Psychiatry 2008 - September 2008 - (Page 37)

TABLE 2. A sample transcript with Joe contrasting a directive approach with a motivational enhancement approach ASSESSMENT USING A DIRECTIVE APPROACH Therapist: Tell me about your drug problem. Joe: I don’t have a drug problem. Therapist: What do you mean you do not have a drug problem? Joe: I use drugs; no problem Therapist: I have reliable information in this chart about your use. Joe: You sound like my dad or a probation officer. Therapist: Sounds like you are in denial of your drug use and consequences. We need to work on changing your negative attitude, otherwise you could be in trouble. ASSESSMENT USING AN MET APPROACH MET TECHNIQUE Therapist: What brings you here today? Active listening, empathy Joe: I’m only here because my dad made me come. Therapist: Tell me more about that. Roll with resistance, maintain empathy Joe: My dad thinks that I have a drug problem. Therapist: Care to tell me why he thinks so? Joe: I’ve been using and it kinda got me in trouble a couple of times. Begin to develop discrepancy between Joe’s understanding of his SUD and the concerns of others who care for him Therapist: Sounds as if you went through some difficulties. Active listening, empathy, further explore discrepancy Joe: I got problems in school and with the police. I don’t see how coming to a place like this is gonna be helpful with that. Therapist: I appreciate your honesty. I am glad that we have an opportunity to talk. If you want, we can meet several times and work together to solve these problems. Shall we schedule a meeting to continue? Joe: [Goes silent] I don’t want to work with you. Therapist: I have a lot of experience working with teenagers like you and I want to help you. However, you have to listen to me so you can make some changes in order not to ruin your life. Joe: I don’t need this lecture. I’m outta here. Roll with resistance, support self efficacy, continue to identify opportunities to highlight discrepancy Joe: Well, O.K. Because Joe demonstrated little motivation for change and the status of his coping skills to resist substance use in high-risk situations was unknown,20 we recommended an integrated intervention of MET/CBT.21,22 Table 2 provides an example of a transcription of a session with Joe utilizing this therapy compared to a directive approach. Periodic urinalyses to monitor abstinence with consequences for negative or positive urines were recommended. A contract negotiated early in treatment between Joe, his 37 father, and the clinician included changes in curfew times, allowance, and other incentives in a form of entertainment items (e.g., CD, DVD, movie tickets) and clothing. Adjustments were made during treatment based upon progress. An effort to engage Joe’s father as an ally in treatment was important in order to encourage Joe to achieve and maintain abstinence as well as contain the drug-using activities of Joe’s older brother at home. Joe met criteria for major depressive disorder (MDD) on clinical assessment. CBT was recommended for Joe’s depression and focused on increasing positive activities, improving problem-solving skills, and learning how to restructure unrealistic negative thoughts. Given his lack of suicidal ideation and moderate severity of depressive symptoms, it was not mandatory to begin antidepressant medication immediately. Since evidence suggests that depression in adolescents is influenced by psychosocial variables and has a high placebo response rate (between 35 and 60% in clinical antidepressant [SEPTEMBER] Psychiatry 2008 37

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Psychiatry 2008 - September 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Letters to the Editor Use of Benzodiazepines in the Treatment of Anxiety Functional Neurosurgery in the Treatment of Severe Obsessive Compulsive Disorder and Major Depression: Overview of Disease Circuits and Therapeutic Targeting for the Clinician Treatment of Comorbid Adolescent Cannabis Use and Major Depressive Disorder Risperidone Long-acting Injections: Successful Alternative Deltoid Muscle Injections for Refractory Schizophrenia Alcohol/Substance Misuse and Treatment Nonadherence: Fatal Attraction Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting Journal Watch Classified Advertising Information for Authors

Psychiatry 2008 - September 2008

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