brief intervention with middle/high school students scott caldwell, ma csac wisconsin department of...

Brief Intervention with Middle/High School Students

Scott Caldwell, MA CSAC

Wisconsin Department of Public Instruction

Safe and Supportive Schools and AODA Grantees Technical Assistance Conference, December 8, 2011

Presentation overview:

Part I – BI background: What, Why, When, and How

Part II – BI in practice, training, lessons learned

Wanted! An intervention model which is…

• Evidence-based and student friendly

• Developmentally and culturally relevant

• Efficient and flexible

• Compatible with existing paradigms

• Simple to deliver with feasible training

Brief Intervention

A student-centered yet structured approach that addresses a target behavior through developing a student’s intrinsic motivation for change. Delivered in an empathetic, collaborative and respectful manner, student ambivalence for change is explored and resolved.

Underlying principles:

• Motivation is a key to change

• State (not trait)

• Ready, willing, able

• Dynamic and fluctuating

• Interpersonal

Underlying principles:

• Motivation is a key to change

• Ambivalence can be a barrier

• Pros/Cons

• Normal to change

• What happens when we champion the side of change?

Something You Feel Two Ways About

• Identify a change you are considering. Something about yourself that you…

– Want to change

– Need to change

– Should change

In other words, something you’re ambivalent about

Speaker: Identify the change you are considering

Counselor: Do these four things, in this order…

1) Explain why the speaker should make the change

2) Provide at least two specific benefits that would result from the change

3) Tell the speaker how he/she could make the change

4) Emphasize how important it is to make the change

Underlying principles:

• Motivation is a key to change

• Ambivalence is a significant barrier

• Practitioner skill drives effectiveness

In Brief Intervention the practitioner is…

• Collaborative

• Evocative with open questions

• Supportive of student autonomy

• Reflectively listening

• AffirmingMotivationa

l Interviewin

g

A Taste of Motivational InterviewingSpeaker: discuss the same change you were

considering

Counselor: Listen carefully with the goal of understanding the dilemma; give no advice

• Ask these three questions:– Why would you want to make this change?– How might you go about it in order to succeed?– What are the two best reasons to do it?

• Offer a short summary of the speaker’s motivations for the change, then ask, “so what do you think you’ll do” and just listen

Brief Intervention(the vehicle) Motivational

Interviewing(the engine)

Why Brief Intervention?

1) Multiple uses

few

many

most

Level of AOD Involvement

Risky, Subclinical

Use

Experimental, infrequent use

or Abstinence

Abuse or

Dependence≈ 10%

≈ up to 30%

≈ 40% + ?

Type of AOD Services

Risky,Subclinical

Use

Experimental, infrequent use

or Abstinence

Abuse or

Dependence Treatment

BI

Prevention

BI (1 session)

(2-3 sessions)

Referral to

Multiple Uses of BI

Why Brief Intervention?

1) Multiple uses

2) Fits within PBIS

SECONDARYPREVENTION

PRIMARYPREVENTION

TERTIARYPREVENTION

• Specialized• Individualized• Systems for students with high risk

• Specialized group• Systems for students with at-risk behaviors

• School-/Classroom-wide systems for all students, staff, and settings

PBIS Paradigm

BI

Why Brief Intervention?

1) Multiple uses

2) Fits within PBIS

3) No problem recognition required!• Meets teens where they’re at

• Ambivalence is normalized

• Harm reduction goals are acceptable

Why Brief Intervention?

1) Multiple uses

2) Fits within PBIS

3) No problem recognition required!

4) It works

#1 Brief Intervention

#2 Motivational Enhancement

Meta Analysis of Adult Alcohol Treatment Outcome: Rank Order Source: Miller & Wilbourne (2002, p. 272)

What does not work:

#41 Standard treatment #43 Confrontational counseling #46 Education

Efficacy of brief AOD interventions with teens:

• Clinical studies consistently show that…• Brief intervention > No treatment• Brief intervention = More extensive

treatment

• Listed in reviews of effective adolescent treatments Deas (2008); Tripodi et al. (2010); Winters et al. (2009)

BI with teens in multiple settings:• Aubrey (1998): AODA treatment *

• Monti et al. (1999): hospital ED *

• Breslin et al. (2002): 4-session treatment

• McCambridge & Strang (2004): school *

• Baer et al. (2004): homeless

• Spirito et al. (2004): hospital ED *

• Knight et al. (2005): primary care

• Stein et al. (2006): juvenile detention *

• Walker et al. (2006): school *

• Monti et al. (2007): hospital ED*

• Winters & Leitten (2007): school *

• D’Amico et al. (2008): primary care*

• Martin & Copeland (2008): community** Randomized Clinical Trial

1) Small but growing literature

2) Teen outcomes: AOD use

AOD consequences

self-efficacy

3) Effective with racially diverse teens

4) Abstinence not typical, however, effects are

rapid and durable

5) High satisfaction ratings by teens

What the research suggests:

Beyond AOD?

School attendance

Homework completion

Self harm

Classroom conduct

Fighting

When BI (stand alone) may not be appropriate:

• Substance dependence• Daily marijuana use• Existence of significant co-

occurring problems

Part II

• BI in practice

• Training

• Lessons learned

Brief Intervention Structure

• Leads with a brief screen

• Typically 1-3 sessions

• Focuses on a target behavior

• Protocol driven

1. Opening strategies

2. Decisional balance

3. Readiness ruler

4. Change plan

5. Confidence ruler

BI Procedures:

1. Opening strategies

2. Decisional balance

3. Readiness ruler

4. Change plan

5. Confidence ruler

BI Procedures:

MI Behavior Counts

Practitioner behavior Benchmark for basic MI proficiency

Open Questions 50% of total questions

Complex Reflections 40% of total reflections

Question to Reflection ratio 1:1

MI Adherent behaviors (e.g., ask permission, affirmation, emphasis on choice)

At least 90%

MI Non-adherent behaviors (e.g., info. without permission, advising, warning, confronting)

No more than 10%

BI Training

1.Exposure

• Background

• Concepts

• Share with leadership

2. Adoption

• Decision by leadership

• 1-2 day training

• Fidelity checks

3. Implementation

• Set up data collection

• Fidelity checks

• On-going learning activities

Implementation Stages

Since 2006…

• 19 Adoption trainings, including 4 CESAs and 7 school districts

• 375 student services staff involved

• 440 tapes submitted, reviewed, and coded with feedback

Observations from the tapes:

• Student services come with talent and skills

• Demonstrating Motivational Interviewing proficiency is not easy– Giving up the “educator” role– Asking fewer questions– More and deeper listening– Acknowledging student choice– Resisting tangents (i.e., sticking to the target behavior)

Observations from the tapes:

• Student services come with talent and skills

• Demonstrating Motivational Interviewing proficiency is not easy

• Self-reported competency doesn’t correlate with actual practice

• Skills develop quickly with dedicated practice, feedback, and involvement in on-going learning activities

Implementation Lessons

• Leadership support is crucial

• Identify the champions

• Adoption training with entire student services team

• Get data collection system into place

• Establish peer group or other on-going learning activities

Summary

• BI is evidence-based and “teen friendly”

• Fits within PBIS

• Provides structure and focus, with flexibility

• Readily adaptable to school settings

• Maximizes limited resources

Thank you!

Scott.Caldwell@wisconsin.gov