addressing teen substance use: a clinical perspective on adolescent brain development ken winters,...
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Addressing Teen Substance Use:A Clinical Perspective on
Adolescent Brain Development
Ken Winters, Ph.D.Department of PsychiatryUniversity of Minnesota
Drug Free Communities – Waukesha County
Waukesha, WISeptember 26, 2013
ResourcesBrief Interventions and Brief Therapies for Substance AbuseTIPS #34, SAMHSA-CSAT www.samhsa.gov/csat/csat.htm
Enhancing Motivation for Change in Substance Abuse TreatmentTIPS #35, SAMHSA-CSAT www.samhsa.gov/csat/csat.htm
MotivationalIinterviewing, Third Edition: Preparing People for ChangeThe Guilford Press (2013)www.guilford.com
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ResourcesAdolescents, Alcohol, and Substance Abuse: Reaching Teens through Brief InterventionsThe Guilford Press (2001)www.guilford.com
Motivational Interviewing with Adolescents and Young Adults The Guilford Press (2011)www.guilford.com
TeenInterveneHazelden Press (2012, 2nd edition)www.hazelden.org
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Outline of Talk
• Brief Interventions (BI)• Screening • Motivational Interviewing (MI) • Teen Intervene Update• Case Example
Outline of Talk
• Brief Interventions (BI)• Screening • Motivational Interviewing (MI) • Teen Intervene Update• Case Example
Why BIs Are Teen-Friendly
• Preference for ….1. physical activity2. high excitement and low effort activities3. activities with peers that trigger high
intensity/arousal4. novelty
• Less than optimal..5. balance of emotion and logic when making decisions6. consideration of negative conseq.
• Greater tendency to…7. take risks and show impulsiveness
Seven Implications of Arrested Development for Adolescent Behavior
Response OptionsAdapted from Broadening the Base of Alcohol Treatment (IOM)
Primary Prevention (Intensive for High Risk)
Abstinence Infrequent use
Dependence
Intensive Treatment
Assess &Referral
Challenges
Drug Involvement
MI has several applications within intensive tx
BriefIntervention
AbuseMisuse
Cost Containment
Abstinence Infrequent use Early abuse Abuse Dependence
Tx Gap Intensive Treatment
Drug Involvement
Adapted from Broadening the Base of Alcohol Treatment (IOM)
Bull Market: 1980’s - mid 1990’s
Prevention
Cost Containment
Abstinence Infrequent use
Dependence
Intensive Treatment
Drug Involvement
Adapted from Broadening the Base of Alcohol Treatment (IOM)
Bear Market: since mid 1990’shigher or more stringent admissionthreshold
Tx GapBrief
Intervention- MIPrevention
MisuseAbuse
Estimates of Mutually Exclusive “Mild-to-Moderate” Drug Abusing Groups of Youth (12-18-years-old) (based on data from SAMHSA, 2005)
5.8 6.3
1.3
11.3
5.2
0
5
10
15
20
Abuse only Binge alc. Heavy alc. Illicit drug Dependnece
%
Binge and heavy alcohol: past 30 daysAbuse only, Illicit drug, and dependence: past year
Total % = 24.7
4.4% light drinkers
65.7% non users
How Brief is a Brief Intervention?
Source: Linda Sobell
How Brief is a Brief Intervention?
• Some have been a few minutes or a single session (usually during an opportunistic situation).
• Typical: 2-4 sessions.
Assumptions of Brief Intervention“Thinking Outside the Box”
• Public health, not disease• Harmful consequences on a
continuum• Recognize abstinence as
ideal but open to alternatives• Does not have to enable
addiction
Therapy asusual
Why Brief Interventions Makes Sense for Youth
• Person-centered approach is appealing to young people.
• Commitment to lengthy and intensive interventions can be difficult at this age.
• Multiple applications
Possible Applications
Primary Prevention
Abstinence Infrequent use
Dependence
Intensive Treatment
Drug Involvement
Adapted from Broadening the Base of Alcohol Treatment (IOM)
BriefIntervention
Schools, courts, pediatric clinics, emergency rooms, mental health clinics
Misuse Abuse
• May not be appropriate for severe end cases (e.g., dependence)
• Supplemental treatment is warranted to address co-existing conditions
• Non-abstinence goals common to brief interventions (e.g., harm reduction, risk reduction) may not be suitable for some settings and for some counselors’ clinical orientation
• Abstinence via shaping (“reduction to abstinence”)
Cautions
Outline of Talk
• Brief Interventions (BI)• Screening • Motivational Interviewing (MI) • Teen Intervene Update• Case Example
Screening Issues
Primary Prevention (Intensive for High Risk)
Abstinence Infrequent use
Dependence
Intensive Treatment
Screening &Referral
Challenges
Drug Involvement
BriefIntervention
AbuseMisuse
Screening Issues
Primary Prevention (Intensive for High Risk)
Abstinence Infrequent use
Dependence
Intensive Treatment
Screening &Referral
Challenges
Drug Involvement
BriefIntervention
AbuseMisuse
1 standardized screening tool& brief clinical interview
Screening vs. Assessment
Prob Identif. Referral Tx Plan
Screening Probable? Assess? NA
Assessment Definitive? Treatment? Goals/Strategy?
My Favorite Screens
• Brief screening• CRAFFT
• Screening• ADI• DAST-Adolescent• PESQ• SASSI-adolescent• GAIN-Short Screen
GAIN-SS
Instrument Purpose Content Examples Group Used
Psycho-metrics
Format Time (min.)
Training Needed
Scoring Time (min.)
Computer Scoring
Fee for Use
Global Appraisal of Individual Needs – Short Screener (GAIN-SS)
Screen for substance use problem severity and related problems
SUDs Externalizing Internalizing Delinquency
Adolescents referred for emotional or behavioral disorders
Very favorable 20-
items, interview
5 no 5 Yes No
Source: Based on information provided by the literature or by authors of the measures.
www.chestnut.org Dennis, M.L., Chan, Y-F., & Funk, R.R. (2006). Development and validation of the GAIN Short Screener (GAIN-SS) for psychopathology and crime/violence among adolescents and adults. American Journal on Addictions, 15, S80-91.
Interview - General Issues
•Who should be in the room for first session?•maximizing adolescent
engagement
•consider dividing the session: •both first, then youth alone, OR•youth first, then parent
Brief Interview - HEADS
H = HomeE = Education/Eating A = ActivitiesD = DrugsS = Sex/Suicidality/Safety
Outline of Talk
• Brief Interventions (BI)• Screening • Motivational Interviewing (MI) • Teen Intervene Update• Case Example
MI = The Counseling Style Used in BI’s
Interviewing Techniques
Confrontationalvs.
Motivational
Exercise:Confrontational Interviewing
How many years have you been abusing alcohol? Abusing marijuana?
The screening test indicates that you are probably chemically dependent.
The test says that you use on a weekly basis, yet you are denying that you are chemically dependent.
Exercise:Motivational Interviewing
The screening test indicated that your use has inceased recently. What specific changes have you noted?
What are some of the benefits that you get from using?
What are some of the negative things about using?
What concerns do you have about yhour current pattern of use?
Contrasts Between Confrontational and Motivational ApproachesMiller & Rollnick, 1991
Confrontational MotivationalHeavy emphasis on self as having a De-emphasis on labels problem and acceptance of diagnosis
Emphasis on personality pathology, Emphasis on personal choice which reduces personal choice and control and responsibility
Therapist presents evidence of problems Therapist focuses on eliciting the client’s own concerns
Contrasts Between Confrontational and Motivational ApproachesMiller & Rollnick, 1991
Confrontational Motivational Resistance is seen as “denial” which is Resistance is met with reflection
confronted. nonargumentation.
Goals of treatment and strategies, Treatment goals and strategies prescribed, client assumed to be are negotiated; clients involvement incapable of sound decisions seen as vital
When is a confrontational style (in light
form) indicated?________________________________________________________________________________________________________________________________________________________________
Motivational
Interviewing
Change
Talk
BehaviorChange
The Goal of MI
Identifying Change Talk
• Desire to change• Ability to change• Reasons for change• Need for change
• COMMITMENT to making a change
Four Principles of Motivational Interviewing
R E D S
R: Roll with Resistance
• Reluctance and ambivalence are to be acknowledged (and even respected) and not confronted directly
• Questions and problems may be turned back to the client for solution
• Explicit permission is given to disregard what the interviewer is saying
• Resistance supplies energy which can be used therapeutically
E: Express Empathy
• Therapist empathy repeatedly shown to be predictor of client success in changing addictive behavior
• The operational definition of empathy is reflective listening
• Empathy indicates that the speaker has been understood
D: Develop Discrepancy
• The discrepancy between client values and current behavior is the location of fruitful therapeutic work
• Weighing pros and cons in nonjudgmental fashion will facilitate this discrepancy
• The client, not the therapist, must verbalize arguments for change
S: Support Self-efficacy
• Efficacy is the belief that a person can make a specific change
• Robust predictor of outcomes with a variety of clinical problems
• Interviewers may search for optimism in client’s previous successes
Decisional BalanceWhat are the pros of the adolescent’s drug use?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What are the cons (negatives) of the adolescent’s drug use?____________________________________________________________________________________________________________________________________________________________________________________________________________
What is accomplished with this procedure?____________________________________________________________________
How does it enhance self-motivation?____________________________________________________________________
How does it help with establishing goals?____________________________________________________________________
Outline of Talk
• Brief Interventions (BI)• Screening • Motivational Interviewing (MI) • Teen Intervene Update• Case Example
teen-intervene
www.hazelden.org
Teen Intervene Update
• Latest research data• Implementation• Use in groups• Learning TI• Collecting follow-up data • New parent project (Home Base)
Teen Intervene Update
• Latest research data• New summary in NREPP (www.nrepp.samhsa.gov)
•Ratings were in the 3-4 range
Teen Intervene Update
• Latest research data• New summary in NREPP
(www.nrepp.samhsa.gov)• Ratings were in the 3-4 range
• Recent publications in scientific literature
•SUD sample - 6 and 12 month outcome JSAT and PAB
•Truant sample – 18 month outcomeJCASA
Teen Intervene Update
• SUD sample - 6 and 12-month outcome
• Full 3-session version is better than the 2-session (youth only)
• although at 12-months, minimal difference
• 2-session better than assessment only
ResearchAbstinence rates at 6-months post-intervention for each of the 3 groups
Variable BI-Y BI-YP Control
Alcohol abstinence, prior 90 days at 6 month follow-up
50% 59% 29%
Marijuana abstinence, prior 90
days at 6 month follow-up
59% 68% 22%
Source: Winters (CPDD, 2008).Notes. Groups: BI-Y = BI-Youth only; BI-YP = BI-Youth and Parent; CON = Control, assessment only .
Teen Intervene Update
• SUD sample – 6 and 12-month outcome
• Full 3-session version is better than the 2-session (youth only)• But 2-session still better than assessment only
• Mechanisms of change: • > utilization of additional services• > problem solving• > motivation to change
Teen Intervene Update• Latest research data
• Implementation• 2nd edition published in 2012
•No substantive changes•Alterations: formatting and wording changes with some worksheets and suggested script
Teen Intervene Update• Latest research data
• Implementation• 2nd edition published in 2012
• No substantive changes• Alterations: formatting and wording changes with some worksheets and
suggested script
• Implemented with more than 75,000 youth in more than 1,500 sites (all 50 States and numerous countries)
• Statewide in 3 states; others in consideration
• Part of many youth SBIRT programs
Teen Intervene Update
• Latest research data• Implementation
• Use in groups
Teen Intervene Update• Latest research data• Implementation• Use in groups
• Learning TI• I am available for long-distance consultation and mini-supervision (either ad hoc or on-going)
• Listening to taped sessions• Self-fidelity checks • Booster training is available
Teen Intervene Update• Latest research data• Implementation• Use in groups• Learning TI
• Collecting follow-up data • Low key model
•baseline and post-intervention (e.g., 6-months) of drug use frequency and motivation to change (use Part 1 and 2 of Client Questionnaire)
• Cadillac model• full battery available from our research group [email protected]
Teen Intervene Update• Latest research data• Implementation• Use in groups• Learning TI• Collecting follow-up data
• New parent project (Home Base)
Home Base
Outline of Talk
• Brief Interventions (BI)• Screening • Motivational Interviewing (MI) • Teen Intervene Update• Case Example
Case Example - Lynette
THANK YOU! [email protected]