Empirical researchDevelopment of a motivational interviewing/acceptance and commitment therapy model for adolescent substance use treatment
Introduction
Current adolescent substance treatment models have significant limitations. First, many adolescents drop out of treatment. For example, a national study of 292 adolescents in outpatient treatment found that 76% did not stay in treatment for at least three months (Galaif, Hser, Grella, & Joshi, 2001). In the Cannabis Youth Treatment study, only 52% of those assigned to 12- to 14-week evidence-based treatments, which included cognitive behavioral therapy (CBT) or multidimensional family therapy, stayed in treatment for at least 90 days (Dennis, Funk et al., 2004). Dynamic factors associated with treatment retention include perceived ability to express oneself openly and honestly, involvement with goal setting, and motivation for change (Orlando et al., 2003, Shroder et al., 2009).
Second, few adolescents reach and sustain abstinence. A national study of 1167 adolescents undergoing outpatient or residential treatment found that in the year following treatment: 1) 20.3% drank five or more drinks in a day at least weekly; 2) 43.8% used marijuana at least weekly; and 3) 42.2% used other drugs (Hser et al., 2001). For the evidence-based treatments tested in the Cannabis Youth Treatment Study, fewer than 25% of adolescents had a month of abstinence at the end of treatment and 12-month follow-up (Dennis & Godley, 2004). At best, when CBT was combined with contingency management for clean urine drug screens, 53% of youth achieved four weeks of abstinence during the 14 weeks of treatment (Stanger, Ryan, Scherer, Norton, & Budney, 2015). However, at three-month follow-up, the proportion with abstinence in the CBT plus contingency management and CBT alone groups did not differ (Stanger et al., 2015).
Third, there are few models that integrate adolescent treatment for both psychiatric and substance use disorders (Hawkins, 2009, Sterling et al., 2010). The lack of integrated treatment models is problematic because 64–82% of youth in substance treatment have a co-occurring psychiatric disorder (Greenbaum et al., 1996, Grella et al., 2001). Furthermore, youth with co-occurring psychiatric disorders, compared to those without, have worse substance treatment outcomes (Grella et al., 2001). Therefore, feasible models to integrate mental health and substance treatment for adolescents are needed.
Finally, current evidence-based treatments are not frequently adapted into real-world settings. One review concluded: “The negative correlation between scientific evidence and treatment-as-usual could hardly be larger if one intentionally constructed treatment programs from those approaches with the least evidence of efficacy (Miller, Sorensen, Selzer, & Brigham, 2006, p. 25).” There are various explanations for this finding. Three relevant explanations include: a) the belief among clinicians that research fails to answer relevant questions, b) the lack of bidirectional collaboration between researchers and clinicians and c) the fact that many substance treatment models were disseminated without proper stage of development testing (Lamb et al., 1998, Miller et al., 2006).
An innovative approach may be needed to improve adolescent substance treatment outcomes. Acceptance and commitment therapy (ACT) represents a paradigm shift in its unique reliance or emphasis on the following (Hayes, Strosahl, & Wilson, 2011). First, it is philosophically influenced by functional contextualism and pragmatism. Second, ACT is based on much research concerning verbal behavior that led to the development and analysis of relational frame theory (Hayes et al., 2011). Finally, instead of targeting symptom reduction, ACT uniquely emphasizes psychological flexibility in the service of one's values as the goal of treatment (Hayes et al., 2011).
ACT's innovative focus may address the limitations of current models in the following ways. First, ACT's use of hands-on experiential exercises may engage youth in treatment and reduce premature drop-out (Hayes et al., 2011). Second, a recent meta-analysis of ACT compared to active controls for adult substance use disorders shows a small to medium effect size favoring ACT, especially at post-treatment follow-up (Lee, An, Levin, & Twhohig, 2015). Third, controlled trials of ACT show promise in the treatment of common co-occurring psychiatric disorders such as anxiety, depression, psychosis and trauma (A-Tjak et al., 2015, Strauss et al., 2015, Woidneck et al., 2014). Finally, collaborative approaches such as ACT and motivational interviewing may incorporate factors described above that are positively associated with treatment retention such as ability to express oneself openly, involvement in goal setting and motivation for change (Orlando et al., 2003, Shroder et al., 2009).
This current study explores ACT combined with MI. Few models exist for combining these two approaches although a recent review concludes: “…there is a great opportunity to develop and empirically test a conceptually-coherent combination of MI with ACT (Bricker & Tollison, 2011, p. 14)…” MI is frequently combined with other treatments as a way to engage clients and enhance their readiness for change and has been widely used as a treatment for addiction (Miller W.R, 2012). Common features of both approaches include: a) an attitude of partnership and collaboration, b) acceptance of the clients’ autonomy and c) an emphasis on connecting with client values (Bricker and Tollison, 2011, Miller and Rollnick, 2012). On a clinical level, there are several differences including: a) MI's emphasis on language content compared to ACT's emphasis on language process; b) MI's emphasis on open-ended questions, affirmations, reflections and summaries compared to ACT's emphasis on metaphors and experiential exercises; d) philosophical differences on acceptance and willingness, and e) ACT's emphasis on helpful self-disclosure (Bricker & Tollison, 2011). As a result, therapists combining these interventions may face choice points about which modality to emphasize. These choice points are described in more detail in the Methods section below.
This current study uses two approaches that may maximize the treatment model's dissemination into community settings. First, the guidelines for the Stage Model of behavior therapy development were used to pilot-test and refine the manual (Rounsaville, Carroll, & Oaken, 2001). Second, this treatment is the result of a bidirectional partnership between clinicians, consumers, and researchers. Such partnerships are thought to enhance the adaptability of evidence-based treatments for clinical settings (Tai et al., 2010).
Therefore, to create a novel adolescent substance treatment model that might improve care, the current study had the following specific aims: a) to evaluate the feasibility of implementing a manual-standardized MI/ACT intervention for adolescent substance use disorders; b) to evaluate the preliminary outcomes of this intervention; and c) to revise the treatment manual, including session content, outcome measures, fidelity monitoring and training procedures in view of the study findings.
Section snippets
Material and methods
Participants were 41 adolescents and young adults (ages 12–26 years) consecutively enrolled in an adolescent substance treatment program in Denver, Colorado, U.S.A., from May 2016 to September 2016. Participants also included six therapists who delivered the substance treatment intervention. This study was approved by the Colorado Multiple Institutional Review Board.
Outcome measures included the following. A clinical interview was used to obtain baseline demographic information and diagnoses
Results
The baseline and clinical characteristics of the adolescent sample are described in Table 1. Overall, the sample was predominantly male and presented for cannabis use disorder. Many youth presented with a co-occurring psychiatric disorder.
Overall, 54% (N = 22) youth were prescribed psychotropic medication. On average, participants attended 7.9 (SD = 3.6) sessions. Youth had an average of 1.1 (SD = 0.7) family sessions. There was a positive, but not statistically significant, correlation between
Discussion
These data support the initial feasibility of using individual MI/ACT with adolescents presenting for substance treatment. This project has produced a novel manual-standardized treatment, called impACT. This manual-standardized treatment includes guidelines for contingency management, psychotherapy, outcome measures, training and fidelity monitoring. This manual is now ready for Stage 1B testing. Such testing would evaluate the feasibility of a larger controlled trial and determine the sample
Conclusions
This study demonstrates the initial feasibility of using an MI/ACT model in adolescent substance treatment. This treatment, called impACT, is available upon request.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of interests
The authors have no conflicts of interest to report.
Acknowledgements
The authors would like to thank the staff (Greg Kuo, RoseMarie Medina, Brad Metzler, Mauricio Yabar) and patients at the Denver Health STEP team for their invaluable support.
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