In 2017, the Child Mind Institute released a special report on the increase in the prevalence of anxiety and depression among teenagers in the U.S. Two years later, the National Institutes of Health (NIH) released their annual Monitoring the Future Survey (2019 MTF), which included data on the increase in rates of binge drinking among adolescents. Both reports created concern – and in some cases, raised alarm – for parents, teachers, adolescent mental health professionals, public policymakers, and anyone involved in the lives of teenagers.

The increase in the prevalence of anxiety, depression, and binge drinking among teens was a primary area of worry, but another situation described by both reports elevated that logical concern to a level that some experts labeled a mental health and substance use crisis: the treatment gap. The reports showed that among teens with anxiety disorders and alcohol use disorder (AUD) – which is sometimes, but not always, present in cases of AUD – the number of teens who received specialized treatment for their anxiety disorder or drinking problem, as compared to the number of teens who needed treatment for an anxiety disorder or AUD, was far too small.

That’s what the treatment gap is: the difference between those who need treatment and those who receive treatment.

This article will address the treatment gap phenomenon by discussing a type of evidence-based therapy for adolescent anxiety and adolescent alcohol abuse that helps teens commit to, engage fully in, and complete their recommended treatment plan. It’s called motivational interviewing (MI). Motivational interviewing is often used as an adjunct or complementary support for teens engaged in two types of talk therapy: cognitive behavioral therapy (CBT) or dialectical behavior therapy (DBT).

Before we offer details on MI, we’ll give you a quick update on the prevalence rates of anxiety and binge drinking among teens.

Anxiety and Binge Drinking Among Teens: Facts and Figures

First, however, we should define both anxiety disorder and binge drinking, so that we’re all on the same page.

Here’s a simple, generic definition of anxiety disorder provided by the National Institute of Mental Health (NIMH):

“Anxiety disorders involve more than temporary worry or fear. For a person with an anxiety disorder, the anxiety does not go away and can get worse over time. The symptoms can interfere with daily activities such as job performance, school work, and relationships.”

Parents reading this article should focus on the two elements of this definition. Whereas typical worries, fears, and anxiety come and go, an anxiety disorder persists. That’s the first thing to understand. And while typical worries, fear, and anxiety do not significantly affect daily life, the presence of an anxiety disorder can significantly impact not only daily life, but also school, friend and family relationships, and work/extracurricular activities.

Now let’s define binge drinking.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines binge drinking as:

“A pattern of consumption that brings blood alcohol concentration (BAC) up to 0.08 g/dl. This happens when you consume 4 drinks in about 2 hours (females), or 5 drinks in about 2 hours (males).”

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines binge drinking as:

“Drinking 5 or more alcoholic drinks on the same occasion on at least 1 day in the past 30 days.”

The SAMHSA definition and does not distinguish between males and females.

Parents reading this article should take two things from this definition. First, a reminder that the legal drinking age in the U.S. is 21 years old, and therefore, any teenager engaged in drinking of any sort – binge or otherwise – is breaking the law. Second, evidence shows that teen binge drinking increases the likelihood of developing problem drinking, severe drinking, and alcohol used disorder (AUD) later in life. Those are important things to know because alcohol is so common in our society that it’s easy to lose sight of the fact(s) that underage drinking is both illegal and dangerous.

The Statistics: Anxiety and Binge Drinking Among Teens

Now let’s get to those prevalence numbers.

Here’s the data on anxiety from the Child Mind Institute, which we mention in the opening paragraph of this article:

Prevalence of Anxiety Disorders: Adolescents in the U.S

Any Anxiety Disorder

• Age 13-14: 31.4%
• Ages 15-16: 32.1%
• Age 17-18: 32.3%
• Females age 13-18: 38%
• Males age 13-18: 26.1%
• Age 13-18, female and male: 31.9%
• With severe impairment, female and male, age 13-18: 8.3%

By Anxiety Type

• Specific phobia: 13%
• Social anxiety disorder: 9%
• Separation anxiety: 8%
• Panic disorder: 2%
• Generalized anxiety disorder: 2%

Parents reading these statistics should understand that the presence of an anxiety order correlates with the presence of and increases risk of developing other mental health disorders, such as depression, behavior disorders, and alcohol/substance use disorder (AUD/SUD). More importantly, the longer an individual goes without receiving treatment for any mental health disorder – including anxiety – the greater their risk of developing severe impairment from the initial disorder, and the greater their risk of developing additional mental health disorders.

Now we’ll share the data on underage drinking from the 2019 Monitoring the Future Survey (2019 MTF):

Heavy Alcohol Use: Binge Drinking Among 8^th, 10^th, and 12^th Graders

• Five or more drinks in a row in the past two weeks:
  • 8th graders: 3.8%
  • 10^th graders: 8.5%
  • 12^th graders: 7.9%
• Ten or more drinks in a row in the past two weeks:
  • 8th graders: 1.7%
  • 10^th graders: 3.3%
  • 12^th graders: 5.3%
• Fifteen or more drinks in a row in the past two weeks:
  • 8th graders: n/a
  • 10^th graders: n/a
  • 12^th graders: 3.2%

Although any alcohol use among teens is not good news, there is something positive to take away from these statistics. On average, our teens are drinking less now than they have in about 25 years. That’s almost an entire generation, depending on how you count. The details: teen drinking peaked around 1995, declined steadily between 1995 and 2015, and leveled off around 2017-2018. The numbers are now stable at the levels measured in 2018-2019.

Now we’ll move on to our discussion of the treatment gap for anxiety disorders and alcohol use disorder, and how motivational interviewing can help reduce both in the teen population.

Teens and the Treatment Gap

Reminder: the difference between the people who need treatment and people who get treatment is called the treatment gap.

Here’s the gap for anxiety disorders among teenagers:

• 31.9% of teenagers in the U.S. meet criteria for an anxiety disorder
  • 8.3% of teenagers in the U.S. meet criteria for an anxiety disorder with severe impairment
• 80% of adolescents in the U.S. do not get specialized treatment in the U.S.

Here’s what the gap looks like right now for AUD among teenagers in the U.S.

• 401,000 adolescents (12-17) meet the criteria for AUD:
  • 173,000 males
  • 227,000 females
• Only 5% adolescents (12-17) with an AUD received treatment for their AUD.
  • 5.6% of males
  • 4.6% of females

We’re finally here: our discussion of motivational interviewing.

Ready? Here goes.

What is Motivational Interviewing (MI)?

Psychologists William (Bill) Miller and Stephen Rollnick created MI in 1983 while treating patients with alcohol and substance use disorder (AUD/SUD). At the time, clinicians in addiction treatment often utilized confrontational tactics to precipitate behavioral change.

Dr. Miller, on the other hand, taught clinicians to empathize, rather than confront or argue with their patients. He found that people with AUD/SUD kept using alcohol and drugs because they lacked the motivation to stop their behavior, not because they didn’t understand alcohol and drug use was bad for them. Empathy, Miller discovered, worked far better than logic in creating sufficient motivation to stop using alcohol and drugs.

In fact, one study he conducted found that the more empathic the counselor, the better the patient outcomes, even years later.

Accurate empathy then became a foundational principle of motivational interviewing. Miller and Rollnick found that – through guided empathy and reflection – allowing the patient to articulate their own arguments for change worked far better than lecturing or confronting the patient on how important it was to change.

Here’s how Dr. Rollnick put it:

“The more you try to insert information and advice into others, the more they tend to back off and resist. This was the original insight that generated our search for a more satisfying and effective approach. Put simply, this involves coming alongside the person and helping them to say why and how they might change for themselves.”

Parents of teenagers can relate to this more than almost anyone on earth. It’s akin to giving a teenager a voice in their treatment, and agency with regards to their recovery. The more they have, the more likely they are to commit, participate, and follow through – three things that are severe stumbling blocks for teens in treatment for anxiety or AUD.

Motivational Interviewing in the 21^st Century

These insights led Miller and Rollnick to define four pillars that they called the spirit of motivational interviewing:

1. Partnership: Therapist and patient work together as equals, in a collaborative process.
2. Acceptance: The clinician is nonjudgmental and understands that the patient has autonomy in their life.
3. Compassion: The therapist wants what’s best for the patient.
4. Evocation: The therapist’s role is to elicit the patient’s own articulations for change.

In turn, these four pillars led to the creation of the four principles of MI which clinicians apply around the world today. When using MI, clinicians:

1. Express Empathy

When clinicians show nonjudgmental acceptance, display genuine interest and curiosity without blame or criticism, teenagers feel respected, supported, and safe. They feel comfortable in the therapeutic relationship and more inclined to honestly explore their true feelings about change.

2. Develop Discrepancy

Teens often don’t want to feel controlled by their anxiety or their drinking. The therapist’s job is to help them see the discrepancy between their current behaviors and their ideal behaviors. When a teenager sees the mismatch, they’re more likely to be motivated to change.

3. Roll with Resistance

In MI, clinicians do not convince teens to change through logical debate. In fact, Miller and Rollnick found that the more you try to convince someone with logic, arguments, or new information, the more likely they are to increase, rather than decrease, their degree of resistance. Therefore, therapists allow teens to explore the concept of change on their own.

4. Support Self-efficacy

When someone is self-efficacious, it means they believe they can accomplish something. Research shows that strong self-efficacy leads to success. If a teen doesn’t believe they can change, it discourages them from trying. Clinicians engaging in MI increase self-confidence by telling their teens they truly believe they can change, despite past setbacks.

The Brass Tacks: How Motivational Interviewing Works With Teens

The four principles of MI and the spirit of MI establish the overall treatment philosophy and set the tone for therapy. On a practical level, with teens, therapists apply the MI process in four distinct steps. The goal of the steps is to resolve any ambivalence about making behavioral change.

1. Engaging

The first step of MI is for the clinician to build a trusting and mutually respectful therapeutic relationship. Without trust, teens are unlikely to open up. That’s why therapists take the time to foster an atmosphere of acceptance and safety. They also avoid labeling teens, avoid speaking like an expert, or telling teens how to fix their problems.

2. Focusing

The next step is for the teen and the therapist to decide what specific problem they want to work on. They collaborate on a clear agenda for therapy. Creating a specific focus helps maintain direction positive forward movement. Therapists may direct a teen toward a particular area of change or guide them toward a decision on a relevant issue. In some cases, teens know exactly what they want to work on. When that happens, the therapist follows the teen’s lead.

3. Evoking

When the teen and therapist decide what to focus on, they move to understanding why the teen should change the target behavior. In this step, the therapist’s role is to elicit change talk from the patient. Change talk is “speech that favors movement in the direction of change.”

4. Planning

The last stage of MI is deciding how the teen will change. Together, therapist and teen formulate a specific plan that’s measurable and achievable. They also create an ideal goal for when they want the change to occur by. At this stage, the teen is typically ready, willing, and motivated to put the plan into action.

Ownership and Agency Make a Difference

 Let’s go all the way back to the beginning of this article, where we talked about the rates of anxiety and binge drinking among teens reported by the Child Mind Institute and the 2019 Monitoring the Future Survey. Both publications discussed increases in those measures before the coronavirus pandemic. By now we’re all aware that the stress and isolation related to COVID-19 increases the risk of developing anxiety and problem drinking. We’re now also aware that anyone – teenagers included – with a diagnosed anxiety or alcohol/substance use disorder before the pandemic was at risk of either an exacerbation of symptoms (anxiety), or relapse (alcohol).

That’s why it’s important for parents of teens with anxiety or a drinking problem (AUD) to understand that treatment works. Evidence shows that motivational interviewing (MI), in coordination with talk therapies like cognitive behavioral therapy (CBT) and/or dialectical behavior therapy (DBT) can decrease the symptoms of an anxiety disorder and reduce rates of binge drinking in the teenage population.

And that’s not all. Motivational interviewing, in general, can increase three key things:

1. The desire to change.

2. Commitment to treatment.

3. Completion of treatment.

Changing these three things can work to decrease the treatment gap, a phenomenon that is both significant and disturbing. When teens have the motivation to change, take action to make change, and follow through on their desired changes, they can and do change their lives. Motivational interviewing leverages teenage characteristics that could otherwise be obstacles to treatment: ownership and agency.

Parents know it’s challenging to force a teen to make any change they don’t decide to make themselves. But when change is self-directed, and a teenager has a voice in how that change will happen, it’s more likely to happen – and far more likely to stick.

That’s how and why motivational interviewing works for teens: among other things, it gives them the respect and responsibility they crave as they navigate the path from youth to adulthood.