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Kevin DucraySenior Clinical PsychologistThe Drug Treatment Centre

Board

November 2006

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Individual Therapy Approaches to Adolescent Substance MisuseIntroduction

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

Adolescent studies often suffer from the following methodological problems :

small sample sizeslack of randomized sample assignmentinadequate measures and descriptions of patterns and levels of usewide ranges of levels of participant drug use (casual / abuse/ dependence)impact of dual diagnosishigh drop out ratesassessment tools loaned from adult treatmentresearchers own/ self developed toolsscales' psychometric properties often unknowninconsistent methodology in terms of time scales (e.g. of prior use, post

treatment outcome)variable methods of determining level and frequency of usewhat 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 syndromesRapid progression from casual use to dependenceHigher degree of co- occurring psychopathologyPsychopathology precedes the onset of substance usePsychopathology often does not remit with abstinenceGreater constellation of needs and problems (often inter- related)Dependence impacts upon developmental pathways Developmental variability between adolescentsNeed for flexible/ tailored approach? Interventions must be sensitive to the above differencesGreater intensity and duration of treatment than adults?Habilitative as opposed to rehabilitative strategies?

(Source: Muck, R et al, 2001)

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Adolescent Drug Abuser's Needs/ Challenges:

Psychological Resistance/ AmbivalenceChaoticDisengagedLow frustration tolerance/ ImpulsiveIrritabilityEmotionally FragileDependency and motivation to change?

Physical Physical illness Hep C/ HIVBasic Needs Unmet (Maslow)

Social No close relationships outside the context of drug useDifficulties of relating to authority figuresPattern of “downward social drift" Power of peer pressurePredilection 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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DevelopmentalNegative impact upon development of:

Coping skillsPro- social identity formationInterpersonal skillsCommunication skillsEducational/ Vocational skillsFamily responsibilitiesWork responsibilities

In extrapolating evidence- based adult models, one needs to be extremely mindful of:

the unique needscharacteristicsdevelopmental issuesproblems 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 TherapyMET- 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

Recognises 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 modelsSocial reinforcementAnticipated effects/ ExpectanciesDirect experience of drug's effect being rewardingSelf efficacy beliefs

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Specific techniques include:Self Monitoring/ Diaries/ Logs/ Mood monitoring

Graded Task Assignment/ Activity Scheduling/ Behavioural contracting

Avoidance of Stimulus CuesDistraction/ Engagement in incompatible actionsModelling/ Role play/ Response and Behaviour Rehearsal/ Refusal SkillsCoping Skills to manage/ resist urges to useFocus on drug effects/ expectancies/ consequences of use/ Decisional analysisUse of Flash Cards

Communication Skills/ Conflict resolution skills/ Social skills training/ Assertiveness Skills

Problem Solving SkillsSelf ImageMood Regulation

Relaxation trainingAnger Management

Clarification of role of cognitions in challenging situations/In situ and in vivo practice to manage threatening situationsRecognition/ challenge and correction of inaccurate/ distorted thoughtsChallenge/ review maladaptive core beliefs/ schema (self, world, others, future)(Re) lapse analysis (preparation, prevention and feedback)Psycho- educationProgressive Muscle Relaxation/ Autogenics Training

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Positive Features

Problem- focussed; perceived as relevant to the adolescent's difficulties Not complex or esoteric

Collaborative- the client is an active equalEmphasis on personal responsibility for change/ EmpoweringCan employ familiar, jargon free language (“homework” assignments; role play”, “practice”) Optimistic outlook/ “Cheap and cheerful”Clear and negotiated structure

Evidence

Indicated for severe dependence and higher “psychiatric severity”, retained drug using networks, the motivatedRelatively large and positive evidence base, esp. in treatment of alcohol and cannabis misuseDifferential effect between adult cocaine and opiate users with greater effect for opiate usersThe unique mechanisms of change of CBT remain to be more fully understoodQuality of the therapeutic relationship is critical(Source: Project MATCH 1996, Beck et al. 1979, Carroll 1996, Crits- Christoph et al. 1999; Woody et al. 1983 and 1995)

Consistent empirical evidence CBT associated with significant and clinically meaningful reductions in adolescent substance misuseSubstantial empirical evidence supporting efficacy of CBT for adolescent substance use disordersCBT an efficacious intervention for youths with substance use related disorders and related problem behavioursEffectiveness with adolescent suffering from problems/ other disorders known to co- occur with drug use well established

(Source: Waldron and Kaminer, 2004)

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Relapse PreventionG Marlatt and J.R Gordon

Relapse notoriously high

Pattern, process and circumstances for relapse are similar across addictive behaviours

RP a behavioural self control programme based on CBT strategies

Self-management program :

1) help clients maintain gains achieved in addictive behaviors treatment 2) as a stand alone programme

Strategies designed to facilitate abstinence and help those who experience relapse

Initially developed for problem drinkers, later adapted for cocaine dependency

RPT programs have also been developed specifically for co-occurring disorders

Recognizes that therapeutic progress occurs in gradual increments or stages of change

Humane and pragmatic

Emphasizes self-management and rejects labelling clients with traits like "alcoholic" or "drug addict."

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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 ModelRichard 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 coachEmpathic and directive, support criticalRole is to give clients the knowledge, structure and support to achieve abstinenceClients learn about issues critical to addiction and relapse(Early recovery skills; Drug education; Relapse prevention; Relapse analysis)Therapeutic relationship is positive and encouragingRealistic and direct, not parental, confrontational (or "therapy" in the classical sense)Self esteem, dignity and self worth is promoted in sessionsHas 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 behavioursImpact 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 experiencesUse 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 difficulties2) Improved outcomes for opiate users with psychiatric problems on MMT3) 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 behaviourAgreed upon sets of behaviours to be changedDaily or weekly goalsRewarding the incremental steps made toward achieving these goals

Equipping the client gain the following types of control:Stimulus Control

Avoid situations associated with drug useIncrease time spent in activities incompatible with drug use

Urge ControlHelp clients recognise and change thoughts/ feelings/ plans that lead to use

Social ControlInvolving significant others in helping the client avoid drugsSignificant others can contribute to therapeutic assignments/ reinforce desired behaviours

Therapeutic behaviours can include:

Completing assignmentsRehearsing desired behavioursRecording and monitoring progressReceipt 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 counsellingDemonstrated to help adolescents attain and maintain drug abstinenceImprovements 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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Solution Focussed Brief TherapySteve de Shazer and Insoo Kim Berg

Initially developed for low- income, socially disadvantaged clients with serious drug and alcohol problems

Treatment interventions concentrate and focus on the presenting or most immediate problem

Two essential components:

1) Potential solutions are based on “Exceptional Moments”, i.e. when the problem does not overpower, overwhelm or incapacitate the client’s ability to function

Therapist attempts to discern what it is that the client is already doing which might contribute to problem resolution

2) A determination of what life would be like without the problem, or with it solved?

Knowledge of client’s goals, desired ‘life destinations’ increases the likelihood of success.

This model stresses that the problem and solution may not necessarily be related

The type of drug used is not viewed as a critical determinant in choice of treatment

Model is designed to help clients exploit their own unique strengths and resources in problem resolution

Approved by Office of Mental Health and Addiction Services (US) as an Evidence- based Practice

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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(>60% of adolescents: Bukstein et al. 1992)

IDDT offers concurrent mental health and addiction interventions in same settingHope, optimism, and a positive atmosphere are core beliefsOther’s recovery is used to promote a positive expectationA personalised treatment plan for both mental health and addiction problems Individualised treatments are determined by stage of recoveryInterventions 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 client’s illnesses and conditionsRelationship counselling and living skillsHelp with budgeting and money managementEmployment adviceSpecialised 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 useFocus on short term behavioural goalsStrategies and tools to help attain and maintain abstinence12 Step participation is strongly encouraged

Also addresses areas of impaired psycho- social functioning salient to drug use:

involvement with negative peer groupscriminal activitiesinterpersonal and family relationseducation

Twelve Step Facilitation (TSF) Therapy(Joseph Nowinski)

Facilitates active participation in AA/ NAAA seen as primary factor responsible for recoveryWidely used internationallyAddiction/ alcoholism a spiritual and medical "disease"Must be managed through- out life

Recovery equated with abstinenceBrief, 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

HonestyDecisions regarding cessation of drug and alcohol useAn action plan for lifestyle changeCorrection 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 interventionsBeneficial effect “additive” rather than independentStand-alone AA/ NA attendance does not improve outcome“Dose effect” foundMerit 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 TreatmentsNancy M. Petry

Widely used in substance misuse researchGaining popularity despite some attitudinal resistanceClients awarded tangible positive reinforcers for objective behaviour changeVouchers for negative urine samplesClinic managed accountStaff purchase requested items (audiovisual equipment, sports goods, clothing, cinema tickets etc.)Positive effects unambiguously demonstrated when compared to traditional treatmentsAlmost 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 settingsIncreases 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 therapyInitially designed for cocaine addictionUsed for cocaine dependent clients who use alcohol/ MMT patients who use cocaine

Goals: Achieve abstinence for sufficient duration to develop life skills to sustain abstinenceReduce alcohol consumption

Clients attend one- two psychotherapeutic sessions weekly aimed at:Improving family relationsDeveloping skills to reduce drug consumptionVocational/ educational related issuesDeveloping 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 significantAccepting but encouraging of changeCentred and firm, yet flexible when requiredNurturing but benevolently demandingClear about their personal limitsTreat with respectImplicit- not able to stop the client from harming herself

Techniques includeContingency managementCognitive therapyExposure based therapies

2) Group skills training3) 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 problemsGoal moderate drinking as opposed to abstinence?Designed for use by professionals not specialised in addiction Little time/ few resources

Includes:Provision of self help materialsBrief assessmentProvision of advice (in a one off session),Assessment of readiness to change (motivational interview),Problem solvingGoal settingRelapse prevention, harm reduction Follow- up

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Brief Interventions(Heather1995)Major elements summarised by acronym FRAMES

FeedbackResponsibilityAdviceMenu of strategiesEmpathySelf 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 costDoes not replace the need for specialist alcohol and drug treatments

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Individual Psychoeducation

Seldom an independent interventionInherent to good care, engagement, establishment of therapeutic allianceProvision of information at appropriate level or detailStress client is not aloneDescribe what improvements can be expected Instill hopeDescribe the treatment modalities that workSuggest and recommend treatment planInvite questions and discuss concerns Reinforce and repeat A major component of all good clinical care and all self help programmesEvidence that understanding about condition/ treatment related to adherenceKnowledge 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 mediaPolitically, 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 resultsIrrespective 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, andHigh 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.

Counselling 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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What seem to be the common features of models discussed in relation to the above:

Quality of the therapeutic relationship is criticalEngagement and retention emphasisedRespectful and non- confrontationalAn optimistic expectation of positive behaviour changeA focus on skills generationDidactic in natureImparting of knowledge and understandingClear focus on readily identified and explicit drug use related goalsUnpretentious and jargon freeFocus on observable behaviour change (increases or decreases)Inclusion of homework and other exercisesEmphasises the support and involvement of significant others/ family(i.e. social network based interventions)Encouragement of more effective communication with othersFocus on relevant quality of life- related problemsDrug and psychological difficulties treated in integrated mannerStructured, standardised, manual based approachesEmphasis on self efficacy

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Thank You