Drug- and alcohol-involved middle and high school students markedly reduced their substance use following two 60-minute sessions that combined motivational interviewing (MI) and cognitive behavioral therapy. The students also reported significantly fewer substance-related symptoms of substance use disorders during the 6 months after the intervention compared with the 6 months before it. Adding a separate 1-hour MI-based session with a parent or primary caregiver enhanced the beneficial effects.
Dr. Ken C. Winters and colleagues at the University of Minnesota Medical School, in Minneapolis, conducted the trial with 315 adolescent and parent/caregiver pairs. Their findings strengthen evidence, which has been inconsistent in smaller trials, that brief interventions can help adolescents move away from drug use.
Motivating Behavior Change
The Minnesota researchers designed their intervention to help teenagers who abuse drugs, drink heavily, or drink in binges, but are not physically dependent and can largely control their intake. Nationally, an estimated 25 percent of 12- to 18-year-olds meet these criteria for “moderate” substance involvement (see graph below).
Source: Winters, K.C. et al. Use of brief interventions in a middle and high school setting. Journal of School Health, 77, 196–206, 2007.
The manualized intervention consists of two meetings with a therapist, 7 to 10 days apart. In the first session, therapist and teen discuss the teen’s substance use, examine the pros and cons of use, discuss the teen’s willingness to change, and identify goals for behavior change. In the second session, the two review the teen’s progress toward achieving the goals, identify high-risk situations associated with drug-use triggers, generate strategies to deal with peer pressure, and negotiate long-term goals related to substance use. A third, parent-only session, which was offered to 123 families, involved the therapist and parent discussing how to improve communication with the teen and to support the teen’s intervention goals.
To test the intervention, Dr. Winters and colleagues recruited Twin Cities students who had been referred for a substance abuse assessment in their public schools. The researchers assessed the students and randomly assigned those having at least a mild substance use problem to receive the intervention (136); an enhanced version of the intervention that added a third session, between a therapist and parent/caregiver (123); or an assessment only, no treatment (56). The therapists typically met the students in their schools and the parents in their homes.
Six months later, compared to when they entered the trial:
- Treated adolescents reported using alcohol on fewer of the past 90 days, while the untreated adolescents reported increased days of alcohol use.
- Treated and untreated youths both reported fewer days of cannabis use during the past 90 days, but the treatment group’s reductions were significantly greater.
- Treated and untreated youths both reported fewer symptoms of alcohol abuse and dependence during the past 60 days, but the treated group’s relief was significantly greater.
Also at the 6-month followup, half of the treated adolescents reported having been abstinent from marijuana for the past 3 months, and half reported having been abstinent from alcohol for the past 3 months, compared to 37 percent and 26 percent, respectively, of untreated students.
Teens whose parents received a counseling session made still larger gains, which included significantly greater reductions in cannabis abuse and dependence disorders compared to the untreated teens. More than 60 percent of this group reported having been abstinent from cannabis for 90 consecutive days at their followup interview.
The teens’ before-and-after self-reports indicated that the intervention strengthened their motivation to resist drugs and enhanced their success in resisting situational triggers for drug use (e.g., peer pressure, boredom). Teens whose parents attended a session in the enhanced intervention also benefited from improved parenting practices and utilized more community counseling and mental health services during the 6-month followup than untreated teens. The researchers suggest that the parent sessions contributed to the intervention’s efficacy mainly by enhancing parents’ recognition of their children’s problems and motivating parents to arrange additional counseling.
Moderate substance use can influence relationships, neurological development, educational attainment, and interpersonal functioning. Typically, adolescents who abuse substances but do not meet criteria for substance use disorders are less likely than nonusers to fully engage in family and school life. As they bond and socialize with like-minded peers, these teens often initiate other problem behaviors, such as delinquency. When faced with difficulties, they may intensify substance use rather than learning healthy coping skills. Because these teens are not yet dependent, however, brief intervention may suffice to put them back on track.
“My colleagues and I believe motivational interviewing is friendly to the developing adolescent brain,” says Dr. Winters. Teens naturally desire independence and individuation, which generates conflict with adults. “Motivational interviewing disarms that tension by focusing on the teen and adjusting the direction of treatment to his or her interests, goals, and motivation level. Rather than telling teens they must stop using drugs, therapists discuss the adolescents’ current problems and realistic goals for their immediate future. This sparks thoughts about change,” says Dr. Winters. Brief interventions are a good fit for adolescents because teens have difficulty envisioning a treatment that involves many steps, let alone a complete lifestyle change, he adds.
A Place for Brevity
Currently, only 10 percent of teens who need treatment for substance use problems receive it, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). Because most teens who abuse substances fall into the moderate use category, effective brief interventions potentially could go far toward making up the gap between treatment need and availability.
“Dr. Winters’ and colleagues’ brief intervention benefits youth with a lower level of substance use,” says Dr. Jessica Campbell Chambers of NIDA’s Division of Clinical Neuroscience and Behavioral Research. “Adolescent substance use problems are quite diverse, so clinicians need an array of therapies.”
Dr. Winters concurs that youth with more severe drug use problems require more help. When assessment results identify moderate substance use, but therapy sessions uncover deeper problems, such as more severe drug use or co-occurring mental disorders, therapists should refer individuals for additional treatment, says Dr. Winters.
Despite the documented positive impact of brief interventions, little is known about how these programs reduce youth substance use. “Identifying this treatment’s particular mechanism of action—what is driving its beneficial effects—would be very valuable, because researchers could then increase its therapeutic potency,” says Dr. Campbell Chambers.
Winters, K.C., et al. Brief intervention for drug-abusing adolescents in a school setting: Outcomes and mediating factors. Journal of Substance Abuse Treatment 42(3):279–288, 2012. Abstract Available