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Skills, Motivational Enhancement, and Family Involvement: How ESTs Approach Adolescent Substance Use

The number of adolescents who meet criteria for substance use disorders is substantial (3.4 million), but fewer than 11 percent enter treatment each year (SAMHSA, 2008). Studies have found that adolescent drug use has increased since the early 1990s (Johnston, O’Malley, & Bachman, 2001) and that teens are using drugs at earlier ages and are becoming more dependent, with the most prevalent substance use diagnoses being cannabis and alcohol use disorders (Winters, 1999). 


We also know that substance problems in teens and young adults are often intertwined with a variety of complex issues as they are in a key developmental stage of life where their bodies and brains are being influenced by hormones and physical growth. Additionally, teenagers who exhibit more problematic behavior—more frequent or intense use—tend to have higher rates of co-occurring psychiatric problems such as mood disorders, ADHD, and severe impulsivity to name a few. Depending on the disorder, some co-occurrence rates approach 90 percent (Kandel et al., 1999; Chan Dennis, & Funk, 2008). They complicate matters and can exacerbate use. Many teens have learning disorders with the ensuing academic problems, or impulse control problems with the ensuing relationship, legal or other institutional and authority problems. The addition of substance use to these problems is like adding gasoline to a smoldering fire.


The people that are involved in a teenager’s life are additional pieces of the puzzle as teens are at a unique stage of life where they are extremely influenced by their home and family life, peers, and academic environment. They are particularly sensitive to life events such as the death of a loved one, divorce or separation of parents, medical or mental illness in a loved one, or the financial strain or unemployment of a parent. Other risk factors associated with adolescent substance use include poverty, single parenting, lack of strong family bond, poor family management systems, and family history of substance use and trauma. 


The effects of trauma may be particularly profound and go largely unnoticed—due to underreporting—and misdiagnosed. Misdiagnosis usually occurs because the symptoms can look like a lot of other problems. The consequences of failing to understand and address trauma in either the parent or the teen can include failure to engage in treatment, an increase in substance use and/or erratic behaviors, apparent lack of motivation, an uneven route of progress, and self-destructiveness (Dube et al., 2003).


Unfortunately, treatment options for adolescents struggling with substance use problems have historically been modeled on adult programs, which have had problems of their own in terms of using evidence-based therapies (Knudsen, 2009). Many assumed the disease model of addiction applied to adolescents—once an addict, always an addict—and that confrontation and negative consequences were effective strategies for instigating change. 


The reality is that developmentally, teenagers and young adults have a very difficult time anticipating the future as their brains are simply bad at it. In addition, many teens and young adults using substances are engaged in completely normal and age-appropriate autonomy seeking behaviors that are not necessarily pathological, even though they might look quite distressing to the adults around them. As a result, speaking to them in a language that implies their future is determined (e.g., “Any substance use at all will result in a long-term problem for you”) is not likely to be believed and mandates that only one outcome is acceptable (i.e., abstinence) are not likely to be heeded. 


Additionally, since many are struggling with identity issues, being told they need to accept the label of addict or alcoholic can increase confusion (“What kind of person am I?”) and defensiveness (“I’m not an addict! Addicts are losers who end up in rehab!”). There is a very real chance that telling a heavy drinking nineteen-year-old that she has the “disease of alcoholism” will push her away from getting the help she needs, even if she is drinking to black out two days a week. Not only is the statement statistically likely to be untrue, it is likely that she doesn’t feel it to be true and will therefore turn off to the treatment provider taking that stance.  


How can we engage teens and young adults and get them to listen to our concerns? What we know now from hundreds of well-conducted studies is that there are a variety of helpful treatments. But we also know most assuredly that one size does not fit all when it comes to treating people with substance use problems. There is no single answer for why teenagers make the decision to use drugs or alcohol and there are a variety of reasons they might continue using once started. As a result, providers need to approach each teen as an individual with a unique set of issues and a unique family and community system. What will help one may not be so helpful to the next. 


Thankfully, clinicians and researchers have joined forces to develop several empirically-supported treatments (ESTs) for teens and their families. The most effective ESTs for teens are grounded in a behavioral approach and teach a variety of skills to both teens and their parents. Studies have found that these treatment options reduce substance use, improve retention rates, and have a positive effect on the co-occurring disorders that teens often experience (Godley, Hedges, & Hunter, 2011). They also improve the functioning of the family as a whole as they almost all include the family and assume parents need to learn new skills in order for the adolescent to change. 


The Best Place to Start  


The importance of an initial professional assessment cannot be overstated. Substance use in young people runs the gamut from experimental and nonproblematic to severe and life-threatening. Since teens often turn to substance use to manage their mood, impulses, feelings of low self-esteem, and stage-of-life insecurities, a good assessment can help a parent identify the best course of action. These could include neuropsychological testing, meeting with a psychiatrist or behavioral treatments. Or maybe this could include no treatment at all and just firmer limits combined with positive reinforcement by the parent.


However, getting a good assessment is often easier said than done, as the qualifications and approach of the person doing the assessment have a huge impact on the recommendations that they will make. An educational consultant might hear about a daily pot habit and refer a teen to therapeutic boarding school, while the nurse at the community clinic might suggest an assessment by a psychiatrist. A psychologist assessing the same teen might suggest individual psychotherapy—which may or may not include the most effective strategies—while a counselor could suggest an intervention and wilderness camp. Similarly, between two assessors recommending a higher level of care like a residential program, one might prioritize psychiatric sophistication and willingness to use medications, while another might ignore or even dismiss those considerations. 


Fortunately, there has been a strong push over the last thirty years to standardize assessment procedures for assessing people’s problems. Perhaps foremost among assessment standards is the Addiction Severity Index (ASI), developed by A. Thomas McLellan which has been adapted for teens (Teen-ASI) (Kaminer, Bukstein, & Tarter, 1991). This standardized interview assesses substance use patterns as well as all of the other significant areas of a teen’s life such as family and peer or school relationships, school and household functioning, legal issues, psychiatric and physical health issues, and more. This wrap-around view helps clinicians develop a full picture of the teen in front of them, which helps to determine how much treatment is needed and in what setting.


The Global Appraisal of Individual Needs (GAIN) is another standardized instrument that takes into account an individual’s background; substance use; physical, emotional, and mental health; risk behaviors; environment; and academic, vocational, and legal issues (Dennis, 1999). Importantly, it has norms established for adolescents, which can help clinicians keep perspective and manage their individual biases of what may or may not be appropriate given the problems identified in the assessment.


Unfortunately, the number of treatment providers versed in evidence-based perspectives of both addiction and mental health issues is small (Sterling, Weisner, Hinman, & Parthasarathy, 2010). There are relatively few professionals who specialize in adolescent psychiatry and mental health, and fewer still that also have experience in evidence-based treatment approaches for substance problems. Smaller communities have even fewer resources. We recommend that parents ask around to their local mental health workers, school counselors, friends, clergy, and anyone else who might know of a well-trained professional. We also suggest that that parents talk to prospective treatment providers in person before introducing them to their child. There is no substitute for meeting the person to understand how he or she approaches substance problems and to see if it’s a good match for the teen. Finally, we encourage parents to arm themselves with a list of questions to ask providers about their approach or treatment philosophy, as it surely influences their recommendations. 


Core Elements of ESTs  


As we begin to explore different ESTs, note that we are not addressing the differences in types of setting which would include residential or inpatient programs, therapeutic communities, wilderness programs, and a range of outpatient service settings including clinics affiliated with hospitals, free standing programs or the office of a private therapist. We are hoping to outline the ESTs that should be a part of any treatment program, no matter the level of care or treatment setting. We would also like to draw attention to the fact that all of the ESTs we describe include three common features: cognitive behavioral skill building, motivational strategies, and family involvement.


Cognitive Behavioral (CBT) Approaches  


These approaches have the goal of helping people learn new ways of thinking and new behaviors. They include the following:


  • Training in communication skills (both positive communication and assertiveness skills)
  • Relapse prevention skills (including drink-refusal skills, dealing with high risk situations, problem-solving skills, avoidance procedures, and relaxation and stress reduction strategies)
  • Cognitive strategies for dealing with negative self-talk, rumination, planning for the future, and thoughts about substance use 




These treatments also address practical matters that are very pertinent to teens and young adults such as job seeking, money management, planning, developing interests, and relationship management.


Many parents and even some treatment providers struggle with the belief that a teen “should know by now” how to behave when it comes to choices around drugs, alcohol, and other risky behaviors. The reality is that as teens enter young adulthood many do not know how to act or how to cope with new feelings and/or experiences, or how to problem solve or set achievable goals, all of which are learned skills. Cognitive behavioral skills are particularly suited to address these developmental needs (Waldron & Kaminer, 2004). They are broadly able to address substance use behaviors and choices as well as emotional and developmental ones and underlying psychiatric issues. There are CBT skills that target just about every issue a teen may be facing.


Motivational Approaches  


These approaches can help motivate people in any treatment and may be particularly well-suited to improve the engagement of teens and young adults in the change process. Briefly, motivational approaches assume the following:


  • Motivation is not a fixed quality in a person struggling with substance use
  • Motivation for a given action is different at different times and changes over time
  • Ambivalence is a normal part of change
  • Empathy is a more powerful and effective tool than confrontation




Historically, many teen treatment programs were military style “boot camps” which operated under the assumption that motivation could be “kicked into gear” with confrontation and a hierarchical treatment structure. Parents were and are frequently encouraged to mandate treatment rather than first trying to include their teenager as a collaborator. What we now know from a plethora of research studies—this is true for adults as much as teens—is that confrontation and aggressive treatment tactics are motivation killers and learning happens best in a healthy, autonomy-supportive environment (Miller & White, 2007). 


Additionally, in keeping with everything we know about motivation, it helps in both the short and long run to try and include the teen in the process of making choices about his or her life. What matters to the teen in front of you? What are his or her goals, values, and aspirations? What does he or she like about substance use and what are the downsides? Including the teen as a partner in determining the course of treatment is not only good modeling of collaborative behavior, it reduces defensiveness and increases the chance of internal motivation taking hold. By helping parents take the same approach, ESTs promote family cohesion as teens are more likely to feel that a parent is working with them rather than against them.


Family Involvement  


Family involvement is crucial to success when working with teens who are using substances. Many parents are overwhelmed about how to address the problem and err on the side of hoping they “grow out of it.” ESTs engage parents by teaching them how to manage their own emotional response to the problem and giving them the skills to manage their relationship with the teen more effectively. Additionally, many parents struggle with their own substance and/or mental health issues and other problems that come along with poverty, co-occurring problems, and/or the challenges of single-parenting. The cognitive-behavioral strategies they learn and therapeutic support they receive can improve their general well-being and functioning.




The following sections provide information about specific empirically-supported treatments for teens. 


Brief Interventions  


Brief interventions do not usually involve “therapy” and are instead time limited. In fact, their success reflects the fact that most people with substance problems get better without any formal treatment (Klingemann, Sobell, & Sobell, 2010). There are several that have been developed to include one to four meetings and have shown evidence of effectiveness for young people. They are most appropriate for children with mild to moderate substance problems, which accounts for about one quarter of all twelve- to eighteen-year-olds. 
While there is no single protocol for brief interventions, several factors seem to contribute to their success. They are usually motivational, not confrontational, not lecturing, and not generic. They often include “normative data feedback,” or comparisons of the individual’s behavior relative to his peers, which speaks powerfully to a teenager’s natural desire to “fit in.” The simple information that state “No, in fact, everyone your age does not smoke pot, and here are the numbers” can have an impact. Brief interventions are usually behavioral, action-oriented approaches to making specific, doable changes and young people particularly like a goal-focused approach.


While many medical professionals in health centers or emergency rooms are trained in brief interventions, many medical and/or counseling professionals in academic settings are also beginning to use them. In particular, a promising approach utilizes three sessions; two with the child alone and a third for the parents without the child. In this brief intervention, teens discuss their substance use, consider pros and cons of using, and negotiate goals themselves, as opposed to goals mandated by the counselor (Winters, Fahnhorst, Botzet, Lee, & Lalone, 2012). They identify risks or triggers for use, including social pressures, and problem solve coping strategies. In their single session, parents learn about the importance of monitoring their child’s behavior and develop a plan to support their child’s stated substance goals. Parents are also encouraged to consider their own use and attitudes towards substances. When they are nondogmatic, nonjudgmental, and empathic, brief interventions are highly effective and may be all that is needed to help change an adolescent’s course. As with all evidence-based approaches for teens, they are more effective when the parents are included.


Adolescent Community Reinforcement Approach (A-CRA)  


A-CRA is a modified version of the Community Reinforcement Approach (CRA) which is a CBT-oriented therapy with perhaps the single largest research base demonstrating efficacy with substance problems (Godley et al., 2001). A-CRA is designed for young people aged twelve to twenty-two and like CRA, it comes from the behavioral therapy tradition that substance use is rewarding to the adolescent and change happens by replacing the rewards or “contingencies” of substance use with alternative, competing, positive behaviors. This time-limited therapy—typically twelve sessions in research studies—includes individual sessions with the adolescent alone, some sessions with the parents alone, and some sessions with parents and child together. It also avoids confrontation and instead focuses on finding the “motivational hooks” that will pull the teen toward wanting change for their own reasons.


This treatment begins with a behavior analysis to discover what teens get from using (i.e., what do they like about it; what are the physical, emotional and/or intellectual benefits) which is the basis for helping teens identify alternative ways to meet those needs and wants. For example, if a teen is smoking pot to fit in and feel relaxed, the treatment would focus on finding other ways to achieve those goals. A-CRA teaches nineteen different skills that can be used flexibly to address the needs of a particular teen and his or her family. The skills are designed to help teens identify and develop prosocial activities that compete with substance use, increase abstinence, and help fill their lives with reasons not to use substances. Parents are included throughout and trained in some of the same skills—communication, reinforcement, medication monitoring—since they are an incredibly powerful part of the recovery environment. Everyone practices skills through role-plays in sessions together, as well as through homework assignments throughout the week. 


In addition, A-CRA encourages siblings, friends, and community supports to all get involved in a healthy way with the teen. Siblings and peers can participate in role-plays to increase positive communication, practice conflict resolution, and identify healthy shared activities. A-CRA enlists the support of a teen’s entire community in a positive, rewarding way that helps him or her achieve goals and decrease unhealthy or destructive behaviors. The effectiveness of A-CRA has been found across gender and racial groups and has also been found to address the needs of teens with co-occurring disorders. In fact, teens with co-occurring disorders were found to have the same or increased rates of abstinence and greater decreases in emotional problems than teens who did not have co-occurring problems (Godley et al., 2014).  


Multidimensional Family Therapy (MDFT)  


Perhaps the most family intensive of all the adolescent approaches, MDFT describes itself as a “treatment system” with flexible and interchangeable parts that can be modified for the individual situation (Liddle, 2002). Typically delivered in an outpatient setting, the treatment takes place over four to six months and includes both individual and group therapy one to three times per week. MDFT targets four domains: 


  • The adolescent, including his or her developmental needs and struggles as well as relationships, family and otherwise
  • The parents, their own functioning as individuals as well as parenting practices
  • The family environment, including patterns of interaction and communication
  • Systems of influence outside of the family, such as schools, mental health courts, and others




Several characteristics of MDFT seem to contribute to its strong record of positive outcomes in research trials and clinical settings. First, treatment builds on a comprehensive assessment of multiple life areas such as family functioning, school, mental and physical health, and legal factors, including deficits and strengths. Second, treatment addresses common factors related to substance problems and psychiatric issues in youth, including family communication, parenting, conflict, and the parents’ use of substances. Third, and a huge strength of this approach, MDFT coordinates multiple spheres of influence with psychiatrists, teachers, legal system personnel, medical providers, and parents all cooperating. Fourth, the treatment addresses emotional and psychiatric problems, with depression, anxiety, and trauma being the most common. MDFT is the opposite of the send-them-away-to-boot-camp approach as it assumes that change cannot happen if the adolescent is “away” and that long-term positive change will depend on an everyday life environment that works better for everyone.


Community-Reinforcement and Family Training (CRAFT)  


We know that parents bear the brunt of navigating the treatment system and experience the burden of motivating their substance using teen or young adult into treatment. The CRAFT approach (Smith & Meyers, 2007) is a nonconfrontational intervention program for concerned family members of individuals with substance use problems who are resistant to or refuse help. While very few people know about it, CRAFT is one of the most robustly supported evidence-based approaches available for families of substance users. The program has three primary goals:


  • To increase the probability that the substance user enters treatment
  • To reduce an individual’s use of substances prior to treatment entry
  • To help concerned family members improve their own psychological functioning




Of course, these are often exactly the stated goals of parents: “I want my teen to get help, I want him to use drugs and alcohol less, and I want to feel better!” As it turns out, CRAFT achieves these goals; studies that compare the outcomes for concerned significant others (CSOs) referred to Al-Anon, classic Johnson-style interventions, and CRAFT, find that CRAFT dramatically outperforms the other options and achieves these goals even when looking at a wide range of ethnicities, socioeconomic backgrounds, substance use types and severities, as well as psychiatric comorbidities. Although CRAFT has demonstrated significant efficacy in promoting treatment entry among drug and alcohol users (69 percent to 80 percent), its dissemination and utilization by the broader treatment community has been limited (Meyers, Miller, Smith, & Tonigan, 2002; Miller, Meyers, & Tonigan, 1999).


Parents who participate in CRAFT develop skills that benefit their families in the present and for the longer-term. The focus on self-care—diet, exercise, reducing isolation—helps parents be better role-models and improve their ability to manage the stress that comes along with parenting a teen or young adult. The communication skills help them collaborate better with their partners and the school, peer, and legal system around the teen and reduce family tension and arguments. The development of empathy and awareness through the use of Functional Analyses helps parents understand their child better (“She’s really anxious about going to school, she’s not just trying to drive me crazy”) as well as increase the odds that they can support viable and healthy alternative behaviors that compete with substance use. 
Finally, the focus on using positive reinforcement strategies combined with naturally occurring consequences, instead of confrontation and punishment, reverses negative patterns and establishes a routine of positive expectation and interaction. Parents are able to create an environment in which their child can succeed by helping them learn skills and be patient with the learning and change process.  




While there are additional treatment options for substance using teens, in describing A-CRA, MDFT, and CRAFT we hope to have illuminated the main concepts included in most ESTs. The core elements of these treatments directly impact the three areas that are key to helping an adolescents change their behavior: skills development, motivational enhancement, and family involvement. They assume much of behavior is learned and that more adaptive behaviors can be learned to replace maladaptive ones. They are also grounded in understanding and influencing reward and reinforcement systems so that sober and abstinent behaviors become more rewarding than negative behaviors. 


Providers trained in these treatments work to understand the connections between how teens think, feel, and behave, and as a result can identify and teach them the coping skills they need to manage their lives more effectively. They utilize a learning perspective and behavioral modeling to help teens practice realistic goal setting and reinforcement strategies to alter their behavior in adaptive ways. When parents learn these skills in tandem, the impact of treatment is enhanced and everyone involved has a chance of enhanced well-being and functioning.







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