Helping teens with addictions and depression: Therapies that work

Is your teenager struggling with both addiction and depression?

Learn how you can help them in this article from Dr. Fortuna, mental health practitioner and advocate for teens! More on how cognitive therapy and mindfulness approaches can work for teens with co-occuring depression and addiction. Then, we invite your questions or comments about helping your child with addiction issues at the end.

Depression and addiction feed into one another

When teens are suffering from depression (or other mental health problem) in combination with a substance use problems this is what we call “dual diagnosis” or “co-occurring disorders”. It means both problems need to be treated and preferably together and in an integrated way.

Depressed teens can reach for drugs or alcohol as a way to lift their spirits or to numb painful thoughts and feelings. As a result, depression and substance abuse feed into each other, and one condition can make the other worse. In fact, anytime a teen who is experiencing depression or anxiety is also using drugs or alcohol, clinicians consider this risky substance use.

Talk therapies for depression and addiction treatment

Treating depression and other mental health conditions can in turn help treat addictions. Medications that have been prescribed to help treat depression include Serotonin Specific Reuptake Inhibitors (SSRIs) such as:

Bupropion
Fluoxetine or
Sertraline

…as well as others. But there are also talk therapies that help both. Some examples of these therapies include:

Dialectic Behavioral Therapy
Mindfulness-Based Relapse Prevention (MBRP)
Mindfulness Based Cognitive Therapy for Adolescents with PTSD and Addictions

A common element of these therapies is that they use some combination of cognitive therapy, and/or mindfulness practice, and all teach skills helpful for recovery in regards to both substance use and mental health conditions(especially depression).

Cognitive Restructuring for depression: How it works

“Cognitive Restructuring” is a long medical term that refers to a widely used approach throughout the cognitive behavioral therapy field. It is used for helping people, including teens, deal with upsetting feelings, including feelings related to depression. How does it work?

Cognitive Restructuring involves teaching people how to identify the thought or belief underlying a feeling such as depression and anxiety. An underlying premise of cognitive therapy is that certain patterns of automatic thinking can have a direct impact on how we feel.

A common example: We feel sad or not, depending on whether we think a friend we wave hello to, who in turn does not wave back, is not doing so because:

a) s/he did not see us
b) s/he purposefully ignored us

The former option leads to little sadness, the latter triggers automatic thoughts of wrongdoing and leads to sadness or anger.

Automatic thoughts are triggered by our perceptions and experiences. These thoughts work so automatically, in fact that at times we do not even notice their content. Yet, we are left with the sadness or anger nonetheless.

What does a Cognitive Restructuring look like?

So, what does a Cognitive Restructuring therapy session look like? And, what is discussed with the therapist? When a therapist uses Cognitive Restructuring it can include:

Describing an upsetting situation
Identifying the feelings associated with that situation, and
Identifying the related underlying thoughts(s)

Cognitive restructuring then allows the teen to evaluate the evidence for and against the upsetting thought(s), and consider if the thought isn’t accurate (or can make a plan to deal with the stress-inducing situation when the thought is accurate, and a behavioral change may be in order).

Cognitive Therapy in addiction treatment

Cognitive Therapy can also be very helpful with recovery from addictions. For example, for each instance of marijuana cannabis use, the therapist and teen can practice identifying the thoughts, feelings, and circumstances that occur around, before, and after the cannabis use.

Early in treatment, this plays a critical role in helping the teen and therapist assess the triggers, or high-risk situations. Becoming aware of triggers can help identify the circumstances that are likely to lead to drug use, and provide insights into some of the reasons why the teen may be using (e.g., to cope with interpersonal difficulties, to numb pain, to experience intense positive emotions not otherwise available in their life, or to celebrate).

Later in treatment, this may help identify those situations or states in which the individual still has difficulty coping, and helps them determine a response or behavioral strategy to help with these situations. This is called cognitive behavioral analysis which has been found to assist in recovery and behavioral change.

Mindfulness Therapy for Dual Diagnosis in teens

Substance abuse is an example of the human tendency to move toward pleasure and away from pain. Drug using teens are often experiencing internal psycho-emotional pain. An, it is critical that they adapt other coping tools for dealing with pain. This is where Mindfulness Therapy can help.

Mindfulness is another type of skill or practice (with origins in meditation) that can help in recovery. Mindfulness is the capacity to observe the thoughts that appear in the field of our mind without trying to push them away. This type of therapy involves cultivating moment-to-moment, nonjudgmental awareness of thoughts, feelings, and surroundings, so that a teen does not have to react automatically or avoid feelings.

With Mindfulness Therapy we are invited to:

Be present to the thoughts that arise.
Differentiate what we are thinking from what we are feeling.
Observe clearly the arising, the maintaining, and the dissolution of the thought.
Observe clearly that thoughts are impermanent, just like clouds.
Reduce the tendency of the mind to exaggerate the negative emotional states, diminishing feelings of guilt, shame, blame, fear, and criticism of ourselves and others.

With the help of Mindfulness, instead of trying to ignore negative thoughts or to stop ourselves from thinking, we simply allow ourselves to observe as clearly as we can what we are thinking and feeling. Mindfulness is taught through regular practice of both short and longer formal mediations and practices (e.g. mindful walking and eating, meditation with awareness to sounds or thoughts).

Key lessons teens learn through Mindfulness

Some key things that teens with dual diagnosis can learn through mindfulness include:

Thoughts, emotions, and sensations are like the waves on the ocean. They start, reach a peak, and slowly recede.
When we begin to pay attention to how our mind works we notice that our mind constantly moves into the past, to memories, regrets, blame, guilt, shame, or it goes to the future with questions about what if this or the other thing happens thus creating fear.
Mindfulness is NOT about the avoidance of visiting the past or future. But when we allow the mind to be constantly stuck in the past, we can easily fall into hopelessness, sadness, depression. When we allow the mind to move constantly into the future, we can easily move into fear, anxiety, and panic attacks. So we don’t want to allow the mind to reside in the past or future, or to gravitate between those two while missing the present moment.

Mindfulness practice teaches that the only moment that we have to learn about ourselves, to grow, and to change in in the present moment. For that reason Mindfulness Therapy can help with long term recovery and decreasing relapse by improving awareness and offering an opportunity to respond in the moment to triggers and automatic reactions and to act differently.

Combining Cognitive Therapy and Mindfulness for addictions

Cognitive Therapy can help teens change behavior through identification and modification of unrealistic thoughts and beliefs, and by allowing them to consider new behaviors. But what if you combine Cognitive Therapy WITH Mindfulness practices?

Combining Cognitive Therapy with Mindfulness training can help teens learn to develop an awareness over the processes that maintain the unrealistic thoughts and beliefs to begin with. That is, the combination of mindfulness and cognitive therapy helps change the process of thinking, not just the content of thoughts.

Evidence based therapies can help teens!

There are other evidence-based therapies that can help teens with depression and substance use disorders, including ones that use a family therapy approach. I will present these in future blogs. But I invite you to explore some of the clinical therapy resources below that use cognitive therapy and mindfulness and have shown evidence that they can assist with addictions and dual diagnosis:

Questions about dual diagnosis treatment for teens

Would you like to know more about the treatment of co-occuring disorders such as depressiona and substance addiction in teenagers? Feel free to post your questions in the comments section below, and we’ll try to respond personally and promptly.

About the author

Dr. Lisa Fortuna, M.D., MPH

Lisa R. Fortuna, MD, is board-certified in child and adolescent psychiatry and in addiction medicine, with over fifteen years of clinical experience with children, adolescents, and families. She is currently faculty at Boston University School of Medicine and medical director of Child and Adolescent Psychiatry at Boston Medical Center. She has published highly cited articles in the areas of post-traumatic stress disorder (PTSD), adolescent substance abuse, and Latino and immigrant mental health. She is the author of (with Zayda Vallejo M. Litt), Treating Co-Occurring PTSD and Addiction: Mindfulness Based Cognitive Therapy for Adolescents with Trauma and Substance Use Disorders (New Harbinger, 2015).