Or if they're struggling with ongoing use despite all these outpatient kinds of care, well then, we need to think about residential treatment centers, RTCs. So these programs basically, you live there, it is round-the-clock care for several weeks to several months, and again, back in the day, we would send people to RTCs for a couple of years at a time and let them grow up more safely for a while, and maybe they wouldn't get into more trouble or God forbid, you know, die from some substance-related or other psychiatric-related problem. But these days, you can't get payment for more than a couple of months at a time, and ironically, now the substance use, particularly with the fentanyl crisis, is more deadly than it was before. So, we're in a fairly precarious position with that. But again, I've sent a lot of people out to RTCs. My feeling about the research on them over the years is that they're mixed in terms of outcomes. A lot of times, you get there, you're not using for months, you're behaving better, you're not causing as much trouble. But then when you come back...

MARA GOVERMAN: It is very hard to reenter.

JOSH FEDER: It is really hard to reenter because you want to try to work with the family while they're there, and most programs will do that, but they come back to very much the same environment, and so, within a few months, a lot of times people have regressed again. So, then some people will send somebody out to, like a therapeutic boarding school sometimes for a few years, if they can afford it, or if a school district will cover the cost. But RTCs, again, I think they have a place. Now. I will say that we have a lot of people who might be adopted or have other attachment issues, and I think you have to be careful about sending someone with an attachment problem/history out to an RTC; it is kind of sending them away again. So, I would be careful about that because that can make it very hard to work with them and again to reintegrate them later on.

MARA GOVERMAN: Rounding out the options. Inpatient treatment should be considered for teens at acute risk of severe withdrawal or in severe immediate distress. And finally, there are some schools that have school-based substance abuse services. That integrates education with substance use treatment.

JOSH FEDER: Yeah, so that kind of rounds out all these different options, and that is why it is so bewildering. Obviously, acute inpatient is the thing most people think about when they think outpatient or maybe IOP or maybe they need inpatient, but we really do reserve that for people who are in some sort of acute situation. And I have a lot of people who I think would be better off impatient when they're withdrawing from whatever it is, even weed, but getting someone in for that, again, if they're not acutely suicidal or...

MARA GOVERMAN: Delusional. The marijuana sometimes.

JOSH FEDER: Oh well, actually, I'm glad you mentioned that Mara because the psychosis rates, we used to say, were about double, but they're probably more like quadruple because of the high potency of THC. So, that's an instance where you can probably get someone in and maybe detox them, and that does happen a lot, and of course, teens and young adults, that's the age when we see this anyway. We have got a whole issue in the Spring of 2025 coming out on psychosis, some of which talks about that, and I'm working on another specific piece on, autism and substance use, that will be coming out in a little bit as well, that might be of some interest. So, there's just so much around that and things that could get you to inpatient care because of added complexity, severe depression, and psychosis, that sort of thing.

MARA GOVERMAN: I want you to comment about emergency rooms and teens who come in because they're having hallucinations, delusions, or other physical manifestations that increase their health risks.

JOSH FEDER: Well, that's right. I mean, one of the top differential diagnoses of somebody coming in with a psychotic condition in an ER, if they're a teen, is substance use. Whether it's that they were tweaking on some sort of amphetamine or weed, even overuse of caffeine-containing products is another big one, and so there are a lot of things that can do it. So yes, important, to be ruling that out, and of course, you're ruling out organic reasons, et cetera. It's always complicated. I also wanted to talk a little bit more about the school-based programs. Honestly, I have not seen a whole lot of impact from those programs, but I haven't seen a whole lot of those programs. I think the research, we're still waiting to see what that is like the problem in part, I think, is this idea that schools might be able to take over care when the people who are at the schools are often beleaguered. They have too many kids.

MARA GOVERMAN: Overworked and Undertrained.

JOSH FEDER: Undertrained. Thank you for mentioning that is where I was going next with this. They are just not necessarily built to be able to manage severe addiction at school, but people want to try that because they don't want to hospitalize people; they want to keep people at school. The worst of those was back a few decades ago when people were doing Red Ribbon Week. I think they still do it, and saying, Just Say No, which didn't work; it just cost millions of dollars to create the program and roll it out. So, I am hopeful that school-based services can be effective, but I feel like there is more to go in terms of trying to develop those in a useful way. And look, I am a proponent of school-based services. We do an anti-bullying program that has been effective for kids with differences, not so much focused on substance use. I know it is possible, but I think there is more to go on that.

MARA GOVERMAN: When choosing a level of care, you can use the American Society of Addiction Medicine, ASAM criteria, which consider six dimensions.

JOSH FEDER: So, yeah, these six dimensions are substance use, severity, and withdrawal risk.

MARA GOVERMAN: Mm-hmm. So, that is, high withdrawal risk may point to inpatient care.

JOSH FEDER: Co-occurring conditions.

MARA GOVERMAN: This includes depression, anxiety, or ADHD. That affects recovery and may require PHP or RTC.

JOSH FEDER: Living environment.

MARA GOVERMAN: A stable home can support IOP. While an unsafe environment may indicate residential treatment is required.

JOSH FEDER: Social environmental stressors.

MARA GOVERMAN: Academic or legal challenges may require more structured treatment.

JOSH FEDER: Engagement in treatment.

MARA GOVERMAN: Teens might not always agree to care, which affects what options are realistic.

JOSH FEDER: And finally, family and social support.

MARA GOVERMAN: Caregiver involvement plays a very big role in treatment success.

JOSH FEDER: The framework helps guide decision-making, but engaging the teen in treatment discussions is very beneficial. Motivational interviewing, which we mentioned before, can really help. And these techniques, which we have published before.

MARA GOVERMAN: These include expressing empathy toward the teen to help build rapport and use reflective listening.

JOSH FEDER: And as an example, you might say something like, It sounds like you're frustrated with people who love you, telling you to stop smoking. And then the next principle is to develop a discrepancy.

MARA GOVERMAN: Raise awareness of the teen's current behavior. Help them to identify differences between goals and values and current behavior and encourage the teen to come up with ways to adjust behaviors to align with stated values and goals.

JOSH FEDER: So, you might say something like, I hear that you enjoy smoking, and yet you're worried that your little sister will start too. What do you think are some ways to prevent that from happening? The next one is to avoid arguing or confrontation.

MARA GOVERMAN: Reframe the statements and acknowledge ambivalence.

JOSH FEDER: So, you might say, I hear that you are not ready to change your smoking behavior. What do you think would be helpful if and when you're ready to make a change? The fourth principle that we talk about in motivational interviewing is to support self-efficacy.

MARA GOVERMAN: Explore past successes in other problem areas and apply to the present situation. Provide strategies and resources that can help assist the teen with change and affirm that the teen is able to choose and carry out personal change.

JOSH FEDER: So, you might say something like, You were able to get in shape and make the soccer team. This is kind of the same. If it is okay with you, I can share some ideas that have worked for other people that might help. And we can also think about other ideas together. You can do this. And then finally supporting autonomy.

MARA GOVERMAN: Reinforce that agency, the power for change lies within the teen versus counselor, teachers, or parents. Listen, as the teen develops an action list of steps to change behavior.

JOSH FEDER: So, you might say something like, You have some really great ideas about how to make some changes. We can continue to talk together as you figure out how you want to do it.

MARA GOVERMAN: I find that when teens feel heard, involved, and supported, they are more open to engaging in treatment, and aftercare plays a big role in maintaining progress.

JOSH FEDER: We do have a lot of examples of this, and I want to refer listeners to our webinar that we put out about a year ago on motivational interviewing for substance use. It has my goofy cartoons and a whole bunch of examples of different people, where we are using different stages of motivational interviewing, like pre-contemplation and contemplation and planning and relapse, things like that. The takeaway is that there are multiple levels of care for adolescent substance use treatment and no one-size-fits-all approach. Clinicians, caregivers, and teens all play a role in shaping what works best.

MARA GOVERMAN: Thanks for joining us for this discussion. It is inspired by Dr. Dhruv Shah and Dr. Brady Heward’s article from our January/February/March Newsletter.

JOSH FEDER: Everything from Carlat Publishing is independently researched and produced. There is no funding from the pharmaceutical industry.

MARA GOVERMAN: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads, and our authors do not receive industry funding. That helps us to bring you unbiased information you can trust.

JOSH FEDER: I hope this conversation helps our listeners make informed choices. If you found this discussion helpful, subscribe for more episodes on mental health and psychiatric care, and please share it with others who may need to hear this message. And remember, when we look for good things, more good can follow.