Teens and cravings: Understand their perspective

In one adolescent treatment group the discussion topic was: “What is your decision today about future use: Quit? Continue? Haven't decided anything yet?” One teen answered this way: “What I want to know is, how do you stop the cravings?” The counselor's reply: “You can't right away, but you can work with your cravings to learn how to deal with them, and they will get less strong over time.”

The teen responded, with frustration: “What good is deciding to quit, then?”

It is a surprise to substance-using adolescents that deciding to quit and not using actually won't stop cravings for substances. In the teen's view, the using keeps the craving going, so stop the using and the craving will just end—sort of “on command.” When this formula doesn't work, the young person has a sense that making a decision to quit without an immediate change in wanting to use is not only useless, but really unfair.

Further, there may be an unwelcome realization for the teen: “I thought I was in control of using alcohol, drugs, and tobacco, and now I find out that I really am not.” In one treatment group an adolescent was trying to decide if she had a “drug problem” and talked about “wanting it” as a factor about which she was concerned. As the group counselor, I asked, “So, if you want it, you have a problem with the drug, and if you don't want it, you don't have a problem. Is that what you are saying?” She replied, “Yes!”

Adolescent-specific issues

What's so different about adolescents dealing with cravings? First, adolescents don't know what to do about wanting to drink or drug once they have decided to quit but their “on command” thinking about cravings doesn't work. They talk about it like they have come to a dead end in their choices.

Second, they try simplistic solutions to the feeling of wanting drugs, such as thinking they can handle it themselves and control their cravings simply by not talking about it. Therefore, being asked to talk about it in a treatment group amounts to an exercise in frustration.

In addition, adolescents are highly peer-influenced, and their support network often includes friends who use. Being around these friends is a craving trigger, but adolescents are reluctant to deal with two sensitive issues about their friends: They do not want to distance themselves from their friends, even when these friends are continuing to use, and they often assume they can be around friends who use without giving in to drugs themselves.

Also, teens are unconcerned or afraid to tell their parents about having cravings. Teens describe some parents reacting to their substance use with high anxiety, uninformed thinking, and naïveté about chemical use, and overly simple solutions or punishing. Given this, teens may think that telling their parents about having cravings will invite an explosive emotional reaction, and who wants that?

By the time they decide to stop use, teens already may have developed some initial signs of a substance use disorder, so stopping can be difficult. Also, they may have a co-occurring disorder with onset during early adolescence, making an alcohol, tobacco, or other drug craving even more challenging to address.

Finally, teens do not want to tell a teacher, school counselor, or other adult that they have been using. This means embarrassment or the possible setting in motion of events they want to avoid: referral for other evaluation, and that parental reaction.

For a teen to remain abstinent, cravings must be dealt with. Being aware of the craving is a vital issue when a teen makes a decision not to use again, since the efforts to avoid use are in their initial, fragile stages. The adolescent's changed direction can falter without self-help that works. What can be done about the cravings, then?

It is important to understand that cravings happen with a blended expression in body, emotion, and thinking. Adolescents say they “just want it,” but usually can't say where they are feeling the bodily “want,” the emotion that goes with it, and the thoughts that accompany both. Bodily changes with a craving can include an increase in heart rate and respiration, muscular tension, digestive system reaction, and perspiration. Emotion that accompanies a craving can encompass anxiety and tension, irritability, aggravation, frustration and anger, or a listless feeling. Thought process becomes constricted, with the teen focusing more on the wanting and “getting it” with repetitive self-talk about using. Self-help about coping with a craving will be strengthened as clinicians assist teens to recognize, learn, and deal with these craving signals in body, emotion, and thought.

The clinician can teach the adolescent to become aware of what she is experiencing and what to do about each “signal”: getting away from peer talk about drugs or a situation where someone is drinking or drugging; doing slow, deep breathing to assist the relaxation response; talking with a trusted someone who understands; intentionally changing thoughts in the moment (thought-switching); doing some mild stretching to release bodily tension; and meditating on a helpful scene or phrase or getting involved in some positive activity that is liked. The goal is to relax the body and tense feelings, to clear the mind of “use thinking,” and to get support from someone who understands.

Helpful interventions

Clinicians also can help adolescents through these other interventions:

• Empathetic reality-talk. Convey your understanding with your view about the reality of having cravings (this won't just “go away,” and the adolescent will have to deal with it to stay abstinent). Also, a decline in having cravings does not mean the substance use issue is over, and an increase in craving frequency does not signal a loss or weakening of coping skill. Further, the teen does not have to label himself as having a “problem” with drugs or alcohol, or have to see it as the same kind of trouble others have. Coach the teen to see himself with his own kind of use “problem” (or anything else he would like to call it). The labeling isn't the issue; the self-help to deal with the craving is.

• Teach the adolescent to practice a routine self “check-in.” Ask her to state two things: “Do you feel like using today?” and “What is your decision about using again … quit, continue, or unsure?” Separating or “unhooking” the thinking from the wanting clarifies the difference. That is, the teen “wanting it” doesn't mean the using has to happen. The next challenge lies in following a decision not to use with behavior supporting avoidance.

• Coach the avoidance of “self-triggering,” which is prompting a craving or behavior that is a prelude to use. Self-triggers can happen by watching other people use, by standing around and talking about using, or by keeping company with peers who are not trying to be abstinent. Other self-triggers can include drug-oriented music and the collecting of posters or other objects that “glorify” substance use.

• Guide the teen in working on a “craving journal.” This is a daily record about having cravings and doing self-help, so the adolescent learns over time which self-care actions work and which do not. Journal entries will include the date of the craving, a strength rating from 1 to 10 for the craving, why the teen thinks he had the craving, the self-help tried, and a re-rating from 1 to 10 with comments after the self-help. Use this journal in individual or group counseling discussion.

• Educate about the “craving curve.” Adolescents say that some cravings can last for hours, yet most last for about 20 minutes. The craving curve is a cycle over time of less to more to less of the body, mind, and emotion character of a craving. Consistent self-help early in this cycle will show benefits over time in lowering the strength and duration of a craving.

• Teach relaxation breathing. Practice this with the teen during individual or group sessions, especially when he is having a craving in the moment because of talking about using. Review how the relaxation breathing is helping or not.

• Recognize any progress in abstinence and help the teen to put this in a realistic perspective about daily recovery. It's not the end of the journey, but it's not still the beginning either.

• Support self-confidence and development of endurance. Name the unhelpful self-talk and guide the teen to replace it; affirm steps taken in dealing with cravings; and confirm that self-help works to reduce the strength of wanting to use.

• Guide parents toward understanding that an adolescent having a craving doesn't signal disaster (“She's going to use again!”; “He's still behaving in the same old ways!”). Cravings are expected during abstinence efforts, and parents can help teens get through these by supporting them in talking about it.

• Other helpful suggestions include changing one's taste or smell (many teens say they can smell cigarettes or marijuana when they crave); listening to favorite music or singing; drawing or journaling; mild exercise; keeping a healthy diet; adequate sleep and recreation; positive activities; supportive connections with other recovering peers; and addressing stressors toward resolution.

There is no doubt that teens will struggle with wanting to use. Clinicians will give the most effective support when keeping in mind that both the perspective of the young person and the reality of having cravings to use must be considered in treatment.