ASA8285 - SECTION 8: MOTIVATING THE ADOLESCENT FOR TREATMENT
Michael is a 15-year old boy who is sitting in your office as you begin your first counseling session with him. He says:
“My parents are always on my back. I can’t even go out with my friend without their wanting to know where I’m going, who I’m with, and they tell me when I have to be home. Now they find one joint in my drawer and they are going crazy. They grounded me and they will not let me go out with my friends or even call them on the phone. They make me come home right after school and do my homework. They make my teachers give them weekly progress reports. It’s not like nobody else my age does it. All my friends drink and smoke marijuana. My parents drink. Adults have no idea what it’s like for kids like me these days. Drugs help us cope. I can quit anytime I want. Someday I may quit, maybe, but not now. I wish my parents would just leave me alone. They only focus on the things I do wrong. I can’t wait until I can leave home. I am here only because my parents said if I would go to a few counseling sessions, they would consider lighten up on some of my restrictions.”
How would you as a clinician handle this type of adolescent client? Please take 5-10 minutes to plan and prepare for an intervention strategy for this client.
Adolescent Help-Seeking Behavior
The research shows that the most frequently reported reasons that adolescents give for not seeking professional help for an AOD use or mental health problem is that:
1. They prefer to manage the problem on their own in their desire to maintain their sense of independence
2. They are concerned about their family, friends, and school personnel finding out about these personal problems
3. They feel that most adults could not meaningful understand and help them with their problems
The research shows that when adolescents do seek help for their problems, they are more likely to seek help from, first, their friends and, then, family. School personnel are among adolescent’s last choices for talking about personal concerns (Schonert-Reichl, 2003). Therefore, it is very important to develop proactive identification, screening, assessment, and treatment procedures to identify adolescents with AOD problems (i.e., urgent care, primary care, and emergency room settings; courts; community groups, religious groups, recreational groups, and schools) and develop more intervention and treatment programs that address the unique needs of adolescents.
Studies show that AOD treatment is effective, but studies show that less than 10% of AOD abusers get treatment for their abuse and, once in treatment, dropout rates are high (typically 30 to 60%). Therefore, it should not be surprising that many people are required or highly encouraged to get treatment by the courts, employers, schools, and friends and family.
The research consistently shows that how a person gets into treatment is not significant, that is, required or coerced clients tend to do as well people who more or less volunteer for counseling or treatment. What does matter is what is done with clients when they are in counseling or treatment (Anglin & Hser, 1990, Fagan, 2004).
Few adolescents volunteer for counseling and once in counseling they can often be very resistant and noncompliant. Traditionally, client resistance has been seen as a characteristic that the client brings to counseling or treatment. Clients do bring various levels of resistance to counseling, but the research shows that resistance arises from the interpersonal interaction and relationship between the counselor and the client. The research clearly shows that that a change in counseling style can directly affect the level of client resistance. It is how the counselor responds to client resistance that makes the difference.
Miller and Rollnick (2002:30) have developed a technique they call “motivational interviewing”, which they define as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” There are four guiding principles that underlie motivational interviewing:
1. Expressing empathy by respectfully listening to people with a desire to understanding their perspectives
2. Creating and amplifying - from the client’s perspective - a discrepancy between present behavior and broader goals and values
3. Rolling with resistance by actively involving the person in the process of problem solving
4. Supporting self-efficacy by enhancing people’s belief in their ability to carry out and succeed with their plan for change.
The relationship between the counselor and the adolescent is one of partnership, rather than expert-recipient. This approach is collaborative, not prescriptive, in which the counselor evokes the person’s own intrinsic motivation and resources for change.
Motivational interviewing does not assume the adolescent is interested in changing, rather, it emphasizes evaluating the adolescent’s motivation through open-ended questions, followed by the use of strategies that are oriented to where the adolescent is in the stages of change and helping him/her progress through the stages.
However, for the method to work, the adolescent must have some intrinsic motivation for change. The counselor cannot impose a desire for change in the absence of some genuine concern within the adolescent. The skill of the counselor is to help the adolescent find motivation for making changes (Moyers & Waldorf, 2003).
Motivational interviewing believes that it is the client who should be voicing the arguments for change. If clinicians find themselves in the role of arguing for change - while their clients are arguing against it - they are in the wrong role. When counselors wrestle with clients, one of them usually leaves the interaction frustrated and dissatisfied.
Motivational interviewing believes that client resistance behavior is a signal of dissonance in the counseling relationship (Barnett, Monti, & Wood, 2001). Resistance is the client’s attempt at self-protection. The research shows that it is possible to enhance motivation for treatment and induce significant change in problem AOD users in a few counseling sessions. Moreover, the research shows that what the counselor does interpersonally, even within the context of a single counseling session, appears to exert a substantial and long-lasting influence on whether the client will get better or worse (Yahne & Miller, 1999).
There are four process categories of client resistance behavior: 1) arguing, 2) interrupting, 3) negating, and 4) ignoring. How the counselor responds to the adolescent’s resistance is what makes the difference. Rather than challenging the resistance, the counselor should explore the reasons for the resistance.
Resistance may be a sign that adolescents fear reprisals from parents and others for revealing secrets about their attitudes and behaviors, their previous experiences with many adults have been hurtful and disappointing, they have a strong belief that their situation is hopeless or other people will not understand them, and/or they do not understand or trust the counseling process.
It is important that counselors try to differentiate themselves from the other adults in the adolescent’s life whom the adolescent feels have been trying to control him/her. Potential options for change or for treatment should only be discussed after great care is made to develop alliances with the adolescent. Merely referring to their AOD use as a “problem” may elicit a defensive reaction.
It is better to talk about their choices, their behaviors, and, perhaps, their risks than their problems or your concerns. Motivational interviewing should be more like dancing with the adolescent and the leading is subtle and not readily apparent to the adolescent. Personalized feedback on the state of the adolescent’s situation, including his/her AOD use, an examination of his/her future goals, and ways in which his/her AOD use might compromise these goals, are the key to this type of intervention (Monti, Barnett, O’Leary, & Colby, 2001).
Discrepancy is fundamental to change. The discrepancy is generally between the adolescent’s present situation and a desired goal. The larger the discrepancy between these two items, the greater the importance of change. The challenge is to first intensify - and then resolve – the client's ambivalence by developing discrepancy between the adolescent’s present situation and the desired future.
Change is facilitated by communicating with the adolescent in a way that elicits the adolescent’s own reasons for, and advantages of, change by talking about the:
1. Disadvantages of the status quo
2. Advantages of change
3. Expressing confidence in the adolescent’s ability to change
4. Strengthening the commitment to change
The therapeutic process has two basic phases. In the first phase the emphasis is on building motivation for change and in the second phase the emphasis is on strengthening the commitment to change through setting goals, considering change options, developing a plan, and eliciting commitment. However, it is important to remember that thinking about change is the not the same thing as taking action towards change.
Research on brief therapies has identified six core features of treatment that are applicable to forming therapeutic alliances with AOD abusing clients and enhancing their motivation for change. The core elements are summarized by the acronym FRAMES: Feedback, Responsibility, Advice, Menu of options, Empathy, and Self-efficacy (Hanson & El-Bassel, 2004).
1. Feedback: The counselor provides personalized feedback about the adolescent’s current circumstances in terms of the health, psychological, and social consequences of their AOD use.
2. Responsibility: The counselor stresses that, ultimately, responsibility for change rests with adolescent.
3. Advice: The counselor offers clear and specific advice about the advantages of changing addictive patterns as well as different ways that change can occur.
4. Menu: The counselor provides a range of viable alternative strategies for changing AOD abuse.
5. Empathy: The counselor demonstrates concern for adolescents and affirms their experiences while supporting the changes they make.
6. Self-efficacy: The counselor expresses confidence and nurtures adolescents’ beliefs that they can carry out therapeutic tasks and meaningful address their AOD use.
For example, an adolescent who is resisting participating in therapy can be approached in this way:
“I know that so far you don’t feel like talking with me. I tell you what we will do. We can just sit here together. You can choose to talk or not say anything. If you choose not to talk, I might sit here with you or I might leave you alone and work at my desk over there. You can decide what you would like to do. I’m here to help you in any way I can, but it’s your time here, and you can use it as you like.”
Initially an adolescent may welcome the opportunity not to have to participate, but clinical experience has shown that most adolescents, when given these kinds of choices, will eventually choose to participate. If an adolescent still refuses or is reluctant to participate, then the counselor should be prepared with other techniques to try to get the adolescent to begin to participate. However, building an adolescent’s trust will take time and patience (Vernon, 1999).
One controversial approach that is being used with adolescents who are unable or unwilling to stop their AOD use, especially adolescents in the early stages of AOD use, is called “harm reduction”. This approach has the potential advantage of engaging young high-risk AOD users and motivating them to participate in programs designed to minimize or eliminate the negative consequences of their AOD use (Denning, Little, & Glickman, 2004; Tatarsky, 2002).
Harm reduction is based upon the principle that AOD use is a reality in our society. Although not condoning AOD use, harm reduction emphasizes reducing the negative consequences of AOD use by employing practical, achievable goals aimed at the safe use of AOD and minimization of the harmful effects associated with continued AOD use.
Although this approach may lead to, or include the possibility of, complete abstinence, it does not require it. While abstinence may be the ideal for many individuals, the harm reduction approach expands the definition of success to include the many smaller steps that may precede or replace abstinence (Seiger, 2004).
A rigid abstinence-only policy will keep some adolescents from getting any type of help for their AOD problems. Harm reduction programs offer an attractive alternative context for engaging resistant adolescents in behavior change when used with adolescents who do not have long and problematic histories of AOD use, who do not identify with the life-long, disease model of addiction, who are at least initially unwilling to quit their AOD use and who are unwilling to get into treatment, or who would like simply to learn skills to use AOD in a less risky manner.
Harm reduction attempts to meet adolescents where they are and minimize the possibility that adolescents will not make any attempt to control their AOD use because they do not want to completely quit using some substances (Marlatt, Tucker, Donovan, & Vuchinich, 1997). The basic philosophy of many harm reduction programs, is that after adolescents begin to gain some control over their AOD use, they may be more open to the possibility of stopping their use altogether or at least stopping their use of more dangerous substances in more dangerous situations (Miller, Turner, & Marlatt, 2001).
Stages of Change
Very few adolescents come to therapy completely voluntarily without some degree of encouragement or coercion from others (Fagan, 1999, 2004). A very effective strategy for dealing with adolescents who are resistant or ambivalent about changing their AOD use is to see change as consisting of stages. There has been significant research on the components or stages of motivation for change.
The most well-developed and empirically supported model is DiClemente’s (2003) five stages of change model. The five stages are: 1) precontemplation, 2) contemplation, 3) preparation, 4) action, and 5) maintenance. The key is to match the therapeutic interventions to clients’ stage of change. The model has proven to be very useful in working with adolescent AOD abuse (Connors, Donovan, & DiClemente, 2001).
Five-Stage Model for Change
Stage I: Precontemplation
In the “precontemplation” stage, adolescents have no intention to change their behavior in the foreseeable future. Resistance to recognizing or modifying a problem is the principle hallmark of individuals at this stage. This applies whether change means modifying or stopping AOD use. Change is seen as irrelevant, unwanted, not needed, or impossible to achieve.
Schaefer (1987) identifies four major defense strategies used by adolescents:
1. Denial (refusing to recognize or accept reality)
2. Projection (trying to make other people, places, or things responsible for one’s behavior)
3. Rationalization (inventing excuses to make one’s unacceptable behavior seem acceptable)
4. Minimizing (trying to make something look less serious than it is)
It is common for adolescents who are using AOD, even adolescents who have gotten into some serious problems as a result of their AOD use, to use one or more of these defense strategies to justify their behavior.
A useful distinction can be made between an acknowledged problem that is admitted to by an individual and an attributed problem that others say the individual has. While families, friends, and school and legal officials may feel there are problems, adolescents at this stage are unaware or under-aware of their problems or they are unwilling or discouraged when it comes to changing them.
If precontemplators present for treatment, they often do so because of pressure or as a requirement from others. They may be very resistant to treatment or they may demonstrate what some have called “psychological attrition” whereby they evidence some degree of behavioral change as long as the pressure is on, but once the pressure is off, they usually return to their old behaviors.
Types of Precontemplators
DiClemente and Velasquez (2002) say that precontemplators' resistance to change is best summarized as the four R’s: 1) reluctance, rebellion, resignation, and rationalization. Reluctant precontemplators, rather than being actively resistant, are actually more passively reluctant to change. They may be fearful of change or comfortable where they are and do not want to risk the potential discomfort of change. For these adolescents, careful listening and providing feedback in a sensitive, empathic manner can be very helpful. Sometimes reluctant adolescents will progress rapidly once they have verbalized their reluctance, feel listened to, and begin to sort out their ambivalence, while for other adolescents the seeds of change are planted for some future time.
Rebellious precontemplators often have a great deal of knowledge about their problem behavior, have a heavy investment in the behavior, and they do not like being told what to do. Providing a menu of options seems to be the best strategy for working with the rebellious precontemplator so that they can begin to shift some of their energy into contemplating change rather than using it to resist. When the counselor agrees with the rebellious precontemplator that no one can force them to change, and the counselor would not think of doing so, it can have the effect of diffusing the strength of their argument. Once a rebellious precontemplator decides to change, the energy often shifts to a positive energy of determination to succeed.
The resigned precontemplators have given up on the possibility of change and seem overwhelmed by the problem. The best strategy with this type of adolescent is to try and instill hope, explore barriers to change, and help them to see that relapse is common and is not to be viewed as a failure. The best way to accomplish these goals is to express your confidence in their ability to change and build confidence a bit at a time in small increments with each small change making bigger changes possible.
The rationalizing precontemplators often appear to have all of the answers. Although it may feel like rebellion, their resistance lies much more in their thinking than in their emotions where it begins to feel like you are in a debate. Empathy and reflective listening seem to work best with this type of adolescent especially with the use of a decisional balance exercise where the adolescent is encouraged to talk about the “good things” about their AOD behavior.
They then begin to quickly realize that the counselor is not going to argue with them and they may be more open to considering that there are also some “not so good” things about their behavior. For this process to work, it is critical that adolescents be able to come to their own conclusions about their behavior. Arguing for change will usually not work.
For most adolescent AOD users there is a simultaneous sense of both wanting and not wanting to change, of liking and disliking the experience, of taking the risk and not taking the risk. At the beginning, most adolescents generally ignores the negative aspects of their AOD involvement and they cling to the part of the experience that produces positive consequences for them.
As the negative consequences increase, AOD users become more aware of their ambivalence and they may begin to express a wish to quit or control their use. However, until the person begins to realize that the costs of the behavior exceed the benefits, they are unlikely to want to stop. Involving parents in developing and enforcing a behavioral contract that includes negative consequences for AOD use and associated behaviors, can increase the costs of their behaviors and encourage them to think about changing their behaviors.
The Balance of Indecision
Miller and Rollnick (2002) identify four “weights” they feel constitute the balance of indecision for AOD users at the precontemplation stage:
1. the benefits provided by AOD use
2. the disadvantages of controlled use or nonuse
3. the negative aspects of continued AOD use
4. the positive benefits of controlled use or nonuse.
They feel that changes in the AOD problem behavior will not occur until this state of ambivalence is examined and the benefits of controlling their use are weighted more heavily than the costs of not controlling their use.
For developmental reasons, adolescents may have more trouble than adults projecting the negative consequences of their use into the future. Patricia Hersch (1998), in her book, A Tribe Apart, relates the story of an 8th grade drug awareness class where students were asked to write down their goals or dreams they held for their lives. The teacher then discussed the threat that AOD use poses to accomplish these goals.
Asked why, with such great hope for the future, a young person might choose to drink or use drugs, one boy responded with a laugh: “Because that’s later and this is now.” For most adolescents, their drug involvement has not occurred for an extended period of time, and thus, multiple and chronic negative consequences have not yet accumulated so it is often difficult for many adolescent to see their AOD as causing significant problems.
When working with adolescents at the precontemplation stage, the challenge is to attempt to move them to a place where they will begin to seriously examine their AOD use and cooperate in treatment. A common strategy used by many counselors and treatment programs, especially programs that use an Alcoholics Anonymous model, is to try to “break through” adolescent’s “resistance” through various confrontational tactics to get them to admit they have an AOD problem.
The research rather consistently shows that using these confrontational tactics typically does not work with most adolescents (Winters, Stinchfield, Opland, Weller, & Latimer, 2000).
If the intervention focuses only on convincing adolescents to change their AOD use, most adolescents will then be equally dogmatic about their desire to continue using. The more adults condemn their AOD use and try to define any use as problematic, many adolescents will, in turn, defend what they are doing because they feel their personal freedom is being threatened.
Adolescents are more likely to take action to change when they perceive they have personally chosen to do so, not when they are told they have no other choice. If the counselor only focuses on the negative aspects of their use, most adolescent AOD users will be equally adamant about the positive benefits. Issues of personal autonomy and the need for independence are very important for most adolescents and when told by adult authorities what to do or what not to do, many adolescent will react and resist.
Many treatment professionals feel it is better to use a style that some have called “rolling with the resistance” as the counselor tries to help the person move through the stages of change. The key is to try to understand their resistance, that is, try to learn more about their reasons for being at this motivation stage. The goal should be to gradually help the adolescent shift their primary focus from the perceived benefits of their use to examining the negative consequences of their continued use.
An effective strategy is to discuss with the adolescent their life values and goals and how their AOD use may be compromising some of these aspirations. It also important to communicate to the adolescent that you sincerely believe they can take meaningful changes in their lives and you will help them in any way you can.
Stage II: Contemplation
Consideration of the value and the need for change represents movement into the “contemplation stage.” At the contemplation stage, adolescents become aware that they may have a problem and are beginning to think about doing something about it, but they have not yet made a commitment to take any serious concrete action.
Contemplators can remain that this stage for long periods of time as they seriously struggle with weighing the positive aspects of their AOD behavior with the amount of effort and energy it will take to overcome the problem. At this stage, part of the person wants to change and part does not.
The contemplation stage involves a process of evaluating risks and benefits, the pros and cons of both their current behavior patterns and the potential new behavior patterns. The task for contemplators is to resolve their decisional considerations in favor of change.
It is very important for treatment personnel to be comfortable with, and recognize, ambivalence as a vital part of the contemplation stage of change. When working with contemplators it is important to assess how long people have been considering change and whether they have made significant past attempts. But it is important to remember that contemplation does not mean commitment.
It is important to remember that it can be hard to give up the known, no matter how distressing and painful, and to travel to an unknown place that will require change and risk (Joe, Simpson, & Broome, 1998). The key is to assist contemplators in thinking through the risks and consequences of their behavior and the potential benefits of change and to instill hope that change is possible.
Personal feedback based upon a thorough assessment on the nature and extent of their problem can have a strong motivational effect to tip the scales in favor of change. But in highlighting the negative aspects of their behavior, the counselor should be careful not to paint such a negative picture that it further discourages people from thinking that change is possible. Overcoming the ambivalence and shifting the decisional balance requires time and patience (Trotter, 1999). The decision to try to change marks the transition out of the contemplation stage and into preparation.
Stage III: Preparation
In the “preparation” stage, most adolescents have progressed through the weighing process to conclude more or less in favor of change. They come to the point of saying that something has to change. They feel they cannot go on like this, but they are not sure what they can or are able to do. Adolescents in this stage often report making some reductions in their problem behaviors, but the changes are not sustained and they do not feel they have gained sufficient control over their AOD use.
Being prepared for action does not mean that all ambivalence is resolved. The challenge is to help them develop a change plan that is acceptable, accessible, and effective. Counselors can do this by gently warning against change plan strategies that seem inappropriate or ineffective and guiding them toward more productive alternatives.
It is critical in the engagement process to construct an individualized rationale for therapy with each adolescent. The basic approach is to communicate to adolescents that there is something here for them, a place where they will get a chance to tell their story, to be heard, to be taken seriously.
As discussed previously, a useful way to begin is to focus on something that is not going well in the adolescent’s life. Then the counselor should support and validate the adolescent’s concerns, but state that he/she is not communicating these concerns very well and in this sense people are not hearing him/her.
The counselor then tries to help find new and more effective ways of communicating these concerns so that others may respond more favorably. In this way, the counselor begins to develop a bond, areas of agreement, where they can begin to build a positive, trusting relationship, before they begin addressing more serious concerns.
One means of enhancing desire for entering and remaining in treatment is to identify any existing motivating forces in adolescents’ lives and use these forces to get them more motivated for treatment. Few adolescent AOD abusers enter treatment without having experienced messages from people around them to get some help.
Involving friends, family members, and others in the recovery process can not only help to bring the adolescent to treatment, but it can also serve the function of educating these people about AOD problems, reduce their own interpersonal distress, and help to decrease any of their behaviors which may be enabling the AOD use. Improving family relationships and functioning and helping the adolescent to find non-AOD abusing friends should be addressed during treatment. When the individual lacks such social supports, self-help groups such as AA or NA can be very critical in the total recovery process (Brooke, Fudala, & Johnson, 1992; Marlatt, Tucker, Donovan, & Vuchinich, 1997).
Stage IV: Action
Action to stop the old patterns of behavior and begin to engage in new ones is the action stage. Many people, including treatment professionals, erroneously equate action with willingness to change and, as a consequence, overlook the requisite work that individuals must do to maintain the changes following action. In the “action” stage, adolescents begin to modify their behaviors and their environment in order to begin to overcome their problems.
Modification of the targeted behaviors to an acceptable level and significant overt efforts to change are the hallmarks of the action stage. However, it is important not to assume that once a person has reached the action stage, it is all downhill from here on. The new behavior must be sustained in order to create the new habits.
Adolescents in the action stage may still have some conflicting feelings about the changes they are beginning to make. Careful listening and monitoring what they are doing is important in this stage including affirming what they are doing that is working and helping them to overcome any barriers they may be experiencing.
There are three common developmental factors in most types of therapy and treatment: support, learning, and action. The assumption is that the support functions precede changes in beliefs and attitudes, which precede attempts at action. However, techniques cannot be separated from the human encounter. The research shows that the client-therapist relationship is very important in successful outcome, with the key being the client’s rating of the counselor acceptance, understanding, and competence.
The research shows that, in general, there is a strong relationship between the amount of treatment and improvement. However, the research shows that no one school or technique is necessarily better than another, rather it is common factors across treatment that are accounting for a substantial amount of improvement found in individuals.
The National Institute on Drug Abuse has identified 13 principles of effective drug addiction treatment. The principles center around the concept that programs need to be flexible with no single treatment being appropriate for all individuals, with treatment decisions guided by a thorough multiple-area assessment for each case (National Institute on Drug Abuse, 2003b).
1. No single treatment is appropriate for all individuals
2. Treatment needs to be readily available
3. Effective treatment attends to multiple needs of the individual, not just his or her drug use
4. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person’s changing needs
5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness
6. Counseling and other behavioral therapies are critical components of effective treatment for addiction
7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies
8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way
9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use
10. Treatment does not need to be voluntary to be effective
11. Possible drug use during treatment must be monitored continuously
12. Treatment programs should provide assessment for infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection
13. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment
Stage V: Maintenance
“Maintenance” is the final stage in the process of change. In the maintenance stage, adolescents try to stabilize their new behaviors and work to prevent relapse. For most AOD abusers, this stage extends from about six months to maybe a lifetime. In this stage, the adolescent works to consolidate the gains he/she has made during the action stage and prevent relapse.
Counselors should prepare themselves and their clients for the termination of counseling or treatment. The counseling relationship can be a powerful presence in the lives of young clients, and they may feel anxious about the counseling or treatment process coming to an end. Going over the gains that the adolescent has made, affirming the relationship between the counselor and the adolescent, offering follow-up sessions if needed, going over any anxieties about the end of treatment or counseling, and giving referral sources if needed can all help to stabilize the gains that have been made during counseling or treatment.
It is important to help adolescents in this stage practice an active and intelligent maintenance of the changes they have made (Carroll, 1997). Prevention of relapse is a significant issue at this stage. Many people tend to view any use of AOD during or following treatment as indicative of treatment or client failure.
However, it is best to view relapse during and/or after treatment as the probable norm - rather than as the exception - for adolescents. Relapse is better viewed as a transitional process, as a series of events that may or may not be followed by a return to pretreatment levels of AOD use. Adolescents should be taught that they may experience “a slip” and the expectation that this is best thought of as a unique occurrence, a mistake that does not necessarily mean they have failed in their recovery.
Marlatt (1998) has identified three primarily high- risk situations that are associated with relapse with most AOD users: 1) negative or unpleasant emotional states, 2) recent or ongoing interpersonal conflict, and 3) direct or indirect social pressure.
In many of the relapse situations, the first lapse occurs in a high-risk situation that individuals unexpectedly encounter. However, in other situations, the lapse appears to be the last link in a chain of events preceding the first lapse. Especially problematic are situations where adolescents come to feel that their desire to use AOD is justified based upon their evaluation of their circumstances, for example, they are experiencing stress or anxiety in a situation.
Adolescents are especially vulnerable to relapsing since they are often still surrounded by AOD using friends and associates and they may still be experiencing some negative social consequences with friends and school personnel as a result of their prior AOD abuse.
Marlatt and Gordon (1985) have identified what they call the (AVE). They postulate that the intensity of potential for relapse will vary as a function of degree of prior effort expended to maintain abstinence, the duration of the abstinence period, and the subjective importance of the prohibited behavior to the individual. Therefore, programs need to help adolescents develop expectations and skills that they can use to successfully cope with these high-risk situations.
There are number of ways to reduce or eliminate relapses. The adolescent must be taught how to recognize high-risk situations that may trigger a relapse. There should be an assessment of the adequacy of adolescent’s current coping abilities. In this way adolescents can learn to develop alternative coping skill approaches for their high-risk situations. This skill-training can involve assertiveness training, stress and anger management, learning relaxation techniques, and problem-solving and social skills training (Hohman & Buchik, 1994).
One way to approach the discussion of the potential for relapse with adolescents is to talk about recovery as a journey which involves continual discovery, dealing with novel situations, improvising when things to not go well, and learning new and useful ways to cope with problems along the way.
It can be useful to tell adolescents that recovery from substance abuse usually proceeds along unremarkably until the adolescent encounters a high-risk situation. This could be anything that threatens the adolescent such as an awkward, stressful social situation or an internal affective state such as anger, anxiety, or depression. The adolescent is then told that handling these high risk situations in an adaptive way is the key to ongoing recovery and how he/she perceives, interprets, and understands a high-risk situation can directly affect the outcome.
Discussion of automatic thoughts and cognitive distortions such as overgeneralization (one slip therefore cannot stop), selective abstraction (focusing on one’s failures), excessive responsibility (personally do not have what it takes to stop using), assumption of temporal causality (if true in the past will always be true in the future), self-reference (I am the sole cause of your problems), catastrophizing (anticipate the worst), and dichotomous thinking (black and white thinking focusing on the negative) can help in this process (Marlatt & Gordon, 1985).
It may be helpful for the adolescent and his family to have some resources to help with the relapse prevention process. Typically in the past, this may have included handouts that outlined both the goals of the relapse prevention process and a master plan for relapse prevention that outlines the potential triggers and solutions for the adolescent to manage the triggers successfully. Below you will find a copy of what such handouts might look like.
Goals of Relapse Prevention
Relapse prevention programs have three important goals:
Goal #1: To Prevent a Return To Alcohol and/or Drug Use: This is done by helping people in recovery to 1) identify high risk situations and prepare - in advance - strategies to avoid or handle those high risk situations; 2) understand and reshape patterns of self-defeating thinking and behavior that predispose them to having relapses.
Goal #2: To Stop Relapse Quickly if and when It Occurs. This is done by helping people in recovery to establish a plan - with specific steps - to 1) return quickly to sober behaviors; 2) access sources of support for sobriety; and 3) minimize the damage that is created from relapse, both in terms of emotional and psychological harm, and in terms of damage to major life roles and relationships.
Goal #3: To Engage Support Systems in Planning Intervention for Relapses. This is done by helping significant others to become partners in recovery, helping them to establish a plan - with specific steps - to promptly initiate a supportive intervention that will 1) maximize the likelihood of a return to sobriety; 2) increase the substance abuser’s motivation to return to sober behaviors; and 3) minimize the damage to the support system, including creating sources of support and relief for the significant others who are aiding in the return to sobriety.
Relapse Prevention Plan
Make a list of situations, events, people or feelings that create the greatest risk for a relapse:
Plan for Addressing Relapse Risks
On the left, write down each situation that may cause you to relapse, and on the right, list your plan for addressing with it or coping with it. (You may list more than one way to cope for each situation.)
1. __________________ ____________________
2. _________________ ____________________
3. __________________ ____________________
4. __________________ ____________________
5. __________________ ____________________
6. __________________ ____________________
7. __________________ ____________________
8. __________________ ____________________
9. __________________ ____________________
10. __________________ ____________________
Negative Self-Talk Corrections
On the left side, list the negative self-talk that contributes to relapse. On the right side, write positive replacements for the negative self-talk. Use this list to reinforce the use of positive self-talk during periods of discouragement or negativity.
Substance use is often an attempt to cope with some difficult feeling or circumstance. Write a list of positive actions or behaviors that you can use instead to help you cope with a difficult feeling or circumstance. Read and follow the list when you are tempted to use substances.
Support System Contact Information
Write the names and numbers of people in your support system, so that it is always easy to reach out for help when you need it.
NAME PHONE NUMBER
Relapse Righting: Feelings
Below make a list of things that you can do to help yourself get past the negative feelings you may experience after having a slip or relapse. If a relapse does occur, use this list to minimize the harm done by the relapse and to return to sobriety as quickly as possible.
Relapse Righting: Actions
Below make a list of actions to take after having a slip or relapse. These actions should help you access your support systems, make good decisions, and return as quickly as possible to the choices that help you maintain sobriety. If a relapse does occur, use this list to minimize the harm done by the relapse and to return to sobriety as quickly as possible.
For adolescents today, whose lives involve the use of multiple platforms for online interactions, it may be more constructive to operate with a relapse prevention plan that can be done in an electronic format. It is also helpful to consider the use of apps and online support resources that might fit better into their culture.
Prevention.org recommends the following apps for use in relapse prevention. Text from the site with App descriptions is included.
JourneyPure Coaching™ App: JourneyPure At The River, a 70-bed addiction treatment center near Nashville, created this app to provide effective aftercare. Creators designed the app to gamify the process and provide a unique tool for coaching those in recovery. When patients complete treatment, they are assigned a personal recovery coach. This coach uses the app to develop an individualized aftercare plan that will help patients transition out of treatment and back into day-to-day life. The app prompts the patient each day to check in and check off completed goals. If tasks (such as attending a meeting) are missed, the app alerts the recovery coach so they can follow up with their mentee and help them stay on track.
ASCENT App: Created by researchers at the University of Wisconsin, this app directly connects those in recovery with a support center of peer coaches. By accessing the app, clients can get advice from coaches and learn about intervention options. The app also provides a daily question that allows clients to alert their coaches if they’re feeling on the verge of relapse. The goal of the app is to keep those in recovery connected to a supportive community and help motivate them to stay on course.
Mobile MORE Field Guide to Life: Hazelden developed this smartphone app inspired by their MORE (My Ongoing Recovery Experience) program they provide to patients as they leave treatment. The app takes users through stages of recovery over the first year of sobriety. It’s organized around the 12 steps and is designed to help users master relapse-prevention skills. It offers daily guidance and inspiration, weekly sober challenges, tools for tracking personal progress and trends, community support systems and meeting finder and specific relapse prevention techniques.
Sober Tool: This goal of this app it to help users identify thoughts and feelings that lead to relapse. App users choose from a list to complete the thought, “I’m feeling…” They can also select their current struggle, such as “I am thinking about relapsing.” Depending on the selection made, users are walked through specific thought patterns to guide them toward healthier, sober thinking. The app also shows users how much money and time they’ve saved by being sober.
Casava: The Casava app offers three main components. App users can locate support group meetings anywhere in the U.S., as well as receive and give feedback on specific meetings. The app also allows users to track their daily moods and activities to monitor all the areas of their lives (nutrition, sleep, relationships, stress), see how they are changing over time, and identify what areas they need to focus on. The app also provides daily reflections and a collection of motivational articles with tips on relapse prevention.
In conclusion, for most adolescents, moving through these stages of change is not linear, rather it tends to be cyclical. Most adolescents will make several attempts (including on their own and as a result of formal treatment) to modify or cease their AOD use. These relapse experiences can contribute information that can facilitate or hinder subsequent progression through the stages of change.