عوامل مرتبط با انگیزش برای استفاده مواد روانگردان و انگیزش برای تغییر در نوجوانان در بستر استبدادی

The use of psychoactive substances (alcohol and drugs) by young people placed in rehabilitation centers in Quebec is well documented, but their motivation to use and to change substance use behavior remains unknown. There has been very little research on the details of the change process in adolescents, and even less in adolescents under supervision in rehabilitation centers. The present study aimed to identify the factors that youth associate with their motivation to use psychoactive substances and the factors that they associate with their motivation to change. Twenty-seven young males (age 14–18 years) were interviewed in the Centre jeunesse de Montreal. The majority of the participants were able to identify motivations to use and to change their substance use behavior. The motivations to use differed depending on the type of substance and the surrounding context in which drug use occurs. The motivations to change were associated with substance-related problems and with the perceived effect of external factors (e.g. constraints) on substance use. Finally, neither the motivations to use nor the motivations to change were strongly associated with the closely supervised setting in which the youth found themselves. Thus the controlled environment of the Centre jeunesse appears to have facilitated the change process for some participants and had no impact on others. The implications of these results for substance-abuse interventions involving troubled youth are discussed.

In Quebec, Centres jeunesse (rehabilitation centers, CJs) are the public institutions mandated to intervene in young people (younger than 18 years old) who are: 1) experiencing a situation considered dangerous for their safety or 2) presenting problematic behaviors that may compromise the security of others. In 2008–2009, 30 297 children were cared for under the Youth Protection Act (YPA). Of these, slightly more than 9% (2825) were placed in institutional resources (rehabilitation centers, intermediate resources), most commonly in response to a serious risk of negligence (32.6%), parental negligence (18.7%), serious behavioral problems (16.6%), or psychological abuse (12%). During the same period, 15 751 adolescents were referred to a CJ under the Youth Criminal Justice Act (YCJA)1. Among those sentenced, 85.6% (4478) served their sentence in the community, while 14.4% (755) were detained in a rehabilitation center (Directeurs de la protection de la jeunesse (DPJ), 2009). Given the reasons for referral to CJs, and the low placement rate in institutional resources in Quebec, the fact that serious issues are typically observed in this clientele is hardly surprising. Toupin, Pauzé, Frappier, Cloutier, and Boudreau (2004) observed serious adjustment difficulties in young people receiving services from CJs. These problems—including suicide attempts (20%), externalized problems (35–45%), internalized problems (10%), and regular use of psychoactive substances (PAS) (25%)—were 3 to 10 times more prevalent in CJs than in the general population of adolescents. Several Quebec studies have reported a high prevalence of psychoactive substances use by young people placed in CJs (Godin et al., 2003, Laventure et al., 2008, LeBlanc, 1994, Pauzé et al., 2004 and Régie Régionale de la santé et des services sociaux et les Centres jeunesse de Québec, 1995). The most recent study focusing on PAS use in CJs is probably that of Laventure et al. (2008), who studied a sample of adolescents (12–17 years old) placed in Quebec City CJs, using the Indice de gravité d'une toxicomanie pour adolescents (IGT-ADO) [index of severity of substance abuse in adolescents]. Their results revealed three profiles: low use (28.9% of participants), moderate use (33.8%), and high use (37.3%). These profiles were differentiated by age, although not by sex: the mean age of the low-use profile was 14.5 years, that of the moderate-use profile 15.6 years, and that of the high-use profile 16 years. Few young people who reported high use of PASs claimed to have a problem or were open to receiving help. The authors called for more comprehensive studies of adolescent motivation, in order to identify effective treatment strategies for substance abuse. Although the motivation of young people to begin regular use of PASs is a recent research interest, several studies have already been published (e.g. Boys et al., 2001, Brunelle et al., 2002, McInstosh et al., 2005, Palmqvist et al., 2003 and Titus et al., 2007). However, there are few studies on the motivations of young people in closely supervised settings. In the same vein, several researchers have noted that research on motivation to change and on the change process in adolescence is in the early stages (Batjes et al., 2003, Berry et al., 2005, Callaghan et al., 2005, Migneault et al., 1997 and Tevyaw and Monti, 2004). Furthermore, little is known about the factors that influence motivation to change in adolescents, as most studies on this phenomenon have been conducted with adult populations. The few studies in young people have generally been conducted in substance-abuse treatment centers; they indicate that motivation is positively associated with age (Melnick, De Leon, Hawke, Jainchill, & Kressel, 1997), and social support (Broome, Joe, & Simpson, 2001). The following section presents some studies that explore either adolescents' motivation to use psychoactive substances or their motivation to change substance use behavior. 1.1. Adolescents' motivations to use psychoactive substances and to change substance use behavior Studies undertaken to elucidate the reasons young people use PASs have generally also proposed strategies to improve programs to prevent substance use. Some researchers believe that understanding the reasons young people use PASs (individual substances and combinations) can lead to the development of more effective prevention programs (Boys & Marsden, 2003). Boys et al.'s (1999) qualitative study of 50 young people (16–21 years old) identified the following motivations to use PASs: relaxing, reducing shyness, improving self-confidence, plans to go dancing, suppressing appetite, boosting energy and motivation for daily activities, facilitating work, controlling the effects of other drugs, relieving boredom and depressive thoughts, and forgetting problems. These themes were confirmed in a quantitative study conducted in a sample of 364 young people who were users of multiple PASs (Boys et al., 2001). The main motivations to use PASs reported by participants were relaxing and the desire to “get stoned”, followed by wanting to “stay up all night during social activities” and “increasing the pleasure of some activity”, and relieving a depressive mood. In addition, adolescents interviewed by Allen (2003) reported being particularly motivated to drug use when they were depressed, fed up, stressed, or bored. The stimulating effects of PASs were also reported in Parks and Kennedy's (2004) study of young adults' motivation to use “club drugs” (ecstasy, GHB, ketamine, Rohypnol, methamphetamine and LSD). The primary reasons cited were increasing energy, staying awake, enhancing the effects of other substances, and achieving insight. These results confirm those of Boys, Lenton, and Norcross (1997), who reported that the main reasons cited by their sample of multiple-drug users aged 16–22 years old for consuming ecstasy were: to “keep going” and increase the pleasure they took in their activities, to become excited, to stay awake, to become intoxicated, to appreciate the company of friends, and to enhance sexual pleasure. Similarly, adolescent cocaine users cited physical (reduction of fatigue, increase in energy), mental (feeling good, self-confidence, mental clarity), and social (chatting, enjoying the company of friends) effects as their primary motivations to use the drug (Van der Poel, Rodenburg, Dijkstra, Stoele, & Mheen, 2009). Building on these results, Boys and Marsden (2003), investigated the association between the motivations for the use of substances and the problems associated in a sample of young multiple-drug users. They concluded that young people who use PASs in order to cope with negative emotional states run a higher risk of developing problems associated with the use of alcohol, cannabis, and cocaine. Among other things, young people who use alcohol, amphetamines, or cannabis “to get stoned” (i.e. for the pleasure associated with the use of substances) are at increased risk of increasing their use of these substances. Young people who use PASs for multiple reasons and in whom—like many of the participants in the current study—drug use fulfils multiple functions, appear to make a rational cost–benefit decision regarding their use of drugs. To some extent, these results replicate those of Novacek, Raskin, and Hogan (1991), who reported frequency of drug use to be positively associated with drug use for pleasure or “to cope”. Less-frequent drug use was associated with motivations such as “to belong to a group” and “to become more creative or aggressive”. In the same vein, Comasco, Berglund, Oreland, and Nilsson (2010) investigated the relationship between the motivation to use alcohol and the problems associated with the use of this substance. The results of their longitudinal study of 11 627 participants indicate that drinking to improve well-being, to obtain social benefits, or to reduce tension and negative emotions is positively associated with alcohol-related problems. Conversely, drinking to increase “personal power” and aggressivity was negatively associated with alcohol-related problems. Similar conclusions were obtained in a sample of young cannabis users (Hyman & Sinha, 2009), who frequently used that substance to cope with stress. In this sample, drug use was associated with negative life events, trauma, and maladaptive coping strategies. Despite the fact that several individuals used cannabis without major negative consequences, those who used this substance to cope with stress were at higher risk of becoming addicted. Like other authors (Austin et al., 2010 and Batjes et al., 2003), we have noted the dearth of studies on adolescents' motivation to change their use of PASs. This is especially true for “spontaneous” processes of change (those that do not involve professional help), as a significant number of studies of adolescents' motivation to change have been conducted in clinical populations, and were intended to shed light on the factors associated with an improved prognosis in individuals in treatment (Batjes et al., 2003). These studies did however identify associations between motivation to change and commitment (Broome et al., 2001 and DiClemente et al., 2008), retention (DiClemente et al., 2008, Fickenscher et al., 2006 and Melnick et al., 1997), and therapeutic effectiveness (Breda and Heflinger, 2007 and Cady et al., 1996). On the other hand, the factors associated with “spontaneous” motivation have received considerably less attention. It appears, however, that one of the factors that favor motivation to change in PAS users is awareness of use-related problems. Batjes et al. (2003) reported that the negative consequences of substance use predicted motivation in their sample of 196 adolescents beginning treatment for substance abuse. More specifically, motivation was positively associated with perceiving problems with PAS in general, having emotional problems, having curtailed one's activities because of PAS use, and having been placed in a rehabilitation center or having been sentenced. In a large-scale drug abuse treatment outcome study, problems due to PAS use were the best predictors of motivation, in both adults and adolescents. In particular, a predisposition to change was directly associated with perceived PAS-related poor health, regardless of age (Handelsman, Stein, & Grella, 2005). Similarly, young adult users of “club drugs” cited negative physical symptoms—such as weight loss, diminished energy, headaches, and muscle pain—as motivations to change substance use (Parks & Kennedy, 2004). Levy, O'Grady, Wish, and Arria's (2005) qualitative study indicates that young people's motivation to change may be influenced by both anticipated and experienced drug-related problems. Young ecstasy users in that study cited the following problems (either experienced themselves or observed in friends) for ceasing their drug use: 1) negative experiences (e.g. weight loss, emotional instability); 2) concerns about health or drug addiction (e.g. psychological dependence); 3) financial considerations (e.g. not having enough money to continue to buy ecstasy, believing that other drugs have a better cost–benefit equation); 4) loss of interest (e.g. preferring other drugs to ecstasy, stating that they had matured and thus lost interest in consuming, feeling that the initial effects, the “magic” had diminished due to overuse); 5) observation of the effect of ecstasy on the behavior of others when they were not intoxicated (e.g. “frightening” alterations in friends' personalities); and 6) fear of legal consequences. Furthermore, an individual's expectations about PAS use appear to have an impact on their motivation to change. This topic has been extensively studied by researchers interested in the etiology of, and motivation to change alcohol use (McNally & Palfai, 2001). McMahon and Jones (1993) analyzed the role of alcohol-related expectations on predisposition to change in individuals in treatment for alcoholism. They concluded that positive expectations were associated with a motivation to use, while negative expectations were associated with a motivation to reduce use. Similarly, McNally and Palfai (2001) study of young college students revealed that, negative alcohol-related expectations were associated with a motivation to diminish or cease use, regardless of the quantity and frequency of the use and the number of problems experienced. However, the researchers noted that some sub-types of expectations were more closely associated with motivation to change alcohol use than others. Specifically, negative, “emotional”, expectations (feeling guilty, depressed or ashamed) significantly predicted motivation to change in this population. Finally, some studies have focused on a specific category of negative PAS-related expectations: the perception of risks (physical, academic, social, etc.). Weinstein (1993) suggests that motivation to change is a function of perceived use-related vulnerability (i.e. an aversive consequence). All in all, however, the results of the studies of the relationship between substance use and perceived risks/consequences related to use appear to be equivocal (Wild, Hinson, Cunningham, & Bacchiochi, 2001). Both positive associations (substance use paralleling perceived risk; Gerrard, Gibbons, Benthin, & Hessling, 1996) and negative associations (substance use and abuse diminishing as perceived risk increases; Bachman, Johnston, & O'Malley, 1990) have been reported. 1.2. Objective In general, helping relationships with adolescents are embedded in relationships of authority, as this population rarely participates in intervention programs spontaneously (Zack, Castonguay, & Boswell, 2007). However, several studies suggest that the exertion of formal authority in a rehabilitation strategy may have a significant influence (positive or negative) on motivation and on openness to interventions (Conte et al., 2008, Girvin, 2004, Slesnick et al., 2009 and Yost and Ellis, 2008). Young people placed in rehabilitation centers find themselves in an “authoritarian context”. They are rarely placed of their own volition, and they generally face more intense adult authority and more pervasive constraints than they are used to. Because they often feel deprived of freedom, they may exhibit signs of discomfort, including resistance to change and lack of openness to educator-initiated rehabilitation strategies (Yost & Ellis, 2008). The present study was therefore undertaken to identify the factors that youth placed in an authoritarian context associate with their motivation to use psychoactive substances and with their motivation to change substance use behavior.

The general conclusion of this study is that participants—who found themselves in an authoritarian setting, and were, for the most part, multiple-substance users—exhibited motivations that were extremely dynamic and variable (as a function of context, circumstances, substance, and emotional state). This complexity remains even after taking into account their motivations to change, as these also depend on the substance and on the context (the controlled environments of the CJs considerably diminishes the opportunity and ease of obtaining PASs while in placement). Interestingly, the intensity of counseling did not influence the participants' narratives. Thus, the perception of counseling appears to be at least as important as objective control strategies in explaining the role of constraints on the motivation to change. The conclusions of research and common sense, i.e. that these young people are not motivated to change, must be taken with a grain of salt. In this connection, it is noteworthy that several studies have used “general” measures to evaluate young people's motivation to change, without distinguishing between the drugs used, and that most studies have adopted a quantitative approach (e.g. Batjes et al., 2003 and Handelsman et al., 2005). Furthermore, while the perception of a problem is certainly associated with motivation to change, as reported in several studies, it appears that this is not the only factor responsible for changes in substance use. The results of this study indicate that a young person may begin a process of change without realizing the consequences of their substance use on their life, simply to obtain certain forms of immediate gratification. Eventually, in a moment of total or partial abstinence, they may begin to recognize their problem, and new motivations may emerge. Interventions involving young people not yet ready to explore the negative consequences of drug use should therefore refrain from emphasizing this dimension, as these consequences are likely to have no “significant weight” in the young person's decisional calculus. These young people may nevertheless be open to consider the possibility of change, especially if the potential benefits of change—rather than the potential costs of substance use—are emphasized. This type of intervention would facilitate transition from completely controlled motivation to more independent motivation (Deci & Ryan, 2000). Interventions in authoritarian settings targeting young people with problematic PAS use should therefore take into account motivation to change, given the important influence of external, and often coercive, agents. It is therefore crucial that the workers involved in these intervention settings better understand, and take into consideration, the nuances and dynamics of the motivations to PAS use and to change in adolescents. They must identify the sources of motivation from the very outset—and continue to do so throughout the intervention—and ensure that their approaches are well suited to their clients' profiles. By so doing, they will facilitate the integration of motivation to change in young people in placement, and thereby help them achieve and maintain change. In particular, it appears essential to allow young people to accept change on their own timetable and regardless of their motivations. Furthermore, given the important role of interpersonal relationships in shaping young people's motivation, relationships with their entourage which favor openness to change must be promoted. In the same vein, workers must be aware of their role as motivational agents for young people. Training in motivational interview techniques (Miller & Rollnick, 2002) would be extremely valuable in encouraging the adoption of an approach that emphasizes empathy, authenticity, and respect in interventions involving young people placed in rehabilitation centers.