Multiple processes influence adolescent substance abuse and delinquency, contributing to their acceleration and increased risk of a broad range of associated problem behaviors, mental health problems, and victimization experiences (Fergusson & Horwood, 1996; Huizinga & Jakob-Chien, 1998). Substance abuse interventions are critical to interrupt processes related to the onset and maintenance of these adverse outcomes among youths and to provide skills to increase their educational, social, and economic opportunities (Pickrel & Henggeler, 1996; Zeitlin, 1999). Although controlled clinical trials of adolescent substance abuse interventions are underway, few intervention programs have been rigorously evaluated (Wagner & Waldron, 2001). This article describes an innovative intervention program currently undergoing a controlled clinical trial. The article describes the development of the brief motivational intervention for substance abuse, Guided Self-Change (GSC), as well as its modification for use with delinquent adolescents. Strategies are outlined to promote the flexible implementation of GSC in community settings with diverse groups of adolescents.
Guided Self-Change (GSC) is a brief skills-oriented motivational intervention for addressing alcohol and other drug problems (Sobell & Sobell, 1993, 1998). It can be used with individuals, with couples, or with groups with minor variations in format and materials. Individual GSC treatment is the prototype and has been standardized and published for clinical and research applications (Sobell & Sobell, 1993). The effectiveness of clinic-based GSC treatment among adults, with or without a relapse prevention component, has been documented: a 53.8 percent reduction in reported alcohol consumption following treatment, a near doubling of abstinence rates one year after treatment, and high consumer satisfaction ratings (Sobell & Sobell, 1993). Subsequent studies have found the intervention to be effective with multiple populations, including community-dwelling problem drinkers recruited through the mail, married problem drinkers and their spouses (Sobell & Sobell, 1998), as well as problem drinkers in Mexico City (Ayala-Velazquez, Echeverria, Sobell, & Sobell, 1997).
Because GSC uses both fundamental behavioral change principles and motivational engagement strategies, it necessarily incorporates individualized treatment targets, change strategies, and substance use goals based on clients' personal experiences. It is this individualization, or idiographic perspective, that makes GSC especially promising for use with diverse client populations. Such an idiographic perspective has been argued to be essential for psychotherapy programs to be successful with multicultural populations (Palmer, 2000). This behavioral, motivational modality may be especially effective for young multicultural clients because of its adaptability for use with adolescent and ethnic minority populations, focus on skill building and client empowerment, and short-term cost-effective nature. In addition, GSC has been translated into Spanish and implemented with success among Mexican adolescents and adults with alcohol and drug problems, which suggests its transportability across cultures (Ayala-Velazquez et al., 1997).
Our research group developed a youth-specific version of GSC treatment for use with juvenile offenders as part of a study funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The general format of GSC remains the same, but materials were modified to make them developmentally appropriate for use with adolescents, applicable to problems that often accompany teenage alcohol and drug use (that is, violence, coping with stress, social skills deficits), and available in either English or Spanish. In anticipation of this study, we conducted pilot work with 15 substance-abusing juveniles. All of them completed the GSC treatment program, and 13 of 15 (86.7 percent) demonstrated clinically significant changes in substance use from pretreatment to posttreatment. We are now conducting a rigorous controlled clinical trial of GSC, which ultimately will test the intervention with 704 juvenile offenders from ethnic minority groups with alcohol and drug problems.
An unpublished treatment manual has been written that contains a standardized format for the delivery of GSC with juvenile offenders; the intervention is divided into five sessions. Session 1 involves explaining the rationale for GSC treatment, providing personalized feedback on current substance use patterns, reviewing a decisional balance exercise, setting goals for treatment, and completing self-monitoring exercises. In session 2 clients review past-week substance use, examine personal antecedents (that is, "triggers") and consequences of substance use, discuss the management of occasional "slips" in attempts to change behavior, review homework assignments, obtain feedback on drug use situation profiles, and discuss their perceptions of their substance use problems. Session 3 involves reviewing past-week substance use, examining feelings and experiences that influence adolescent problem behaviors, introducing refusal and social skills training, developing an options and actions plan for managing substance use and trigger situations, reviewing personal priorities, and developing a change plan. In session 4 clients review a second assessment of drug use situation profiles and review past-week substance use. In addition, clients discuss general causes of stress, coping with stress, and stress prevention. Session 5 involves reviewing and discussing goals for change, reviewing past-week substance use, developing a list of short- and long-term life goals, re-evaluating the client's perceptions of their substance use problems, and discussing positive social supports for maintaining changes. As another adaptation for work with adolescents, clients are permitted to request up to two additional sessions for more work on specific elements of the intervention.
Change-Producing Procedures in GSC
The overarching goal of GSC is to guide clients through a process of making changes in their substance use or related problem behaviors by providing skills to help them understand their substance use, factors associated with substance use, and supports for or barriers to attempts to reduce or stop their substance use. Following are key change-producing procedures used by GSC.
Decision to Change Checklist.Clients and therapists collaborate in developing this checklist. Clients are asked to develop a list of "good things" and a list of "less good" things about their current substance use and reducing or stopping substance use. Therapists use the checklists to explore positive and negative elements of clients' current substance use patterns and to specify in concrete terms what it will take for clients to initiate behavioral changes in the immediate future. This discussion is used to explore and clarify clients' perceptions of their substance use and to raise their awareness of ambivalence regarding reduction of substance use. In this exercise, the therapist begins to develop an understanding of client motivation, supports, and barriers to implementing change.
Goals for Change Questionnaire. This questionnaire is a continuation of the Decision to Change exercise, in which clients rate how important it is and how confident they are that they can reduce or stop their substance use. The therapist discusses the significance of goal setting and explores issues related to planning and goal attainment. For example, by reviewing how other goals have been achieved, responses to goal attainment, and short- and long-term accomplishments, the therapist raises clients' awareness of the importance of goal setting; provides opportunities for modeling, rehearsal, and feedback; and elicits self-motivational statements.
Session Check-In.Each session of GSC begins with a "session check-in" that examines clients' substance use during the preceding week, when they thought about using, actions taken after thinking about using, and their substance use goals for the next session. This exercise helps clients monitor their use and recognize the multistep process that precedes substance use, thereby increasing their awareness of patterns of use or environmental influences.
Triggers and High-Risk Exercise.The concept of triggers for substance use is reviewed and applied to clients' experiences. Clients describe personal triggers, behaviors following the triggers, and positive or negative consequences. This exercise is used to help clients recognize personal triggers for substance use, alternative options for behavior, actions necessary to implement those options, and potential positive and negative consequences. The role of triggers in the prevention of relapse is discussed with clients. The triggers exercise is connected to other GSC activities in which clients examine their confidence that they could resist substance use when faced with trigger situations (for example, unpleasant or pleasant emotions, physical discomfort, and conflicts or pleasant times with others). Clients are encouraged to discuss supports for and barriers to implementing behavioral alternatives to substance use in these situations.
Implementation and Effectiveness of GSC with Delinquent Youths
The GSC intervention is particularly developmentally appropriate and effective for delinquent adolescents with substance use problems (Gil, Tubman, & Wagner, 2001; Gil, Wagner, & Tubman, 2002). GSC was developed initially for problem drinkers rather than clients demonstrating more severe patterns of dependency, that is, for adolescents who typically demonstrate episodic alcohol and drug use or problems. GSC is heavily reliant on behavioral techniques, which have been shown to be more effective than nonbehavioral approaches in reducing problem behaviors, including alcohol and drug abuse, among adolescents with conduct problems (Mulvey, Arthur, & Reppucci, 1993). Given its motivational framework, GSC promotes the type of treatment atmosphere (for example, therapeutic genuineness, active and direct communication, the ability to withstand limit testing) thought to be optimally effective for youths with conduct problems, who are often at earlier stages of change or who demonstrate high levels of anger (Heather, Rollnick, Bell, & Richmond, 1996; Richards & Sullivan, 1996). When implemented in community-based settings, our version of GSC may be more ecologically valid, and hence more effective, than traditional substance abuse interventions for adolescents. In addition, the short-term, cost-effective nature of GSC may make it a particularly efficient way to engage juvenile offenders with alcohol and drug problems, a chronically underserved population, as either a stand-alone intervention or as a component in broader intervention packages.
- Tubman, Jonathan G., Wagner, Eric F., Gil, Andres, & Kerensa Pate; Brief Motivational Intervention for Substance-Abusing Delinquent Adolescents: Guided Self-Change as a Social Work Practice Innovation; Health & Social Work; Aug 2002; Vol. 27; Issue 3.
Reflection Exercise #12
The preceding section contained information
about self-guided change for substance-abusing delinquent adolescents. Write
three case study examples regarding how you might use the content of this section
in your practice.
What types of skills does GSC (guided self-change) identify to make changes in adolescent substance use or related problem behaviors? Record the letter of the correct answer