Kevin Ducray Senior Clinical Psychologist The Drug Treatment Centre Board

November 2006

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Individual Therapy Approaches to Adolescent Substance Misuse

Introduction 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 sizes lack of randomized sample assignment inadequate measures and descriptions of patterns and levels of use wide ranges of levels of participant drug use (casual / abuse/ dependence) impact of dual diagnosis high drop out rates assessment tools loaned from adult treatment researchers own/ self developed tools scales' psychometric properties often unknown inconsistent methodology in terms of time scales (e.g. of prior use, post treatment outcome) variable methods of determining level and frequency of use what constitutes successful outcome? (Source: Waldron and Kaminer 2004; Kaminer 2001; Muck et al. 2001) 3

Tendency to extrapolate empirically validated adult models to adolescent populations.

Clinical Differences between Adults and Adolescents:

More susceptible to development of dependence syndromes Rapid progression from casual use to dependence Higher degree of co- occurring psychopathology Psychopathology precedes the onset of substance use Psychopathology often does not remit with abstinence Greater constellation of needs and problems (often inter- related) Dependence impacts upon developmental pathways Developmental variability between adolescents Need for flexible/ tailored approach? Interventions must be sensitive to the above differences Greater intensity and duration of treatment than adults?

Habilitative as opposed to rehabilitative strategies?

(Source: Muck, R et al, 2001) 4

Adolescent Drug Abuser's Needs/ Challenges: Psychological

Resistance/ Ambivalence Chaotic Disengaged Low frustration tolerance/ Impulsive Irritability Emotionally Fragile Dependency and motivation to change?

Physical Social

Physical illness Hep C/ HIV Basic Needs Unmet (Maslow) No close relationships outside the context of drug use Difficulties of relating to authority figures Pattern of “downward social drift" Power of peer pressure Predilection 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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Developmental

Negative impact upon development of: Coping skills Pro- social identity formation Interpersonal skills Communication skills Educational/ Vocational skills Family responsibilities Work responsibilities

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

the unique needs characteristics developmental issues problems 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 8

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” 9

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 Therapy

MET- 4 planned, structured and individualised check up and follow- up sessions for problem drinkers MI is the “style”, philosophy or approach used 10

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 11

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 12

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 models Social reinforcement Anticipated effects/ Expectancies Direct experience of drug's effect being rewarding Self efficacy beliefs 13

Specific techniques include:

Self Monitoring/ Diaries/ Logs/ Mood monitoring Graded Task Assignment/ Activity Scheduling/ Behavioural contracting Avoidance of Stimulus Cues Distraction/ Engagement in incompatible actions Modelling/ Role play/ Response and Behaviour Rehearsal/ Refusal Skills Coping Skills to manage/ resist urges to use Focus on drug effects/ expectancies/ consequences of use/ Decisional analysis Use of Flash Cards Communication Skills/ Conflict resolution skills/ Social skills training/ Assertiveness Skills Problem Solving Skills Self Image Mood Regulation Relaxation training Anger Management Clarification of role of cognitions in challenging situations/ In situ and in vivo practice to manage threatening situations Recognition/ challenge and correction of inaccurate/ distorted thoughts Challenge/ review maladaptive core beliefs/ schema (self, world, others, future) (Re) lapse analysis (preparation, prevention and feedback) Psycho- education Progressive Muscle Relaxation/ Autogenics Training 14

Positive Features

Problem- focussed; perceived as relevant to the adolescent's difficulties Not complex or esoteric Collaborative- the client is an active equal Emphasis on personal responsibility for change/ Empowering Can 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 motivated Relatively large and positive evidence base, esp. in treatment of alcohol and cannabis misuse Differential effect between adult cocaine and opiate users with greater effect for opiate users The unique mechanisms of change of CBT remain to be more fully understood Quality 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 misuse Substantial empirical evidence supporting efficacy of CBT for adolescent substance use disorders CBT an efficacious intervention for youths with substance use related disorders and related problem behaviours Effectiveness with adolescent suffering from problems/ other disorders known to co- occur with drug use well established (Source: Waldron and Kaminer, 2004) 15

Relapse Prevention G 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." 16

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) 17

The Matrix Model Richard 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 coach Empathic and directive, support critical Role is to give clients the knowledge, structure and support to achieve abstinence Clients learn about issues critical to addiction and relapse (Early recovery skills; Drug education; Relapse prevention; Relapse analysis) Therapeutic relationship is positive and encouraging Realistic and direct, not parental, confrontational (or "therapy" in the classical sense) Self esteem, dignity and self worth is promoted in sessions Has 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) 18

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 behaviours Impact 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 experiences Use 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 difficulties 2) Improved outcomes for opiate users with psychiatric problems on MMT 3) Maintained gains for longer Has been manualised for treatment of opiate and cocaine dependence (Source: Luborsky 1984; Woody et al. 1987) 19

Behavioural Therapy for Adolescents

Unwanted behaviour can be changed by: Demonstration of the desired behaviour Agreed upon sets of behaviours to be changed Daily or weekly goals Rewarding the incremental steps made toward achieving these goals Equipping the client gain the following types of control: Stimulus Control Avoid situations associated with drug use Increase time spent in activities incompatible with drug use Urge Control Help clients recognise and change thoughts/ feelings/ plans that lead to use Social Control Involving significant others in helping the client avoid drugs Significant others can contribute to therapeutic assignments/ reinforce desired behaviours

Therapeutic behaviours can include:

Completing assignments Rehearsing desired behaviours Recording and monitoring progress Receipt 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 counselling Demonstrated to help adolescents attain and maintain drug abstinence Improvements shown in related indices such as school attendance, quality of relationships, depression and alcohol use (Source: Azrin et al 1994 and 1994) 20

Solution Focussed Brief Therapy Steve 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 21

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 setting Hope, optimism, and a positive atmosphere are core beliefs Other’s recovery is used to promote a positive expectation A personalised treatment plan for both mental health and addiction problems Individualised treatments are determined by stage of recovery Interventions 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 conditions Relationship counselling and living skills Help with budgeting and money management Employment advice Specialised counselling focussing on symptom management Approved by Office of Mental Health and Addiction Services (US) as an Evidence- based Practice 22

Individualised Drug Counselling

Emphasis on stopping or reducing drug use Focus on short term behavioural goals Strategies and tools to help attain and maintain abstinence 12 Step participation is strongly encouraged Also addresses areas of impaired psycho- social functioning salient to drug use: involvement with negative peer groups criminal activities interpersonal and family relations education

Twelve Step Facilitation (TSF) Therapy (Joseph Nowinski)

Facilitates active participation in AA/ NA AA seen as primary factor responsible for recovery Widely used internationally Addiction/ alcoholism a spiritual and medical "disease" Must be managed through- out life Recovery equated with abstinence Brief, structured, manual driven approach 23

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 Honesty Decisions regarding cessation of drug and alcohol use An action plan for lifestyle change Correction 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 interventions Beneficial effect “additive” rather than independent Stand-alone AA/ NA attendance does not improve outcome “Dose effect” found Merit 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) 24

Contingency Management Treatments Nancy M. Petry

Widely used in substance misuse research Gaining popularity despite some attitudinal resistance Clients awarded tangible positive reinforcers for objective behaviour change Vouchers for negative urine samples Clinic managed account Staff purchase requested items (audiovisual equipment, sports goods, clothing, cinema tickets etc.) Positive effects unambiguously demonstrated when compared to traditional treatments Almost 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 Some political and ideological criticisms - as efficacious as the voucher system - costs reduced by two thirds - “ 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 settings Increases proportion of drug negative samples submitted in methadone settings (Source: Petry 2006) 25

Adolescent Community Reinforcement Approach (CRA) with Vouchers

Developed as individual counselling approach (alcoholism) CRA with Vouchers is an extensive 14- 24 week out patient therapy Initially designed for cocaine addiction Used for cocaine dependent clients who use alcohol/ MMT patients who use cocaine Goals: Achieve abstinence for sufficient duration to develop life skills to sustain abstinence Reduce alcohol consumption Clients attend one- two psychotherapeutic sessions weekly aimed at: Improving family relations Developing skills to reduce drug consumption Vocational/ educational related issues Developing 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 26

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 27

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 significant Accepting but encouraging of change Centred and firm, yet flexible when required Nurturing but benevolently demanding Clear about their personal limits Treat with respect Implicit- not able to stop the client from harming herself Techniques include Contingency management Cognitive therapy Exposure based therapies 2) Group skills training 3) 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) 28

Brief Interventions (Heather1995)

Frequently used for maladaptive drug use (esp. alcohol, cannabis) Clients not yet dependent, few problems Goal moderate drinking as opposed to abstinence?

Designed for use by professionals not specialised in addiction Little time/ few resources Includes: Provision of self help materials Brief assessment Provision of advice (in a one off session), Assessment of readiness to change (motivational interview), Problem solving Goal setting Relapse prevention, harm reduction Follow- up 29

Brief Interventions (Heather1995)

Major elements summarised by acronym FRAMES Feedback Responsibility Advice Menu of strategies Empathy Self 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 cost Does not replace the need for specialist alcohol and drug treatments 30

Individual Psychoeducation

Seldom an independent intervention Inherent to good care, engagement, establishment of therapeutic alliance Provision of information at appropriate level or detail Stress client is not alone Describe what improvements can be expected Instill hope Describe the treatment modalities that work Suggest and recommend treatment plan Invite questions and discuss concerns Reinforce and repeat A major component of all good clinical care and all self help programmes Evidence that understanding about condition/ treatment related to adherence Knowledge 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 media Politically, 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 31

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 results Irrespective 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, and High level supervision and training - optimises outcome, irrespective of intervention 32

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) 34

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

Quality of the therapeutic relationship is critical Engagement and retention emphasised Respectful and non- confrontational An optimistic expectation of positive behaviour change A focus on skills generation Didactic in nature Imparting of knowledge and understanding Clear focus on readily identified and explicit drug use related goals Unpretentious and jargon free Focus on observable behaviour change (increases or decreases) Inclusion of homework and other exercises Emphasises the support and involvement of significant others/ family (i.e. social network based interventions) Encouragement of more effective communication with others Focus on relevant quality of life- related problems Drug and psychological difficulties treated in integrated manner Structured, standardised, manual based approaches Emphasis on self efficacy 35

Thank You

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