Program Profile: School-Based Guided Self-Change

This brief, cognitive behavioral, motivational intervention was designed to address alcohol and other drug use as well as aggressive behaviors among English- and Spanish-speaking adolescents who were already involved in drugs and aggressive behavior. This program is rated Ineffective The study found no statistically significant differences in measures of substance use and aggressive behaviors between adolescents in the treatment group, compared with adolescents receiving standard care.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program note:The Guided Self-Change approach has been refined and extended to various populations (adults, adolescents, Spanish speakers, males and females, alcohol users, and other drug users), and settings (outpatient alcohol programs, primary care centers), and individual and group formats.

Program Goals

Guided Self-Change (GSC) treatment was a brief, cognitive-behavioral, motivational intervention was designed to address alcohol and other drug use as well as aggressive behaviors among school-age, English- and Spanish-speaking adolescents. The program employed 1) a motivational client–therapist interactional style; 2) a cognitive–behavioral approach to planning, implementing, and maintaining changes in alcohol and other drug behaviors; and 3) a harm-reduction perspective for the treatment of addictive behaviors. GSC was intended as a middle step in a stepped-care model of alcohol and other drug treatment and is meant to take place before self-change efforts and brief motivational interviewing, but after more intensive interventions such as family or residential therapeutic approaches.

Target Population

GSC targeted adolescents between the ages of 14 and 18, with at least six instances of alcohol and other drug use, who were involved in at least one act of aggressive behavior (relational or predatory violence). Relational violence included hitting or threatening to hit a family member or someone outside the family; predatory violence included the use of force or threats of force to obtain money or items from people, involvement in gang fights, attacking someone with the intent of seriously hurting or killing them, or carrying a hidden weapon (Ellickson and McGuigan 2000).

Program Theory

GSC was based on 1) motivational interviewing theory, which suggests that the motivation to engage in delinquent behavior is changeable, and thus can be a target of treatment; and 2) cognitive social-learning theory, which suggests that people are more committed to goals when they are able to set them for themselves (Bandura 1986). Also, GSC adopts aspects of relapse prevention (RP) theory (Marlett and George 1984), a social-cognitive therapeutic intervention, which suggests that both cognitive and behavioral strategies can be used to prevent or limit relapse. However, as the GSC approach assumes participants have sufficient behavioral skills and resources to achieve successful outcomes, the approach includes only the cognitive aspects of RP theory such as providing a structure or guidelines for cognitive tasks that are expected to impact behavior and providing personalized feedback in terms of where drug use fits with societal norms and the types of health risks (Sobell and Sobell 2005).

Program Components

GSC followed a one-on-one, 5-week session format. However, GSC sessions could be extended by up to two sessions by participant request. The major treatment components included 1) weekly self-monitoring of adolescent behaviors targeted for change; 2) treatment goal advice, with adolescents selecting their own goal; 3) brief readings and homework assignments exploring high-risk situations, options, and action plans; 4) motivational strategies to increase an adolescent’s commitment to change; and 4) cognitive relapse-prevention procedures.

GSC used both fundamental behavioral change principles and motivational engagement strategies. It incorporated individualized treatment targets and changed strategies and substance use goals based on clients’ experiences (Gil, Wagner, and Tubman 2004). Although GSC was similar to other cognitive–behavioral brief interventions for alcohol problems, it was also different in several ways. First, GSC explicitly allowed clients to choose their goals. Second, it routinely used self-monitoring logs as a clinical procedure, for data collection, and to provide clients with feedback in terms of changes in substance use. Third, it included a cognitive relapse-prevention component to provide a realistic perspective on recovery and management of goal violations. This component included a long-term perspective on recovery and viewing change as incremental; interrupting a slip (i.e., goal violation) as soon as possible to minimize consequences; and understanding a slip as a learning experience (i.e., what can be learned from it) and not attributing it to a personal failure. Fourth, it was flexible rather than fixed in its structure (clients could request additional sessions after basic sessions had been completed). Fifth, it included a planned aftercare telephone contact 1 month after the last treatment session. Finally, GSC used brief readings and homework assignments to improve decisional balance and problem-solving components (Sobell and Sobell 2005).

Study

Wagner and colleagues (2014) conducted a school-based, randomized controlled trial to evaluate the effectiveness of Guided Self-Change (GSC) in reducing alcohol and other drug use and aggressive behavior. Adolescents in the GSC treatment program were compared with adolescents receiving standard treatment provided by school counselors.

Participants were recruited from 16 of the 57 high schools in the Miami-Dade County (Florida) Public School System, which is the fourth largest school district in the United States and covers geographical locations ranging from rural to suburban to urban. Interested students were recruited during assembly presentations and were asked to provide parental telephone contact information. Project staff obtained verbal and written parental consent. To be eligible for the study, adolescents had to have 1) been 14 to 18 years of age, 2) had at least six occasions of alcohol and other drug use in the past 90 days, and 3) had at least one act of relational or predatory violence in the past 90 days. Exclusion criteria included repeated dangerous behaviors such as drinking while driving, identified suicidal risk, pregnancy, and significant health problems.

Using a random number generator, students who were deemed eligible for the study were assigned to receive either GSC (odd number) or standard care (even number). The standard care condition consisted of 1) the educational lessons school counselors received on how to prevent the onset of alcohol and other drug use and violence, 2) brief alcohol and other drug or violence assessment, and 3) referrals to outside treatment providers but without a requirement for participation in a formal substance abuse or violence early intervention program.

Of the 514 participants included in the study, 279 were assigned to the treatment group, and 235 were assigned to the standard care condition (control group). Demographic information, such as age, gender, race/ethnicity, and nativity, were obtained from self-reports on a Personal Experience Assessment Questionnaire. Adolescents in the sample were between the ages of 14 and 18 and were 41 percent female and 59 percent male. Of the total sample, 57 percent identified as Hispanic, 23 percent as Black, 6 percent as white, and 14 percent as other race/ethnicity. Foreign-born adolescents made up 21 percent of the total sample and 41 percent of the Hispanic subsample. There were no statistically significant differences between the treatment and control groups on any demographic variable.

Data on substance use and aggressive behavior was collected using the Timeline Follow-Back (TLFB) assessment tool (Sobell and Sobell 1992). Using these self-reports, the TLFB defined substance use by the total number of alcohol use days, average number of drinks per drinking day, maximum number of drinks per drinking day, total number of drug use days, and total number of aggressive behavior incidents. Drug use days were estimated based upon the days in which participants used drugs on their own without a prescription. Aggressive behaviors were defined as engaging in relational violence and/or predatory violence.

Structural equation modeling was used to longitudinally compare immediate and long-term treatment effects on substance use and aggressive behavior. Other multivariate analyses were used to examine possible differences between the samples. All participants were assessed at baseline and post-intervention and had 3- and 6-month follow-up contacts. No subgroup analyses were conducted.

Guided Self-Change (GSC) was provided by five master’s-level counselors who received 2 weeks of project-specific training, using written treatment manuals. Role-play exercises evaluated clinical competency in conducting GSC. Once judged competent by the clinical supervisor, the counselors were assigned participants. All treatment sessions were audio-recorded; and weekly, 2-hour, group, clinical supervision meetings were conducted to maintain adherence and fidelity. Ten percent of session audio recordings were randomly selected and rated on a 5-point, multi-item GSC adherence scale by undergraduate research assistants who were blind to the project goals. Ten exemplar sessions and their corresponding adherence items scores, which were derived by consensus rating by the project’s investigators, were used to train adherence raters to criterion (Wagner et al. 2014).

For this study (Wagner et al. 2014), GSC followed a one-on-one, 5-week session format similar to the original adult version (Breslin et al. 2002; Gil, Wagner, and Tubman 2004). However, materials were modified to make language, illustrations, and examples developmentally appropriate for adolescents and Spanish-speaking individuals; to be applicable for both AOD use and violence; and to address stress, coping, and social skills in relation to high-risk situations.

The Guided Self-Change approach has been refined and extended to various populations (adults, adolescents, Spanish speakers, males and females, alcohol users, and other drug users), and settings (outpatient alcohol programs, primary care centers), and individual and group formats.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile: