Kevin Ducray

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• Kevin Ducray
• Senior Clinical Psychologist
• The Drug Treatment Centre Board
• November 2006

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• Individual Therapy Approaches to Adolescent
  Substance Misuse
• Introduction
• Challenging and intimidating?
• In its own infancy (or "adolescence")?
• Complex clinical condition
• Associated with co morbid psychiatric/
  psychological disorders
• Client- related barriers to treatment
• Interplay of biological, psychological and social
  difficulties
• Role of politics, economics, culture and ideology
  in shaping attitudes?
• (Disease, abstinence, confrontation,
  criminalisation versus harm- reduction,
  pragmatism, collaboration, egalitarianism)

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Paucity of research on effectiveness of
adolescent psychological treatments Adult
treatments well researched Paucity of research
on adolescent psychological interventions Adoles
cent studies often suffer from the following
methodological problems small sample
sizes lack of randomized sample
assignment inadequate measures and
descriptions of patterns and levels of
use wide ranges of levels of participant drug
use (casual / abuse/ dependence) impact of
dual diagnosis high drop out
rates assessment tools loaned from adult
treatment researchers own/ self developed
tools scales' psychometric properties often
unknown inconsistent methodology in terms of
time scales (e.g. of prior use, post treatment
outcome) variable methods of determining
level and frequency of use what constitutes
successful outcome? (Source Waldron and
Kaminer 2004 Kaminer 2001 Muck et al. 2001)
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Tendency to extrapolate empirically validated
adult models to adolescent populations. Clinical
Differences between Adults and Adolescents More
susceptible to development of dependence
syndromes Rapid progression from casual use to
dependence Higher degree of co- occurring
psychopathology Psychopathology precedes the
onset of substance use Psychopathology often
does not remit with abstinence Greater
constellation of needs and problems (often inter-
related) Dependence impacts upon developmental
pathways Developmental variability between
adolescents Need for flexible/ tailored
approach? Interventions must be sensitive to
the above differences Greater intensity and
duration of treatment than adults? Habilitative
as opposed to rehabilitative strategies? (Sourc
e Muck, R et al, 2001)
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Adolescent Drug Abuser's Needs/
Challenges Psychological Resistance/
Ambivalence Chaotic Disengaged L
ow frustration tolerance/ Impulsive Irritabi
lity Emotionally Fragile Dependency
and motivation to change? Physical Physi
cal illness Hep C/ HIV Basic Needs Unmet
(Maslow) Social No close relationships
outside the context of drug use Difficulties
of relating to authority figures Pattern
of downward social drift" Power of peer
pressure Predilection for testing
limits Disruptive deviant associates
disrupt/ undermine progress Violence and
harm (debts, dealers, disputes, pimps and
family) Absence of effective pro- social
reinforcers that compete with drugs?
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Developmental Negative impact upon development
of Coping skills Pro- social identity
formation Interpersonal skills Communication
skills Educational/ Vocational skills Family
responsibilities Work responsibilities In
extrapolating evidence- based adult models, one
needs to be extremely mindful of the unique
needs characteristics developmental
issues problems characteristic - of young
people who misuse drugs
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Individual Therapy Approaches to Adolescent
Substance Misuse Objectives (1) Provide
brief overview of approaches regarded suitable/
appropriate for adolescent substance
misuse (2) Sensitise delegates to their
many existing competencies (skills/ knowledge/
attributes) Generic competencies required to
assist adolescents with drug problems.
Addiction shares principles of genesis,
acquisition, and maintenance with other
psychological disorders Addiction rarely occurs
in absence of related psychological
problems Evidence based approaches for treating
alcohol/ drug problems are familiar to many
practitioners Cultivating a respectful
relationship, accurate empathy, individual psycho
education, instilling hope is generic and is
associated with positive outcomes.
(Obviously would not detract from the
practitioner's need to obtain the necessary
training and supervision should they wish to
formally apply these approaches within the
context of a defined care plan)
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Motivational Interviewing (William R Miller and
Stephen Rollnick) Motivational Interviewing is
a directive, client- centred counselling style
for eliciting behaviour change by helping clients
to explore and resolve ambivalence"(Miller, R
and Rollnick, S, 1991, pg. 8) Explicitly
egalitarian and respectful Most influential,
exciting and promising recent therapeutic
development within addiction? Spirit of
MI Motivation elicited not
imposed Client's role to articulate and
resolve their ambivalence Therapist's role
to highlight ambivalence impasse, guide client to
a resolution that triggers change Persuasion/
confrontation counter productive Quiet,
respectful and eliciting, never argumentative or
confrontative "Resistance and denial" not
client traits but product of therapeutic
interaction Therapeutic relationship more a
partnership than a expert/ recipient
role The "spirit" or interpersonal style
gives rise to therapeutic behaviours Notion
of "set of techniques being used on people" is an
antithesis to MI
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Recommended strategies for building motivation
for change 'Open ended' questions Listen
reflectively Affirm Summarise Ascertain
readiness for change (e.g. Explore advantages
and disadvantages for problem behaviour) Elicit
self- motivational statements Goal is for
client to realise cost of problem behaviour
exceeds any benefits Strengthen commitment to
change Negotiate a treatment plan Support
Self-Efficacy - There is no right way
to change
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Particular Utility? Angry clients Cross
cultural therapeutic relationships/ Minority
groups Low motivation, ambivalence, reluctance
to change Problem behaviours are highly
rewarding Produce/ evoke rapid, internally
motivated change No significant psychological/
psychiatric pathology MI shown to improve
outcomes of subsequent other evidence based
interventions A safe and economic starting
point for one to one psychosocial therapy May
be suitable framework to initially address client
motivation, who once motivated to change, can be
assisted with skill development? (Source
Project MATCH Research Group 1999, Miller et al
1995, Miller 2006) Motivational Enhancement
Therapy MET- 4 planned, structured and
individualised check up and follow- up sessions
for problem drinkers MI is the style,
philosophy or approach used
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Cognitive Behaviour Therapy (CBT) Heterogeneous
mix of interventions aimed at improving
cognitive and behavioural skills to change drug
related behaviour A combination of Cognitive
Therapy (CT) and Behaviour Therapy (BT) BT -
seeks to inhibit maladaptive behaviour by
reinforcing desired behaviour and extinguishing
undesired behaviour CT- a system of
psychotherapy that attempts to reduce excessive
emotional reactions and self defeating behaviour
by modifying the faulty or erroneous thinking
and maladaptive beliefs that underlie these
reactions (Beck et al, 1991, pg. 10) CT-
facilitates positive behaviour change by
examining and changing distorted patterns of
thinking. CBT- integrates cognitive
restructuring' with behaviour modification
techniques and skills generation Abnormal
thinking changed by Verbal techniques
(explanation, discussion, questioning and testing
of assumptions) Behavioural actions which can
be used to change the way someone thinks
(Learn from their experience, use real life
experience to challenge faulty cognitions
) Behaviourally there is an emphasis
on Increasing the ability to cope with
(interpersonal and intra personal) situations
that precipitate or maintain drug
use And Overcoming skills deficits
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Schema (fundamental core beliefs) giving
rise to enduring assumptions, attitudes and
thoughts which set in motion problematic
behaviours may be focus of attention Drug use
(according to Social Learning Theory) is also
functionally related to major life
problems Addressing this broad range of
problems will be more effective than addressing
drug use alone Treating concurrent disorders
and other life problems seen to be a legitimate
focus Emphasis on learning and practicing a
variety of coping skills (some cognitive and some
behavioural). Can be didactic in early
stages CBT- Practitioners approach drug use
behaviour as a Learned Behaviour Substance
misuse and related problems are learned
behaviours Initiated and maintained in a
particular environmental context As behaviours
are learned so they can altered by application of
learning principles
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Operant conditioning- focus on important and
particular reinforcers ( and -) Manage
("extinguish") urges Explore reinforcers for
competing behaviours Classical conditioning-
pairing Paraphernalia, places, people, times,
mood states, feelings associated with the
various stages of drug use Preoccupation,
planning, procurement, use Anticipate and
avoid high-risk situations (settings, times,
places which serve as triggers or stimulus
cues) Social Learning Model- Modelling/ -
copying and watching others Incorporates
classical and operant learning principles Recogn
ises influence of environment on behaviour
acquisition Acknowledges role of cognitive
processes (how environmental influences are
appraised and perceived) Drug use and misuse
thus influenced by Observation and imitation
of parents, siblings, peers, role
models Social reinforcement Anticipated
effects/ Expectancies Direct experience of
drug's effect being rewarding Self efficacy
beliefs
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Major components (1) Aimed at helping
clients anticipate and avoid an initial slip or
lapse (2) Designed to reduce the intensity,
duration, and harmful consequences of any slips
that do occur (3) Following a lapse, to
encourage clients to continue their journey and
accept that change involves both advances and
setbacks. (4) Development of skills to
increase ability to deal with these high risk
situations (5) Learn to create more balanced
lifestyle (Engage in Meditation, Exercise,
Spiritual Practices) Encouraging
evidence RPT is an effective psychosocial
treatment for alcohol and drug problems
Effective for poly- drug use when alcohol is
one of the substances misused Skills learnt
during interventions remain after completion of
treatment Gains maintained for 12
months (Source Carroll 1996 Carroll et al.
1991 and 1994 Irving et al. 1999 Marlatt and
Gordon 1985)
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The Matrix Model Richard Rawson, Ph.D
Intensive 16 week outpatient framework for
helping clients achieve abstinence (esp.
stimulants) Weekly aftercare sessions Draws
upon other tested modalities (Urine testing,
family, group, social support and self- help
approaches) Focus on the fundamentals of
stabilisation, abstinence, maintenance and
relapse prevention Individual therapeutic
relationship is seen to be critical for client
retention Teacher and a coach Empathic and
directive, support critical Role is to give
clients the knowledge, structure and support to
achieve abstinence Clients learn about issues
critical to addiction and relapse (Early
recovery skills Drug education Relapse
prevention Relapse analysis) Therapeutic
relationship is positive and encouraging Realist
ic and direct, not parental, confrontational (or
"therapy" in the classical sense) Self esteem,
dignity and self worth is promoted in
sessions Has been manualised into systematic
treatment protocols Shown to Facilitate
statistically significant reductions in drug/
alcohol use (effective across substances)
Improve psychological indicators Reduce
high-risk sexual behaviours (Source Huber et
al. 1997 Rawson et al. 1995)
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Supportive Expressive Psychotherapy (Adapted for
heroin and cocaine abuse) Time limited,
focussed, psycho dynamic treatment Concentrates
on Role of drugs in relation to problem
feelings and behaviours Impact of inner
struggles on behavioural/ emotional problems
Exploration of how problems and difficulties
can be solved without resorting to drug
use Major features Use of supportive
techniques to assist clients feel at ease in
relating their personal experiences Use of
expressive techniques to help clients recognise
and resolve interpersonal and relationship
difficulties Adult clients on MMT with mental
health difficulties who were exposed to this
intervention had 1) Lower cocaine use and
required less methadone for opiate
difficulties 2) Improved outcomes for opiate
users with psychiatric problems on MMT 3)
Maintained gains for longer Has been manualised
for treatment of opiate and cocaine dependence
(Source Luborsky 1984 Woody et al. 1987)
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Behavioural Therapy for Adolescents Unwanted
behaviour can be changed by Demonstration of
the desired behaviour Agreed upon sets of
behaviours to be changed Daily or weekly
goals Rewarding the incremental steps made
toward achieving these goals Equipping the
client gain the following types of
control Stimulus Control Avoid situations
associated with drug use Increase time spent
in activities incompatible with drug use Urge
Control Help clients recognise and change
thoughts/ feelings/ plans that lead to
use Social Control Involving significant
others in helping the client avoid
drugs Significant others can contribute to
therapeutic assignments/ reinforce desired
behaviours Therapeutic behaviours can
include Completing assignments Rehearsing
desired behaviours Recording and monitoring
progress Receipt of rewards and privileges for
accomplishing assigned/ negotiated goals Urine
samples are collected on a regular and structured
manner to monitor chemical use More effective
than supportive counselling Demonstrated to help
adolescents attain and maintain drug
abstinence Improvements shown in related indices
such as school attendance, quality of
relationships, depression and alcohol
use (Source Azrin et al 1994 and 1994)
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Integrated Dual Diagnosis Treatment (IDDT) Robert
Drake, Susan Essock, Andrew Shaner, Kenneth
Minkhoff et al Many people with addictions have
co- occurring mental illness (gt60 of
adolescents Bukstein et al. 1992) IDDT offers
concurrent mental health and addiction
interventions in same setting Hope, optimism,
and a positive atmosphere are core
beliefs Others recovery is used to promote a
positive expectation A personalised treatment
plan for both mental health and addiction
problems Individualised treatments are
determined by stage of recovery Interventions
are structured in a stage- wise fashion given
their relative significance to treatment (Some
services are important during the earlier phases
of treatment and vice versa) Interventions are
comprehensive and long- term Interventions
include Psycho- education about clients
illnesses and conditions Relationship
counselling and living skills Help with
budgeting and money management Employment
advice Specialised counselling focussing on
symptom management Approved by Office of Mental
Health and Addiction Services (US) as an
Evidence- based Practice
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Individualised Drug Counselling Emphasis on
stopping or reducing drug use Focus on short
term behavioural goals Strategies and tools to
help attain and maintain abstinence 12 Step
participation is strongly encouraged Also
addresses areas of impaired psycho- social
functioning salient to drug use involvement
with negative peer groups criminal
activities interpersonal and family
relations education Twelve Step Facilitation
(TSF) Therapy (Joseph Nowinski) Facilitates
active participation in AA/ NA AA seen as
primary factor responsible for recovery Widely
used internationally Addiction/ alcoholism a
spiritual and medical "disease" Must be managed
through- out life Recovery equated with
abstinence Brief, structured, manual driven
approach
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Implemented on an individual basis in 12- 15
sessions Treatment based on spiritual,
cognitive and behavioural principles that form
the basis of AA and NA fellowships Template
12- Step Programme- stepped sequence of treatment
and lifestyle goals Honesty Decisions
regarding cessation of drug and alcohol use An
action plan for lifestyle change Correction of
past wrongs where possible, continue a recovery
plan for the rest of life) Increasing
scientific attention Greater abstinence at 12
months than other approaches (Project MATCH
1996) AA/ NA enhances outcome when component of
ongoing formal interventions Beneficial effect
additive rather than independent Stand-alone
AA/ NA attendance does not improve
outcome Dose effect found Merit in
encouraging 12 step attendance as an adjunct to
formal treatment. Increasingly accepted by
clinicians? (Source Project MATCH 1996
Alford et al. 1991 Fiorentine1999 Fiorentine
and Hillhouse 2000 Winters et al. 1999 and
2000)
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Contingency Management Treatments Nancy M.
Petry Widely used in substance misuse
research Gaining popularity despite some
attitudinal resistance Clients awarded tangible
positive reinforcers for objective behaviour
change Vouchers for negative urine
samples Clinic managed account Staff purchase
requested items (audiovisual equipment, sports
goods, clothing, cinema tickets etc.) Positive
effects unambiguously demonstrated when compared
to traditional treatments Almost doubles average
period of abstinence when added to
psychotherapy Barriers - cost
- attitudes, esp in parts of the world
where abstinence orientated, confrontational
approaches dominate Prize Contingency
Management - as efficacious as the voucher
system - costs reduced by two
thirds Some political and ideological
criticisms - the technique "mimics
gambling" - why pay addicts what they
should do anyway? Payments to drug users have
rarely induced drug use and have not led to an
increase in gambling Improves retention and
stimulant use abstinence in non- methadone
settings Increases proportion of drug negative
samples submitted in methadone settings
(Source Petry 2006)
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Adolescent Community Reinforcement Approach (CRA)
with Vouchers Developed as individual
counselling approach (alcoholism) CRA with
Vouchers is an extensive 14- 24 week out patient
therapy Initially designed for cocaine
addiction Used for cocaine dependent clients
who use alcohol/ MMT patients who use
cocaine Goals Achieve abstinence for
sufficient duration to develop life skills to
sustain abstinence Reduce alcohol
consumption Clients attend one- two
psychotherapeutic sessions weekly aimed
at Improving family relations Developing
skills to reduce drug consumption Vocational/
educational related issues Developing new
recreational interests, activities,social
networks Vouchers received for drug (esp.
opiates and cocaine) negative samples (various
systems) Vouchers are exchanges for goods
which are consistent with a drug (esp. opiates
and cocaine) free lifestyle Cocaine or Heroin
positive urines reset value of voucher to initial
baseline level Focus on fostering engagement
and a systematic gain in periods of
abstinence Voucher- Based Reinforcement Therapy
in Methadone Maintenance Therapy (MMT) Very
similar to above model

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Dialectical Behaviour Therapy (DBT) Modified
for Substance Abuse (DBT- S) DBT adapted for
adolescents Marsha Linehan DBT increasingly
extended to older adolescents with addiction,
dual diagnosis and mental health
issues (Suicidal concerns, deliberate self harm,
poor emotional and impulse control,dramatic
interpersonal styles and impaired
interpersonal skills) Included
as Adolescent alcohol use disorders predictors
of adult borderline personality disorder
(Thatcher et al, 2005) Individuals with BPD
often suffer from alcohol and substance abuse
(Benjamin, 1993 ) A complicated reciprocal
relationship exists between BPD and drugs (Stone,
1993 ) Individuals with BPD are characterised
by drug seeking behaviour (relief and escape)-(
Millon,1996 ) Individuals with BPD are "the
best candidates for developing addictive
disorders" (Richards, 1993 ) The treatment of
any character disorder is the road to recovery
for addiction (Khantzian et al, 1990 )
"...borderline patients pose tremendous
challenges to therapists who are working
diligently to help them overcome addictions
to drugs" and "As separate identities,
substance abuse and...the borderline syndrome are
difficult to treat. In combination, the clinical
picture becomes extremely challenging indeed"
(Beck et al, 1993) Cited in
Ekleberry, 2000 The borderline schema "I'm
bad and deserve to be destroyed" supports self
harm, self sabotage and hatred - would run
contrary to the goals of self interest which
commonly appeal to most other clients -
motivate avoidance of treatment strategies aimed
at personal achievement, recovery or wellness
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Primary strategies to promote validation
(acceptance and understanding) and problem
solving (change) Modes of therapy 1)
Individual psychotherapy (the main basis of
treatment) Patient and Therapists
Agreement is significant Accepting but
encouraging of change Centred and firm, yet
flexible when required Nurturing but
benevolently demanding Clear about their
personal limits Treat with respect Implicit-
not able to stop the client from harming
herself Techniques include Contingency
management Cognitive therapy Exposure
based therapies 2) Group skills
training 3) Telephone coaching between
sessions Skills taught/ imparted
Mindfulness (focussed attention and awareness
to the here and now, Zen meditative
techniques) Emotion regulation (changing and
reducing distressing emotional states) Distress
tolerance (tolerating intense emotional states
that cannot be changed) Interpersonal
effectiveness (maintain sound relationships, self
esteem and asserting needs and objectives) With
modification DBT has been shown to be effective
in treating addiction disorders for women and has
also been adapted for adolescents
(Linehan,1997)
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Brief Interventions (Heather1995) Frequently
used for maladaptive drug use (esp. alcohol,
cannabis) Clients not yet dependent, few
problems Goal moderate drinking as opposed to
abstinence? Designed for use by professionals
not specialised in addiction Little time/ few
resources Includes Provision of self help
materials Brief assessment Provision of
advice (in a one off session), Assessment of
readiness to change (motivational
interview), Problem solving Goal
setting Relapse prevention, harm reduction
Follow- up


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• Brief Interventions
• (Heather1995)
• Major elements summarised by acronym FRAMES
• Feedback
• Responsibility
• Advice
• Menu of strategies
• Empathy
• Self efficacy
• Restricted to 5 or less sessions, ranging from
  a few minutes to an hours duration
• Not considered suitable for clients with
• more complex problems
• psychological/ psychiatric issues
• severe dependence
• poor literacy skills
• difficulties related to cognitive impairment
  
• Can result in significant gains at minimum cost

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Individual Psychoeducation Seldom an
independent intervention Inherent to good care,
engagement, establishment of therapeutic
alliance Provision of information at
appropriate level or detail Stress client is
not alone Describe what improvements can be
expected Instill hope Describe the treatment
modalities that work Suggest and recommend
treatment plan Invite questions and discuss
concerns Reinforce and repeat A major
component of all good clinical care and all self
help programmes Evidence that understanding
about condition/ treatment related to
adherence Knowledge has been shown to improve
outcome (Craighead et al,
1998) Treatment that harms or is of little
positive effect Boot camp (etc.) popularised
by the media Politically, societally and
economically popular (faddish and cost
effective) Data suggests these approaches do not
work but also increase problematic behaviours
(Dishion et al. 1999) Confrontational
Counselling/ Psychoanalytic Therapy seen to have
little or no effect
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Meta- Analysis Major systematic review of
alcohol interventions (Miller et al. 1995) MI
Skills based Cognitive Approaches, Community
Reinforcement- effective Confrontational
Counselling, Psycho- analytic approaches,
lectures of little use CBT and 12- Step
Approaches achieved equal results Irrespective of
pure or dual diagnosis or mandated to
treatment (Source Ouimette, Finney and Moos
1997) Project MATCH 1996 (largest addiction
trial ever conducted) 12 Step Facilitation,
Cognitive Behavioural Skills and Motivational
Enhancement Therapy were equally highly
effective Project MATCH 3 year follow- up
(1999) Standardised, manual based protocols,
and High level supervision and
training - optimises outcome, irrespective
of intervention
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In 2000 NIDA released the first ever
science-based guide to the treatment of drug
addiction. Based on a 30 year review. Findings
included No single treatment for
everyone. Treatment needs to be readily
available. Effective treatment attends to
multiple needs, not just drug use. Treatment
and services plan must be assessed continually
and modified to ensure plan meets changing
needs. Remaining in treatment for an adequate
period of time is critical for effectiveness. C
ounselling is critical for treatment of
addictions. Mental health and substance
problems should be treated in an integrated
way. Treatment need not be voluntary to be
effective. Recovery frequently requires
multiple treatment episodes. (National
Institute on Drug Abuse (2000). Principles of
Drug Addiction Treatment. Washington, D.C.
NIDA. )
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Effectiveness versus efficacy Controlled
psychological treatment outcome studies for
children and adolescents treatment done in real
life representative clinics (effective) shows far
more modest effects in comparison to those done
in pure laboratory (efficacy) settings. Many
studies of clinic based adolescent treatments
have found no significant effects.
(Weisz et al. 1992) This is a
concern in psychological treatment research and
why it is recommended that clinicians engage in
routine and systematic monitoring of the outcome
of their clinic based work. It has been
repeatedly suggested that the similarities rather
than the differences between psychological
treatment approaches may be primarily responsible
for change. (Wampold, 2001)
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• Thank You