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WVSBIRT West Virginia Screening Brief Intervention and Referral

DEALING WITH YOUTH SUBSTANCE ABUSE AND

RESISTANT BEHAVIOR PROBLEMS

“HOW TO AVOID THE TUG OF WAR”

West Virginia Screening, Brief Intervention and Referral to Treatment

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Training Objectives

• Review of prevalence of youth substance abuse•Define the basic components of SBIRT and it’s application with youth•Motivational Interviewing basics and applicability with the SBIRT Model•Elements of effective interventions with youth•Practical strategies for dealing with resistance

TRAINING SCHEDULE

10:00 - 10:30 Adolescent SA Prevalence/Overview of SBIRT10:30 – 11:00 Motivational Interviewing Basics11:00 – 11:30 O-A-R-S11:30 – 12:00 Small Group OARS exercise 12:00 – 1:00 Lunch1:00 – 1:45 Dealing with Resistance 1:45 – 2:00 Wrap-up/Questions

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SUBSTANCE USE AND YOUNG PEOPLE

EXTENT OF THE PROBLEM

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Did you know?

Children who start to use drugs/alcohol or use drugs during adolescence are 4X more likely to become substance involved as adults.

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PREFRONTAL CORTEX

1. Judgment/Reasoning2. Decision Making3. Planning4. Learning from their experience/consequences

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Between 1992 and 2003, prescription drug abuse in 12-17 year-olds rose 212%. Teens abuse RX drugs more than heroin, cocaine, meth, crack or ecstasy. They see prescriptions as ‘safer’ than other drugs (shared by family and friends).

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West Virginia at 8.9% is among the top five states leading the country in teen abuse of prescription pain relievers (SAMHSA, 2007)

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In 2005‐2006:

WV exceeded national rates of Illicit Drug Use among

18-25 year olds.

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Reported drinking in the past month

26% of 8th Graders40% of 10th Graders51% of 12th Graders

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Binge Drinking

During the last two weeks

16% of 8th Graders 25% of 10th Graders 30% of 12th Graders

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Consequences of Underage Drinking

Fatal Vehicle Accidents Other Traumas Risky Sexual Behavior Victimization Developmental Delay

SYMPTOMS OF TEEN SUBSTANCE INVOLVEMENT

1. Sudden Personality Changes Including Work or School Attendance2. Unusual Flare-Ups or outbreaks of Temper3. Withdrawal from Responsibility4. Loss of Interest in hobbies or pursuits5. Change in Friends 6. Difficulty in Concentration7. Sudden Jitteriness, nervousness or aggression8. Increased Secretiveness9. Deterioration in Physical Appearance or Grooming10. Unusual Borrowing money from Friends, Co-Workers or family11. Stealing

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What is the Solution?

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We Must Start To Intervene Early!.

WHAT IS SBIRT?

1. Paradigm shift from traditional view of substance abuse interventions2. Views Substance Abuse as a public health issue and focus on risk reduction as well as abstinence3. Focus on identifying “misuse” early and providing brief interventions4. Is comprehensive in it’s approach

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~ BRIEF TX OR REFERRAL

Risky or Harmful

25%

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NO INTERVENTION Low Risk or Abstinent

70%

BRIEF INTERVENTION

SUBSTANCE USE IN THE GENERAL POPULATION

SBIRT INTERVENTION

Addiction5%

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UNDERLYING PREMISE OF SBIRT INITIATIVES

The majority of Americans see a health care provider at least annually. By encouraging health care professionals to:

* Identify at-risk individuals * Intervene early* Promote concept of substance misuse as a health issue* Reduce Stigma associated with seeking intervention

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STEP 1BRIEF SCREENING

STEP 1BRIEF SCREENING

STEP 2CONDUCT INTERVENTION

STEP 2CONDUCT INTERVENTION

STEP 3ASSESS READINESS

ENGAGE CLIENT

DEVELOP A PLAN

STEP 3ASSESS READINESS

ENGAGE CLIENT

DEVELOP A PLAN

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SBIRT PRESCREENINGCRAFFT

AGE 12-17

1.Have you ever ridden a a car driven by someone who was high or had been using drugs alcohol?2.Do you ever use alcohol or drugs to relax, feel better about yourself or fit in?3.Do you ever use alcohol or drugs while alone?4.Do you ever forget things you did while using alcohol/drugs?5.Have you ever gotten into trouble while you were using alcohol or drugs?

MOTIVATIONAL INTERVIEWING BASICS

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What is Motivational Interviewing?

Motivational Interviewing is a semi-directive, client

centered counseling style for eliciting behavior

change by helping people to explore and

resolve ambivalence.

Spirit of Motivational Interviewing

•Collaboration – Working in Partnership

•Evocation – Learning from the person

•Autonomy – Person is responsible for own change

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More About the MI Philosophy

Empowers people to take ownership of their own

health management by:•Providing information respectfully•Partnering •Supporting sense of self-efficacy•Places patient is role as the expert regarding how to change their behavior

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Basic Assumptions of MI

•Motivation is a state of readiness to change that fluctuates with time and situations.

•Motivation can be increased through interaction.

•The process of making a change often includes mixed feelings*

*Ambivalence is a normal part of the change process.

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Motivational Interviewing

The task of the practitioner is to:

•Tap into the person’s potential for change•Guide the natural change process already within the individual

• Impart hope, belief in, and confidence that the person can make desired changes.

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WHAT IS O-A-R-S?

OARS is a Core Motivational Interviewing Strategy

•Open-Ended Questions

•Affirmations•Reflections •Summarizations

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Open Ended Questions to Promote Change

•How do you feel about your current alcohol/substance use?

•What worries do you have about your substance use ?

•What would you like to do about this?•What makes you feel that now is a good time to get started?

Turning Closed into Open Questions

•Do you drink a lot of alcohol in the evening?• How much alcohol (or other substance ) do you use in the evening?

•Do you want to reduce your use?• How do you feel about making changes in your use?• What might make you want to reduce your use?

•Do you know that substances can be harmful?• What do you know about the risks of using?

AFFIRMATIONS

Recognizing statements that support self-efficacy (self-confidence) is done by havingclients give voice to changes they have made and making a statement that supports attempts at change.

The objective is to increase their self confidence that they can change.

Examples of Eliciting Statements Supporting Self-Efficacy/confidence.

• “It seems you’ve been working hard to quit smoking. That is different than before. How have you been able to do that?”

• “Last week you were not sure you could go one day without using cocaine, how were you able to avoid using the entire past week?”

After asking about changes clients have made, it is important to follow-up with a question about how clients feel about the changes they made.

• “How do you feel the changes you made?”

Reflective Listening

Is a process of…

- Hearing what the speaker has to say,- Making a “guess” at what he or she

means, - Giving voice to this “guess” in the

form of a statement.

Forming Reflections

For starters…•I

t sounds like you are not ready to stop drinking.•I

t seems that you are having a problem remembering things.•I

t sounds like you are feeling guilty about your drinking.•F

rom what you are saying, you are having trouble limiting your drinking.

As you improve, you can shorten the reflection….

•You’re not ready to stop drinking.

•You’re having a problem remembering things.

•You’re feeling guilty about your drinking.

•So you’re having trouble limiting your drinking.

Levels of ReflectionS

imple Reflection--Repeating or rephrasing – C

omplex Reflection-- Extends what person is saying, reflects implied feeling, thought or experience

General Rule of Thumb ~

Begin with simpler reflections and delve into deeper reflections as understanding increases.

The Value of Reflective Listening

•Lets the person know that you are listening and encourages him/her to tell you more

•Perceived as non-judgmental

•Allows the person to hear you repeat/rephrase what he or she is saying for further consideration

•Allows the person to clarify his/her thoughts.

Finding the Potential for Change…

“I know I should probably not drink so much. I often feel a bit fuzzy the next day, and sometimes I forget things that I need to do. But drinking helps me relax at the end of the day, and it helps me forget my pain.”

Reflections to Promote Change

• “So if you could find a way to relax without alcohol, you might feel better.”

• “Drinking alcohol gets in the way of your doing things that you need to do.”

• “You’re worried that if you don’t do something about your drinking, you might forget something really important.”

• “You’re in a lot of pain and need to find a way to make things better.”

Finding the Potential for Change

“Why should I stop drinking? Sometimes I wonder if I should not drink so much, but then I always find myself drinking with my friends. We all do it. Sometimes I try to limit myself to one drink, but then I always have another. I’m not sure if I’m strong enough to give it up.

Reflections to Promote Change• “So you tell yourself to cut back on drinking

sometimes.”

• “You’re afraid that something really bad might happen to you if you continue to drink so much.”

• “You’ve tried to cut back on your drinking, but you weren’t able to limit yourself.”

• “You’re wondering how you could cut back on your drinking when all of your friends drink.”

CONDUCTING BRIEF INTERVENTIONS

Brief Intervention Steps:

10-15 minute intervention

4 Components:1. Raise the Subject2. Provide Feedback 3. Enhance Motivation4. Develop a Plan

Effective Brief Interventions

•Elicit values and goals •Explore discrepancies between current behavior and future aspirations

•Tailor feedback and advice to address concerns and needs

Effective Brief Interventions – Cont.

•Use reflections and summaries to respond to the person’s reasons for considering change target behavior.

•Identify steps he or she would take, who would help him/her, obstacles and how he/she would know the plan is working.

•Use Importance/Confidence Readiness Ruler to elicit and reinforce change talk.

•Monitor person’s progress with plan

FRAMES: Elements of Effective Brief

Interventions

•Feedback

•Responsibility

•Advice

•Menu of Options

•Empathy

•Supporting person’s sense of self efficacy

Importance and Confidence Rulers

Importance

• How important would you say it is to cut back or quit using? Why did you pick a ___ and not a (lower number)? What concerns do you have about your use?

Importance Ruler

Confidence

If you were to decide right now to cut back, how confident are you that you could succeed? Why did you pick a ___ and not a (lower number)? What would help you to have a higher number?

Confidence Ruler

Behavior Change

Assess readiness to change use:

• In thinking about your use and related risk, how ready are you to change your use?

•Use rulers to assess aspects of readiness and motivation

Assess Ambivalence

Reducing or Stopping Using

Pros (Good Things)

Cons(Downsides)

Using the Same

It helps me relax

I can forget my pain

I forget things that I need to do.

Makes me tired; Lack energy and motivation

Changing Use

Would not forget things

Would feel better

Have more energy

I would feel more pain

I would be bored or have nothing to do in the evenings.

All guys drink

Behavior Change

Explore Person’s Goals:

• Explore person’s desired outcomes, hopes and expectations.

“What are your goals; What would you like to see happen?”

• Help person identify specific, achievable goals.

• How will change impact what’s most important to him or her?

• Explore options and resources for change.

• Find ongoing support from family, friends, community, and appropriate referrals.

• Follow-up and clarify understanding of plan

Behavior Change

Offer assistance, based on readiness:

• If in (pre)contemplation: Encourage person to continue to think about change; explore ambivalence and have future discussions with practitioner

• If in preparation: Help person create a plan; set goals.

Goal Setting

Specific

Measurable

Achievable

Realistic

Timeframe

Shaping Behaviors Toward Goals

1) Help the person set a series of goals that move him or her ahead in small steps to reach a distant point;

2) Help the person find ongoing rewards for achieving these steps to help them want to keep the change process going.

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WHAT IS THE NUMBER ONE THING WE WANT TO AVOID WHEN INTERVENING WITH YOUNG PEOPLE

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The quality of not yielding to a force or external pressure.

“Push Back”.

RESISTANCE

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WV SBIRT Principles of Engagement

1. “Roll” with resistance. 2. Practice using “open-ended” questions.3. Avoid Labels: Stay away from words with negative meanings (i.e. “addiction”, “treatment”, “therapy”) and replace with concepts that will be more easily embraced (i.e. misuse, behavioral change)4. Use silence effectively. Use Reflection and summarize often.5. Use affirmation: Comment on client strengths, positive behaviors et cetera.6. Use the "Colombo" technique for clarification7. Minimize defocusing and keep them in the middle of the process8. Bring in a “compassionate friend”/ third party9. Frequently utilize the most useful words in clinical interventions - "tell me more"10. Focus on impetus for change- emotional laden “teachable moments”

Contact Information:

Jim Matney, SBIRT Clinical DirectorEmail: James.A.Matney@WV.GOVPhone: 304-356-4773

Steve MasonEmail: Steve.S.Mason@WV.GOVPhone: 304-356-4811

THANK YOU!