Trials Using Guided Self-Change Model of Treatment
Acosta, S. L., Hospital, M. M., Graziano, J. N., Morris, S., & Wagner, E. F. (2015). Pathways to drinking among
hispanic/latino adolescents: Perceived discrimination, ethnic identity, and peer affiliations. Journal of
Ethnicity in Substance Abuse, 14(3), 1-17. doi:10.1080/15332640.2014.993787
We examined whether discrimination experienced by Hispanic/Latino adolescents is associated (a) directly with
adolescent alcohol use or (b) indirectly with adolescent alcohol use via mediation by ethnic identity and/or peer
associations. Data were drawn from an NIAAA-funded randomized controlled trial evaluating the efficacy of a
Guided-Self Change intervention for Hispanic/Latino youth with alcohol and interpersonal violence problems (R01
AA12180; see Wagner et al., 2014). The current sample included 371 Hispanic/Latino teenagers (mean age = 16.3
years [SD = 1.37]; 38% female). Using structural equation modeling (SEM), results revealed that perceived
discrimination was indirectly related to alcohol consumption through positive (non-drinking) peer affiliations.
Additionally, ethnic identity was found to moderate the relationship between discrimination and positive peer
affiliation. These findings further our understanding about how discrimination and ethnic identity interact, as well as
provide directions for how the effectiveness of prevention models may be enhanced for reducing underage drinking
among Hispanic/Latino adolescents.
Andréasson, S., Hansagi, H., & Oesterlund, B. (2002). Short-term treatment for alcohol-related problems: Foursession Guided Self-Change versus one session of advice—A randomized, controlled trial. Alcohol, 28(1),
57-62. doi:10.1016/S0741-8329(02)00231-8
The aim of this study was to compare two short-term treatments for alcohol-related problems. The study was
performed at an outpatient clinic for substance misuse, and subjects (65 men and 28 women) were recruited through
advertisements in the local newspaper. The subjects were randomized to either a four-session guided self-change
group or a one-session advice group. Alcohol consumption, degree of alcohol dependence, negative consequences of
drinking, and health-related quality of life were measured or assessed, respectively, by using the timeline followback technique, the Short Alcohol Dependence Data (SADD) questionnaire, The Drinker Inventory of
Consequences questionnaire, and the Nottingham Health Profile questionnaire. Biological markers for high alcohol
consumption [carbohydrate-deficient transferrin (CDT) and gamma-glutamyl transferase (γ-GT) levels] were
analyzed. All assessments were made at baseline and at 9- and 23-month follow-up periods after treatment. Selfreported alcohol consumption was significantly reduced (P < .0001) in both treatment groups at the 23-month
follow-up period, as were measures of alcohol dependence, negative consequences of drinking, and health-related
quality of life, whereas no corresponding reduction was found in CDT or γ-GT values. No statistically significant
differences in self-reported alcohol consumption were found between the two groups. Patient satisfaction was
significantly higher with the four-session guided self-change treatment than with the one session of advice. This
finding seems to indicate that individuals, although suffering from alcohol-related problems of relatively low
severity, appreciate more time with a therapist.
Ayala-Velazquez, H., Cardenas, C., Echeverria, L., & Gutierrez, M. (1995). Los resultados iniciales de un programa
de autocontrol para bebedores problema en México. Salud Mental, 18(4), 18-24. id:164566
La búsqueda de modelos de tratamiento efectivos para problemas relacionados con el consumo excesivo del alcohol,
ha sido preocupación creciente de las autoridades de salud a nivel internacional, ante la evidencia reciente ineficacia
de los modelos tradicionales de abordaje a esta problemática. En el presente estudio, se presentan los resultados
iniciales de la aplicación de un programa de tratamiento de auto control dirigido de consulta externa a una muestra
de 108 bebedores problema en la ciudad de México. Este programa de tratamiento de corte cognoscitivo-conductal,
se caracteriza por ser una intervención brevé, en la cual el usuario elige su meta de tratamiento sea ésta, moderación
o abstinencia, y donde la responsabilidad para el cambio se centra en el propio bebedor. La comparación entre el
patrón de consumo de este grupo de bebedores durante el periodo previo al tratamiento y durante la fase de
tratamiento, muestra un incremento en los días en que éstos permanecen abstemios, y una reducción tanto en el
número de copas que consumen en días que beben, como en las ocasiones de consumo excesivo. Estos resultados
son similares a los que se reportan en otros países, utilizando el mismo de la necesidad de modificar políticas de
salud pública que reflejen una concepción contemporánea y científica del fenómeno del alcoholismo, y que
impulsen acciones de prevención y tratamiento dirigidas al núcleo de la población muestra la mayor proporción de
problemas relacionados con el consumo del alcohol y una mayor probabilidad de responder con éxito al tratamiento:
los bebedores problema (AU).
The search for effective models of treatment for problems related to excessive alcohol consumption has been a
growing concern of health authorities worldwide, but recent evidence indicates that traditional approaches to this
problem are ineffective. The present study reports the initial results of the application of a guided self-change
outpatient treatment program on a sample of 108 problem drinkers in Mexico City. This cognitive-behavioral
treatment is characterized by a short dialogue in which the user chooses the goal of their treatment, either
moderation or abstinence, and emphasizes that the responsibility for change focuses on the drinker himself. The
comparison between the consumption pattern of this group of drinkers during the period prior to treatment and
during the treatment shows an increase in the days when they remain abstinent, and a reduction in both the number
of drinks they consume in days drinking, and heavy drinking occasions. These results are similar to those reported in
other countries using the same program and indicate the need to change public health policies to reflect the
contemporary scientific understanding of the phenomenon of alcoholism, and to boost prevention and treatment
aimed at the core population which shows the highest proportion of problems associated with alcohol consumption
and an increased likelihood of responding successfully to treatment: problem drinkers (AU).
Ayala, H. V., Echeverría, L., Sobell, M., & Sobell, L. (1997). Autocontrol dirigido: Intervenciones breves para
bebedores excesivos de alcohol en México. Revista Mexicana Psicología, 14(2), 113-127.
Breslin, C., Li, S., SdaoJarvie, K., Tupker, E., & IttigDeland, V. (2002). Brief treatment for young substance
abusers: A pilot study in an addiction treatment setting. Psychology of Addictive Behaviors, 16(1), 10-16.
doi:10.1037//0893-164X.16.1.10
The present study evaluated a motivationally based, 4-session outpatient intervention for young substance abusers
presenting for addiction treatment. Follow-up interviews were conducted 6 months after assessment on (a) clients
who sought additional help (n = 22) and (b) clients who did not seek additional help (n = 28). Results indicated that
(a) participating in an assessment and brief intervention was associated with reduced use and consequences and
increased confidence in high-risk situations up to 6 months after entry into the program, and (b) clients who
participated in additional treatment showed less of a decrease in substance-related consequences. These findings
suggest that brief interventions can serve as either a stand-alone intervention for individuals who need short-term
assistance or a first-step intervention for those with more specialized or long-term needs.
Breslin, F. C., Sobell, M. B., Sobell, L. C., Buchan, G., & Cunningham, J. A. (1997). Toward a stepped care
approach to treating problem drinkers: The predictive utility of within-treatment variables and therapist
prognostic ratings. Addiction, 92(11), 1479-1489. doi:10.1111/j.1360-0443.1997.tb02869.x
Aims: Cost containment, a central issue in current health planning, encourages the use of brief interventions.
Although brief interventions for problem drinkers have proved successful, a portion of such individuals do not
change their alcohol use during treatment. Design: Repeated measures design (pre-treatment, within-treatment and 6
months post-treatment). Setting and participants: To identify individuals at risk for continued problem drinking,
predictors of post-treatment drinking were examined for 212 problem drinkers who presented for treatment in an
outpatient treatment clinic. Intervention. All participants completed a brief cognitive behavioral motivational
intervention. Measurements. At the pre-treatment assessment demographic, drinking pattern, severity of dependence
and other cognitive variables (e.g. self-efficacy, goal choice) were collected. Within-treatment, drinking pattern and
cognitive variables such as self-efficacy and goal choice were again measured. Findings: Regression analyses
showed that therapist prognosis ratings contributed significantly to the prediction of outcome even when pretreatment variables were controlled. However, when within-treatment variables were included in the prediction,
variables such as within treatment drinking eliminated the predictive utility of therapist prognosis ratings. This
pattern held for both percentage of days abstinent and drinks per drinking day at a 6-month follow-up. Conclusions:
It is suggested that a stepped care approach based on prediction models that include clients' within-treatment
response can be applied to the treatment of problem drinkers who show little initial response to treatment.
Breslin, F. C., Sobell, M. B., Sobell, L. C., Cunningham, J. A., Sdao-Jarvie, K., & Borsoi, D. (1998). Problem
drinkers: Evaluation of a stepped care approach. Journal of Substance Abuse, 10(3), 217-232.
doi:10.1016/S0899-3289(99)00008-5
The present study evaluated a stepped-care model for the treatment of problem drinkers; those not severely
dependent on alcohol. The initial treatment consisted of a motivationally based, four-session outpatient treatment.
Based on previous research, treatment nonresponders were defined as having consumed more than 12 drinks per
week between the assessment and third session. Six-month follow-up interviews were conducted on three groups of
problem drinkers: (1) those who responded to the initial intervention (n=67); (2) those who did not respond to the
initial treatment (n=36); and (3) those who did not respond to the initial treatment and received a supplemental
intervention (n=33). The last two groups were used to evaluate whether providing treatment nonresponders with an
additional “step” would improve treatment outcomes. The primary dependent measures were posttreatment percent
days abstinent and posttreatment drinks per drinking day. Results suggested that: (1) within treatment drinking can
help identify treatment nonresponse in stepped-care models; (2) the supplemental intervention did not influence
posttreatment drinking; (3) treatment responders and nonresponders sought additional help at the same rate. The
present study is the first study on stepped care for alcohol treatment and provides a methodology for evaluating
stepped interventions. Recommendations for future research in this area include more attention to assessing the
needs of treatment nonresponders and help seeking behavior of both responders and nonresponders after an initial
intervention.
Floyd, R. L., Sobell, M., Velasquez, M. M., Ingersoll, K., Nettleman, M., Sobell, L., et al. (2007). Preventing
Alcohol-Exposed Pregnancies: A Randomized Controlled Trial. American Journal of Preventive Medicine,
32(1), 1-10. doi:10.1016/j.amepre.2006.08.028
Background: Prenatal alcohol exposure is a leading preventable cause of birth defects and developmental disabilities
in the United States. Design: A randomized controlled trial (2002–2005; data analyzed 2005–2006) of a brief
motivational intervention to reduce the risk of an alcohol-exposed pregnancy (AEP) in preconceptional women by
focusing on both risk drinking and ineffective contraception use. Setting/Participants: A total of 830 nonpregnant
women, aged 18–44 years, and currently at risk for an AEP were recruited in six diverse settings in Florida, Texas,
and Virginia. Combined settings had higher proportions of women at risk for AEP (12.5% overall) than in the
general population (2%). Interventions: Participants were randomized to receive information plus a brief
motivational intervention (n=416) or to receive information only (n=414). The brief motivational intervention
consisted of four counseling sessions and one contraception consultation and services visit. Main Outcome
Measures: Women consuming more than five drinks on any day or more than eight drinks per week on average,
were considered risk drinkers; women who had intercourse without effective contraception were considered at risk
of pregnancy. Reversing either or both risk conditions resulted in reduced risk of an AEP. Results: Across the
follow-up period, the odds ratios (ORs) of being at reduced risk for AEP were twofold greater in the intervention
group: 3 months, 2.31 (95% confidence interval [CI]=1.69–3.20); 6 months, 2.15 (CI=1.52–3.06); 9 months, 2.11
(CI=1.47–3.03). Between-groups differences by time phase were 18.0%, 17.0%, and 14.8%, respectively.
Conclusions: A brief motivational intervention can reduce the risk of an AEP.
Gil, A., Wagner, E., & Tubman, J. (2004). Culturally sensitive substance abuse intervention for Hispanic and
African American adolescents: empirical examples from the Alcohol Treatment Targeting Adolescents in
Need (ATTAIN) Project. Addiction, 99(s2), 140-150. doi:10.1111/j.1360-0443.2004.00861.x
Aims: This study presents preliminary analyses examining the effects of an alcohol and other drug use (AOD)
intervention with minority juvenile offenders. Furthermore, the study investigates the impact of cultural factors on
baseline AOD use among Hispanic and African American youth, as well as on treatment outcome. Design, setting,
and participants: Participants were 213 juvenile offenders referred for treatment (mean age = 15.7 years), 97 of
whom have completed treatment to date. The intervention was carried out in clinics placed within the neighborhoods
in which the participants resided. Intervention: Alcohol Treatment Targeting Adolescents in Need (ATTAIN) is a
controlled clinical trial evaluating the effectiveness of a brief motivational, cognitive behavioral intervention, guided
self-change (GSC). Participants are assigned randomly to the individual format of guided self-change (I-GSC), the
family involved format of guided self-Change (F-GSC), choice of one of these two, or a waiting list control
condition. Only participants involved in active intervention are included in the present report. Measurements: Data
were collected via structured face-to-face interviews. Alcohol and marijuana use measures were collected using the
Time-line Follow-back interview (TLFB). Findings: There were significant reductions in alcohol and marijuana use
for all ethnic groups from baseline to post-intervention. Cultural factors (discrimination, acculturation, ethnic pride
and cultural mistrust) were associated with pre-intervention levels of alcohol and marijuana use. Among Hispanics,
pre-intervention level of substance use were higher among foreign-born than US-born youth. Analyses conducted
with the US-born Hispanic group showed that ethnic orientation and ethnic pride were associated positively with
greater reductions in alcohol use. Conclusions: The intervention provided through ATTAIN appears to be effective
with a multi-ethnic population of juvenile delinquents. Cultural factors, such as ethnic orientation and ethnic
mistrust, appear to constitute amenability to treatment factors, with US-born Hispanic youth lower in acculturation
responding better to the intervention.
Lozano-Blanco, C., Sobell, L. C., & Velasquez, H. A. (2002). Dissemination of the Guided Self-Change treatment
program, for alcohol abuse, in health institutions in Mexico. Revista Latinoamericana de Psicologia, 34(3),
259-273. url: http://www.redalyc.org/pdf/805/80534306.pdf
The Guided Self-Change Treatment program (GSCT) for problem drinkers has been evaluated in Canada and
Mexico. Written originally in English, the materials were translated and evaluated with Spanish-speakers. All
previous studies with the GSCT have shown significant reduction of alcohol consumption with follow-up a year
later. The Mexican Social Security Institute asked the National Autonomous University of Mexico to develop a
national project for disseminating the treatment in health institutions. The present article discusses the model
diffusion of the treatment among physicians in Mexico.
Sobell, L. C., Sobell, M. B., & Agrawal, S. (2009). Randomized controlled trial of a cognitive-behavioral
motivational intervention in a group versus individual format for substance use disorders. Psychology of
Addictive Behaviors, 23(4), 672-683. doi: 10.1037/a0016636
Although group therapy is widely used for individuals with substance use disorders (SUDs), randomized clinical
trials (RCTs) comparing the same treatment in a group versus individual format are rare. This paper presents the
results of a RCT comparing guided self-change (GSC) treatment, a cognitive–behavioral motivational intervention,
conducted in a group versus individual format with 212 alcohol abusers and 52 drug abusers who voluntarily sought
outpatient treatment. Treatment outcomes demonstrated significant and large reductions in clients’ alcohol and drug
use during treatment and at the 12-month follow-up, with no significant differences between the group and
individual therapy conditions. A therapist time ratio analysis found that it took 41.4% less therapist time to treat
clients using the group versus the individual format. Participants’ end-of-treatment group cohesion scores
characterized the groups as having high engagement, low levels of interpersonal conflict, and low avoidance of
group work, all desirable group characteristics. These findings suggest that the GSC treatment model was effectively
integrated into a brief group treatment format. Health care cost containment compels further evaluations of the
efficacy of group treatments for SUDs.
Sobell, L. C., Wagner, E., Sobell, M. B., Agrawal, S., & Ellingstad, T. P. (2006). Guided Self-Change: A brief
motivational intervention for cannabis users. In R. Roffman & R. Stephen (Eds.), Cannabis dependence: Its
nature, consequences, and treatment (pp. 204-224). Cambridge, UK: Cambridge University Press.
doi:10.1017/CBO9780511544248.011
Studies of treated cannabis abusers (Ellingstad et al., 2002; Sobell et al., 1990; Stephens et al., 2000) and those who
have recovered without treatment (Sobell et al., 2000) are few in number compared with studies of other drug
abusers. Since national surveys have repeatedly shown that cannabis is the most widely used illicit drug (Substance
Abuse and Mental health Services Administration, 1997, 1998, 2000a, b) this finding is somewhat counterintuitive.
In fact, a recent review of drug treatment studies found that only 8% (2 of 28) that met review criteria including
primary cannabis abusers in their treatment samples (Ellingstad et al., 2002). Further, a review of natural recovery
studies found that only 1 of 40 reported data from cannabis abusers (Sobell et al., 2000). Given cannabis popularity,
an interesting question is why only about half a million of the 6.8 million frequent cannabis users (defined as using
cannbis ≥ 50 times) enter treatment (Substance Abuse and Mental Health Services Administration, 2000a). One
possible reason is that compared with other illicit drugs, the negative consequences of cannabis use are fewer, and if
they occur, are much less severe. For example, most of those who initiate abstinence from cannabis do not report
severe withdrawal symptoms (Budney et al., 2001; Wiesbeck et al., 1996; Zimmer & Morgan, 1995) and the most
frequently reported problems appear more related to personal dissatisfaction with drug use rather than objective
negative consequences (Stephens et al., 1994, 2000).
Sobell, M. B., Sobell, L. C., & Gavin, D. R. (1995). Portraying alcohol treatment outcomes: Different yardsticks of
success. Behavior Therapy, 26(4), 643-669. doi:10.1016/S0005-7894(05)80037-1
An important issue in the alcohol field is how to present treatment outcome findings in a way that conveys the
nature of the full range of outcomes (i.e., how individuals fared). Results should also be presented so as to be readily
understood by practitioners. To illustrate how treatment outcome reports can be enriched by graphic portrayals of
outcome findings, previously unpublished results from a study of Guided Self-Change treatment for problem
drinkers are first presented in a traditional manner. Then, supplemental graphic methods of data reporting, including
the use of frequency distributions and scatter plots, are presented. These portrayals are shown to address issues that
receive little attention in reports limited to statistical analyses. It is also shown that reported success rates,
“yardsticks of success,” are highly dependent on small changes in the criteria used to define success.
Sobell, M. B., Sobell, L. C., & Leo, G. I. (2000). Does enhanced social support improve outcomes for problem
drinkers in Guided Self-Change treatment? Journal of Behavior Therapy and Experimental Psychiatry,
31(1), 41-54. doi:10.1016/S0005-7916(00)00007-0
Although social support has been repeatedly identified as a strong correlate of recovery from alcohol problems,
enhancing social support has seldom been a focus of treatment research. Married problem drinkers who were willing
to have their spouses involved in their treatment were randomly assigned among two brief outpatient treatment
conditions: directed social support (DS, n=28) and natural social support (NS, n=28). In both conditions the
treatment in which the problem drinkers participated was an identical program of guided self-change, a cognitivebehavioral motivational intervention involving an assessment and four individual treatment sessions. Problem
drinkers’ spouses each attended two individual counseling sessions where they were informed about the counseling
procedures. The conditions differed in that spouses in the DS group were encouraged to play an active role in
helping their partner by being supportive and particularly by reacting to relapse episodes in a manner consistent with
a relapse prevention model. One year follow-up found that participants in both groups improved significantly from
pretreatment to the end of treatment, and that the gains were maintained over follow-up. The two groups did not
differ significantly from one another at any point in time. Possible explanations for the results include that (a) the
baseline level of social support in this population may have created a ceiling effect, and (b) the prognosis for this
population may be so positive that it is difficult to demonstrate significant enhancement of outcomes.
Tubman, J. G., Wagner, E. F., Gil, A. G., & Pate, K. N. (2002). Brief motivational intervention for substanceabusing delinquent adolescents: Guided self-change as a social work practice innovation. Health & Social
Work, 27(3), 208-212. url: http://dx.doi.org/10.1093/hsw/27.3.208
Discusses the Guided Self-Change (GSC) brief motivational intervention for substance abuse, and modification of it
for use with delinquent adolescents. GSC is a brief skills-oriented motivational intervention for addressing alcohol
and other drug problems. GSC uses both fundamental behavioral change principles and motivational engagement
strategies, making it especially promising for use with diverse populations. GSC aims to guide clients through a
process of making changes in their substance use or related problem behaviors by providing skills to help them
understand their substance use, factors associated with substance use, and supports for or barriers to attempts to
reduce or stop their substance use. Three significant changes made to the GSC were: (1) development of a families
version to reflect differences in the structure and other characteristics of Hispanic and African-American families;
(2) attention to culturally specific amenability to treatment factors for Hispanic and African-American youth; and (3)
delivery of the GSC in communities where the youth reside.
Wagner, E. F., Hospital, M. M., Graziano, J. N., Morris, S. L., & Gil, A. G. (2014). A randomized controlled trial of
Guided Self-Change with minority adolescents. Journal of Consulting and Clinical Psychology, 82(6),
1128-1139. doi:10.1037/a0036939
Objective: Adolescent substance use and abuse is a pressing public health problem and is strongly related to
interpersonal aggression. Such problems disproportionately impact minority youth, who have limited access to
evidence-based interventions such as ecological family therapies, brief motivational interventions (BMIs), and
cognitive behavioral therapies (CBTs). With a predominantly minority sample, our objective was to rigorously
evaluate the efficacy of a school-based BMI/CBT, Guided Self-Change (GSC), for addressing substance use and
aggressive behavior. Method: We conducted a school-based randomized, controlled trial with 514 high school
students (mean age 16.24 years, 41% female, 80% minority) reporting using substances and perpetrating aggression.
We used structural equation modeling to compare participants randomly assigned to receive GSC or standard care
(SC; education/assessment/referral-only) at posttreatment and at 3 and 6 months posttreatment on alcohol use, drug
use, and interpersonal aggression outcomes as assessed by the Timeline Follow-Back. Results: Compared with SC
participants, GSC participants showed significant reductions (p < .05) in total number of alcohol use days (Cohen’s
d = 0.45 at posttreatment and 0.20 at 3 months posttreatment), drug use days (Cohen’s d = 0.22 at posttreatment and
0.20 at 3 months posttreatment), and aggressive behavior incidents (Cohen’s d = 0.23 at posttreatment). Moreover,
treatment effects did not vary by gender or ethnicity. Conclusions: With minority youth experiencing mild to
moderate problems with substance use and aggressive behavior, GSC holds promise as an early intervention
approach that can be implemented with success in schools.