The specific age group thats the focus of this paper could be categorized as the

Millennials, who have been defined by leading researchers Howe and Strauss, as those born
between 1982 to 1997 (Howe & Strauss, 2007). The millennials are a generation entering a very
difficult economic period, in terms of ease of social climbing and an ability to acquire a livable
income or wage. I believe that millennials require special considerations for different
health/mental health needs because of the fact that we were the first generation to grow up with
the internet and a completely different economic climate than we were raised in, and therefore
are uniquely at risk for bad outcomes.
In a very dense and detailed article cited by Time Magazine, Phillip Longman who
lectures at John Hopkins University, described a very different and difficult situation for
Millennials than previous generations. Mr. Longman cites a report by an economist from M.I.T.,
which graphs how in 1970 the inflation adjusted real wage median income for males between the
ages of 24-35 was almost $45,000 and was below $35,000 in 2012 (Longman, 2015). Mr.
Longman also found that average net wealth, which is total assets minus total liabilities, has been
decreasing ever since those born in 1952 and after adjusting for inflation, the median net worth
of families headed by a person thirty-five to forty years old was 30 percent less in 2010 than it
was for their counterparts in 1983 (Longman, 2015). Combined with the increasing cost of real
estate and the stock market, the slow disappearance of social security, the ever diminishing return
of private pension plans, and a larger than ever population, a disastrous mix is in the works
(Longman, 2015).
Not only are Millennials facing one of the most uncertain and difficult economic times
since the great depression, but a recent survey by the American Psychological Association finds
that Millennials report the highest levels of stress compared to older generations, and cite money,
work, and the economy as the primary reasons for their high stress; Millennials and Gen Xers
report the highest levels of stress per generation - 5.5 on a 10-point scale for millennials vs. 5.4
for Gen Xers, 4.5 for boomers and 3.5 for matures (American Psychological Association, 2015).
Another alarming finding was that, Millennials are more likely than other generations to say
that stress has a very strong or strong impact on their physical (30 percent vs. 27 percent of Gen
Xers, 25 percent of boomers and 12 percent of matures) and mental health (37 percent vs. 33
percent of Gen Xers, 23 percent of boomers and 11 percent of matures (American Psychological
Association, 2015). Taking all of the aforementioned information into account, as well as the fact
that stress and addiction have long been known in research to be highly correlated, Millennials
may be uniquely at risk for developing addictions and substance use disorders (Cornelius,
Kirisci, Reynolds, and Tarter, 2014).
The present client, Aaron, is a single heterosexual 30 year old Caucasian adult who
recently graduated from a master's program at Columbia Business School, but has not been able
to find a job for the past 2 years. Within the past year, he started using substances that he
acquired through the internet which he says was to deal with the depression and stress of not
finding employment. Namely different strains of marijuana, and hallucinogens like LSD,
MDMA, Psilocybin, and DMT rich substances. Aaron reports that he was a social or casual
marijuana and alcohol user in college but only casual alcohol use during his master's program,
but that his use had skyrocketed during the past year due to his depression and stress about not
being able to find a job and had been getting into spiritual videos on the internet as somewhat of
an escape. He reports that he has not had any type of substance abuse treatment or mental health
treatment before because it has never been this bad before. He currently has moved back in
with his parents in Westchester because he was unable to continue affording rent without a job.

He has one older sibling who does not live at home, and his parents are both working
professionals who pushed him to get help because of his substance use. He reports no legal
issues as he's very careful about how he purchases substances online with the use of bitcoin. He
denies any of the schizophrenia screeners in the bio-psycho-social such as hearing voices or
having visions that are not actually there. He answers in the affirmative to whether he felt life
was not worth living or having suicidal thoughts, and that he does have a plan about how he
would attempt, but no current intent to commit suicide. His mental status evaluation is that he
appears disheveled, oriented x3, above average intelligence, calm, blunted affect, normal speech,
in tact thought process and no hallucinations or delusions. Aaron also reports that he has no
known medical conditions or chronic pain and that he has had a physical in the last 6 months. He
also reports that he has been tested for STD's and HIV within the past 3 months. Aaron also
reports that he sleeps about 8 hours a day and eats around 3 times a day. Further, Aaron reports
that he is heterosexual and is involved in a committed long term relationship and that he does not
have any other sexual relationships. Client reports no history of physical or sexual abuse. Client
reports good relationship with parents and siblings, though recently his issues have caused some
strain at home. In regards to the spirituality assessment, Aaron feels very strongly that the only
way to escape his current struggle is to focus on his spirituality with the aid of hallucinogens,
marijuana, and guided meditation. He reports that he does not belong to a particular religion but
definitely believes in a higher power and that he is a spiritual being.
Aaron further reports that he spends most of his time listening to spiritual and business
lectures and doing yoga, and even cites how the aforementioned Ray Dalio mentions that
meditation, more than anything in my life was the biggest ingredient for whatever success I've
had in my life (Dalio, 2012). Aaron seems very preoccupied with the current economic situation
and is not sure whether he could even perform at the level required at a standard business job
today. He reports that he attempted to start his own business but that he did not have the adequate
funds, especially with the current cost of real estate, in that renting an office is an exorbitant fee.
He has been researching many videos and information from the internet to further evidence his
cause. For instance, he mentions Dr. Jon Kabat Zinn, the founder of Mindfulness Based Stress
Reduction, who has a talk where he discusses how when he started his MBSR program in the
1970s, he mentions how people would be confused when he told them he specializes in stress
reduction, because people would ask him what stress? Aaron further mentions how Dr. KabatZinn then agreed that he has seen stress levels increase over the years, partially because of how
I could get more work done in a day than I used to be able to in a month, because of the
internet, which Aaron echoes that the expectations at work are so much higher now, and he
doesn't feel he can keep up with the current requirements (Kabat-Zinn, 2008). Further Aaron
goes into how much more difficult it is to make money as a businessman, and he cites a lecture
by Ray Dalio, who is CEO and Founder of the largest Hedge Fund in the world, where he cites
that we will only see a 4% increase in the overall market for the next 10 years, and Aaron feels
that being a businessman is almost impossible now because of how much it costs to start a
business with salaries and benefits, and renting office space, while he already has over $100,000
worth of student debt. (Dalio, R. 2012).
Aaron also cites P.H.D. Economist Tyler Cowen, who write in his book, that a lot of the
low hanging fruit has already been taken, including free land, simple technological
breakthroughs, and smart, uneducated competition as evidence of how hard it is to start a
business now because a lot of the easier ideas have already been taken (Cowen, 2011) Aaron
also cites how interest rates are much lower now, and how you could essentially become rich in

the 1970's just by keeping your money in the bank because rates were around 10% (Lewitinn,
2013). Aaron keeps saying he doesn't want to be a slave working 12 hours a day just doing busy
work for the next 10-20 years and never moving up in the ladder, or only slightly moving up that
it doesn't work in regards to cost/benefit. Finally, he cites the rising cost of real estate and how
the previous generation could buy homes for cheap, and now it costs around at least $1 million to
buy even an apartment in New York City. However, he also reports and exhibits mental health
issues, which seem to be related to his preoccupations and presentation.
In order to inform the assessment, it would be beneficial to start with the macro and work
our way in, in order to understand something about the theories of addiction and where the
current state of research lies. The theories of addiction in general range the gamut from
biologically, psychologically, socially, and spiritually based theories (Doweiko, 2014). However,
as with mental health, the dominant model is still that addiction is primary and often chronic
disease of the brain even though research and clinical data reveal no single etiological factor
that accounts for addiction as opposed to abuse (Straussner, 2014). Twin studies have led to
researchers believing that genetics and biochemical wiring of the brain are strong determinants to
whether and individual will become an addict (Straussner, 2014). In regards to the psychological,
some view addiction through the lens of various psychological theories, due to various based on
four different ideas: 1) resulting from insecure attachment due to interpersonal childhood
adversities, 2) an attempt to deal with poor ego development, 3) regression to or fixation at the
stage of pathological narcissism, and 4) an effort to overcome a deficiency in the sense of self,
and the substance serves as a substitute to an adequately integrated self (Straussner, 2014).
Family has also been found to be an important determinant of whether an individual is at risk for
addiction, most notably due to whether the relationship between caregiver and child was
adequate (Straussner, 2014). Finally, the spiritual theories underlying addiction and substance
abuse have to do with understanding one's place in the world, understanding one's self, and
transcending one's inflated self image/ego through humility (Doweiko, 2014).
In regards to the neuroscience, the authors Begin and Brown assert that the research has
found that around 50% of substance use disorders are caused by genetics and the other half was
due to another source, which echoes the aforementioned sentiments found in twin studies
(Straussner, 2014). Genes passed down from generations can affect or influence the biological
mechanisms of the brain and body (Straussner, 2014). In regards to the actual brain, the
amygdala, which plays a role in drives, emotions, and attention, is believed to be responsible for
determining which experiences related to pain and pleasure will be encoded into memory,
which relates to the euphoric recall of addicts where they are quick to remember the positives of
addiction and leave out the negatives (Straussner, p. 44 2014). Another important aspect
regarding the brain is the role of neurons, and the release of neurotransmitters which can alter
feelings and felt experience; also much of the effect substances have on the human brain is a
result of the interaction between the substance and the brain's neurotransmitters. Finally,
neuroplasticity introduces another important aspect of how the brain functions, because it's now
understood that the brain can add, delete, and rearrange neural components in the brain based on
environment and experiences (Straussner, 2014).
In regards to assessment, there are important differences between assessing and treating a
mental health issue versus assessing and treating a Substance Use Disorder. Starting with the
assessment of substance use disorders, there are various different screening tools that can give a
clinician a good starting point of which to work from, that have proven their validity, but there is
no definitive way to know whether someone has a substance use disorder and all the information

gathered must be taken into account (Doweiko, 2014). If a screener tool leads to the inference
that one has a substance use disorder, than a full assessment must be done; one important
symptom to note is whether an individual is experiencing withdrawal symptoms which is a
strong indicator for a substance use disorder (Doweiko, 2014). A quick verbal screening tool that
can be used is TWEAK, which asks about tolerance, whether others have bothered them about
use, whether they've had a substance first thing in the morning, whether they've had amnesia
during use, and whether they've felt the need to cut down; a yes response to any question
suggests a possible SUD (Doweiko, 2014). In the present case, Aaron answered in the affirmative
to at least one TWEAK question and also we learned that he is experiencing withdrawal
symptoms from the bio-psycho-social it is now clinically necessary to move to a more thorough
assessment in order to understand the severity and frequency of the substance use disorder, and
what kind of treatment is appropriate (Doweiko, 2014). However, there is no one size fits all
standard form for the assessment process, as a lot of the determination is controlled by agencies
and regulators (Doweiko, 2014). When working with individual clients, it's optimal to create a
single case design strategy in order to properly assess an individuals (Di Noia & Tripodi, 2008).
An important point regarding single case designs is that each separate substance or mental health
symptom requires a separate baseline measure in order to gauge progress and inform treatment;
it's also important to gather several baseline data points over time in order to ensure proper
sample size (Di Noia & Tripodi, 2008). Some of the background information that has been
found to be clinically relevant in conducting a full assessment to correctly identify a substance
use disorder is as follows: 1)circumstances of referral, 2)substance use patterns, 3) past
treatment history, 4) legal history, 5) past military record, 6) educational/vocational history, 7)
developmental/family history, 8) psychiatric history, 9) medical history, and 10) personality
disorders (Doweiko, 2014). Another important assessment tool is toxicology data, however it's
again important to gather toxicology data over time and not diagnose a substance use disorder
from one dirty toxicology reading (Doweiko, 2014). In regard to the DSM-5, the new format
lists each individual substance as a separate use disorder that ranges from mild, moderate, to
severe; for example, in the present case it's possible that Aaron has a Cannabis Use Disorder
(American Psychiatric Association, 2015). However it's important to note that the criteria listed
under each substance use disorder in the DSM 5 is not definitive or comprehensive assessment
tool for identifying Substance Use Disorders; it's rather a list of possible signs that have been
found to be correlated with substance use disorders (Doweiko, 2014). There is also another
important assessment tool and level of care determinator created by the American Society of
Addiction Medicine (ASAM), which includes 6 different dimensions of assessment: 1) acute
intoxication and/or withdrawal potential, 2) biomedical conditions and complications, 3)
emotional, behavioral, or cognitive conditions, 4) readiness to change, 5) relapse, continued use,
or continued problem potential, and 6) Recovery/living environment (ASAM, 2015).
Starting with the first set of criteria, Aaron was referred to treatment with the influence of
his family who were concerned about his well being, and in regard to his use he answers that he
uses marijuana daily, and different hallucinogenics about once a week. He denies any past
treatment history, in regard to either mental health or substance use, as well as any legal history
or a past military record; he also, has not ever had a full time job since high school as a waiter.
Client reports that his parents are immigrants from France and he was raised in a loving home
with his older sister, however he cites an issue with the fact that his parents never went to college
and started working without much education in business jobs. He also mentioned that his parents
went through a lot of trauma, as they were both raised in poverty by substance abusing and

abusive parents without much family in terms of sibling or cousins, and lost faith in religion and
spirituality as a result of their difficult life. This is part of what Aaron cites as his fixation on
spirituality, meditation, and hallucinogenics because he didn't grow up with spirituality in his
home and feels very drawn to it because he says he missed out. In terms of psychiatric history,
Aaron mentions how he had struggled with some depression and anxiety growing up, but never
sought treatment for it and was able to function enough to get through college. Therefore, he's
never been tested or had a mental health or substance use diagnosis. In regards to medical
history, Aaron reports that he does not have any known medical issues, and that a recent physical
returned his blood work all at healthy levels.
In regards to the ASAM criteria, the first dimension dictates to explore an individual's
past and current experiences of substance use and withdrawal. (ASAM, 2015) It's important to
note that each individual substance has it's own withdrawal symptoms in order to know what to
look for, it's not a one size fits all approach to just look for general withdrawal signs (Doweiko,
2014). In regards to marijuana, withdrawal symptoms that researchers have noted are
irritability, aggression, anxiety, depression, insomnia, sweating, nausea, tachycardia, anorexia,
cravings for marijuana, and vomiting (Doweiko, 2014). The second dimension refers to
biomedical or physical health conditions, both past and present, and has already been discussed
in this paper, there are no medical conditions that Aaron's test results or Doctors believe to be
present, and Aaron denies any noteworthy medical conditions from his past (ASAM, 2015) The
third dimension deals with exploring an individual's thoughts, emotions, and mental health
issues,which can be determined by utilizing different mental health screeners and eliciting
information from Aaron (ASAM, 2015). In this case, a mental health screener that could be
utilized would be the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure- Adult,
which was released by the American Psychiatric Association (American Psychiatric Association,
2015). If the scoring of the screener comes back positive for exceeding the clinically acceptable
threshold, then the DSM-5 Level 2 Cross Cutting Symptoms Measures or another measure
geared toward a specific symptom, would be appropriate to test the severity of the specific issue,
i.e. depression, stress, etc. (American Psychiatric Association, 2015). In this case, Aaron tested
positive and expressed clinical issues with stress and depression, therefore it would be important
to gather data points through questionnaires over a period of time in order to establish Aaron's
stress and depression baselines (Di Noia & Tripodi, 2008) Gathering baseline data is important
so that a clinician can gauge an individual's progress over time in order to understand if the
treatment is actually working and to have a better objective understanding as to the client's
current mental health status (Di Noia & Tripodi, 2008). Moving on, the next ASAM dimension
has to do with an individual's readiness to change. (ASAM, 2015). This dimension is related to
client motivation and the stages of change: precontemplation, contemplation, preparation,
action, and maintenance (Straussner, 2014, p. 379). It's important to assess an individual's
readiness to change with a measure in relation to each specific issue or disorder that you're
working with, as their readiness to change may not be uniform, for instance a client may be
ready to deal with their depression but not their alcohol use disorder (Straussner, 2014). Further,
each stage correlates to a different strategy targeting a different aspect of individual recovery
(Straussner, 2014) In the present case, it's likely a measure would find that Aaron is either in the
precontemplation or contemplation state in regard to his substance use of both marijuana and
hallucinogenics, because he's still actively using and has not decided that he should quit
(Doweiko, 2014). The next dimension of the ASAM criteria, dimension 5, has to do with relapse
and continued use, and we know that Aaron continues to use both marijuana and hallucinogenics

because he admits to it and it shows up in his toxicology tests (ASAM, 2015). Finally, the last
dimensions has to do with where an individual lives, and the people, places, and things he's
surrounded by (ASAM, 2015). Here, Aaron reports that since he lives with his parents that they
drink only occasionally in social situations but do not smoke marijuana or use any
hallucinogenics, and do not use any other substances unless prescribed for a particular issue
though that's not currently an issue.
In regards to the DSM 5, it must be found that the substance led to a problematic pattern
of use leading to clinically significant impairment or distress, as manifested by at least two of the
following, occurring within a 12-month period (American Psychiatric Association, 2015).
However, it's again important to note that the DSM-5 criteria are not meant to be an all
encompassing diagnostic tool, and other information should be taken into account, though the
DSM-5 categorizes each substance use disorder on a range from mild, moderate, or medium
based on how many of the listed criteria are determined to be present (Doweiko, 2015).
However, taking the criteria on its face, Aaron would most likely be considered to have a
Cannabis Use Disorder, fulfilling at least 3 of the listed symptoms, namely: 1) craving, or a
strong desire to use Cannabis, 2) tolerance, and 3) withdrawal symptoms of aggression and
depression. Aaron would also probably be found to have an Other Hallucinogen Use Disorder,
because again he meets some of the criteria, namely: 1) craving, or strong desire or urge to use
the hallucinogen, 2) continued use despite interpersonal problems with family, and 3) failure to
fulfill major obligations because he cannot find a job or take care of himself adequately in being
independent (American Psychiatric Association, 2015).
The cultural aspect is also an important consideration in assessment and delivering
treatment for clients, however it's also still important to honor the individual and not to
categorize clients and assume things about them. Culture can be found to include aspects of an
individual like: race, history, values, education, age, sex, religion, and immigrant status (Evans,
Achara-Abrahams, Lamb, & White, 2012). In regard to Aaron it's important to note that he is a
30 year old American born Caucasian male of French descent, though he does not speak French,
and his parents have a history or being raised in a traumatic environment. Aaron also obtained a
Master's Degree, and does not identify with a specific religion, but considers himself very
spiritual. When asked about values, Aaron cites that he was raised with a strong business sense
and that respecting money is an issue for him, perhaps partially because his parents were raised
in poverty. It's important to take these cultural considerations into account throughout treatment,
in both assessment, and during intervention because it's important to know how to optimally
communicate with another individual during the therapeutic process.
In discussing treatment or intervention approaches it's important to note that not only are
treatment level of care determinations important, but that aftercare treatment is also very
important in order to ensure an individual's long term stability rather than just receiving a short
spike of wellness (Doweiko, 2014). I believe the best form of care to start with for Aaron would
be an outpatient program suited toward other clients his age and race, as well as one that has an
adequate spiritual focus, as that's something very important to him. A definition of outpatient
substance abuse rehabilitation programs might be defined as a formal treatment program
involving one or more substance abuse rehabilitation professionals, designed to help the person
with a substance use disorder develop and maintain a recovery program, which will utilize a
variety of treatment approaches and marital therapies, individual and group therapy formats,
which is designed to do so on an outpatient basis (Doweiko, 2014, p. 430). Partially why I
believe Aaron would do well at an outpatient program is because he would receive care from

different types of professionals, and it would not be as traumatic as sending him to an inpatient
setting when he's not far along the stages of change and does not appear to be in immediate
danger due to his substance issues, as well as his concern for money as residential programs can
be very expensive. I believe Aaron would benefit from attending group therapy at least 2-3 times
per week, as well as twice a week hour-long individual sessions through outpatient care. I think
the group therapy will allow him to meet and hear others who are going through similar issues,
as well as having his family involved in some way, as some programs have family nights to
hear concerns from family members (Doweiko, 2014). The outpatient setting will give Aaron
structure and co-create a treatment plan with him, in order to help him work on his goals through
a partnership with care providers. It would also be important while Aaron was in outpatient
treatment to determine whether his mental health issues are being caused by the substances or if
they're separate, as it can be difficult to determine which symptoms are being caused by a
substance using client (Doweiko, 2014).
In terms of expected results, I think it's important to have a realistic idea of where the
client will be in the near future and over the long term. I think for Aaron it will take some time to
work through his ambivalence about his substance use and progress through his spiritual journey
enough so that he feels satisfied. It may take Aaron a while to come to grips with the difficulties
and suffering in life, because he seems to feel or be brought up to believe that he should be able
to live happily and not in an overwhelmingly difficult state of affairs. Some feel that substances
take the place of the spiritual in order to numb themselves from the pain of life, but Aaron feels
that the substances are tools to help him move forward in his spiritual search, which may take a
long time to work out in treatment (Doweiko, 2014) I think in treatment they will have to utilize
his ambivalence and target that state of readiness to change by teaching him of some of the ill
effects that are possible through using these substances, as well as offering him hope of picking
up where his life left off (Doweiko, 2014). I also think targeting his mental health issues by
creating specific baselines for each symptom will allow clinicians to slowly move Aaron away
from substances by showing him he can feel better without them. As was once was told to the
found of A. A. Bill Wilson, ego deflation is a necessary first step in the process of recovery, and
something that Aaron may already be working toward (Straussner, 2014). I also feel that a
spiritually minded program and spiritually minded clinicians will allow Aaron to learn in a way
related to Yalom's therapeutic factors; most notably through the universality of Aaron's
experience in others, and also through support and guidance of others who have had to navigate
through similar issues (Yalom, 2005). I also think utilizing motivational interviewing will also
allow Aaron to see how he may be working against himself, because he is fairly motivated to
find a job and move forward with his life, but needs to see that the way he's going about his
substance use and working toward spirituality may ultimately be counterproductive to his long
term goals (Straussner, 2014). An important aspect of motivational interviewing is utilizing a
client's own motivation and rolling with resistance, in order to elicit from them their goals and to
try and have them come to their own conclusions and realizations of how to proceed in a healthy
and positive way without force or condemning their behavior (Straussner, 2014).
In conclusion, I feel that from this assignment I learned more about how substance use
disorders are identified and assessed, and ultimately treated. Specifically, what methods, tools,
and measures are used to identify and assess a substance use disorders, and some of the different
treatment method options based on the type of substance being abused and the severity. Also, I
feel that I reviewed all we have studied behind theories of addiction as well, such as the
neuroscience behind addiction. I think I may want to know more about the different assessments

measures and tools, as well as the level of care determinators, such as how the ASAM criteria
actually works to determine level of care. It also showed me how the substance abuse field
requires understanding of so many different areas, such as the brain chemistry science, different
substances and their interactions, the many ways different substances are absorbed into the body,
the spiritual aspect of addictions, and all the different treatment options to those addicted to
substances.

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