1. West Virginia Screening, Brief Intervention and Referral to Treatment
DEALING WITH YOUTH SUBSTANCE ABUSE AND RESISTANT BEHAVIOR PROBLEMS “HOW TO AVOID THE TUG OF WAR”

2. 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

3. TRAINING SCHEDULE 10: :30 Adolescent SA Prevalence/Overview of SBIRT 10:30 – 11:00 Motivational Interviewing Basics 11:00 – 11:30 O-A-R-S 11:30 – 12:00 Small Group OARS exercise 12:00 – 1: Lunch 1:00 – 1: Dealing with Resistance 1:45 – 2: Wrap-up/Questions

4. SUBSTANCE USE AND YOUNG PEOPLE
EXTENT OF THE PROBLEM

5. 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.

6. PREFRONTAL CORTEX Judgment/Reasoning Decision Making Planning
Learning from their
experience/consequences

7. Between 1992 and 2003, prescription drug abuse in 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).

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

10. In 2005‐2006: WV exceeded national rates of Illicit Drug Use among 18-25 year olds.

11. Reported drinking in the past month 26% of 8th Graders 40% of 10th Graders 51% of 12th Graders

12. Binge Drinking During the last two weeks 16% of 8th Graders 25% of 10th Graders 30% of 12th Graders

13. Consequences of Underage
Drinking Fatal Vehicle Accidents Other Traumas Risky Sexual Behavior Victimization Developmental Delay

14. Symptoms of Teen Substance Involvement

15. 1. Sudden Personality Changes Including Work or School Attendance 2
1. Sudden Personality Changes Including Work or School Attendance 2. Unusual Flare-Ups or outbreaks of Temper 3. Withdrawal from Responsibility 4. Loss of Interest in hobbies or pursuits 5. Change in Friends Difficulty in Concentration 7. Sudden Jitteriness, nervousness or aggression 8. Increased Secretiveness 9. Deterioration in Physical Appearance or Grooming Unusual Borrowing money from Friends, Co-Workers or family Stealing

16. What is the Solution?

17. We Must Start To Intervene Early!.

18. What is SBIRT?

19. 1. Paradigm shift from traditional view of substance abuse interventions 2. Views Substance Abuse as a public health issue and focus on risk reduction as well as abstinence 3. Focus on identifying “misuse” early and providing brief interventions 4. Is comprehensive in it’s approach

20. 1

21. 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

23. STEP 1 STEP 2 STEP 3 BRIEF SCREENING CONDUCT INTERVENTION
ASSESS READINESS
ENGAGE CLIENT
DEVELOP A PLAN

24. SBIRT PRESCREENING
CRAFFT
AGE 12-17
Have you ever ridden a a car driven by someone who was high or had been using drugs alcohol?
Do you ever use alcohol or drugs to relax, feel better about yourself or fit in?
Do you ever use alcohol or drugs while alone?
Do you ever forget things you did while using alcohol/drugs?
Have you ever gotten into trouble while you were using alcohol or drugs?

25. Motivational Interviewing basics

27. 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.

28. Spirit of Motivational Interviewing
Collaboration – Working in Partnership
Evocation – Learning from the person
Autonomy – Person is responsible for own change

29. 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

30. 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.

31. 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.

32. What is o-a-r-s?

33. OARS is a Core Motivational Interviewing Strategy
Open-Ended Questions
Affirmations
Reflections
Summarizations

34. 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?

35. 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?

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

37. 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?”

38. 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.

39. Forming Reflections For starters…
It sounds like you are not ready to stop drinking.
It seems that you are having a problem remembering things.
It sounds like you are feeling guilty about your drinking.
From 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.

40. Levels of Reflection
Simple Reflection--Repeating or rephrasing – Complex 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.

41. 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.

42. 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.”

43. 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.”

44. 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.

45. 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.”

46. Conducting brief interventions

47. Brief Intervention Steps:
10-15 minute intervention
4 Components:
Raise the Subject
Provide Feedback
Enhance Motivation
Develop a Plan

48. Effective Brief Interventions
Elicit values and goals
Explore discrepancies between current behavior and future aspirations
Tailor feedback and advice to address concerns and needs

49. 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

50. FRAMES: Elements of Effective Brief Interventions
Feedback
Responsibility
Advice
Menu of Options
Empathy
Supporting person’s sense of self efficacy
Elements of effective brief interventions

51. Importance and Confidence Rulers
Importance Ruler
• 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?
Confidence
Confidence Ruler
 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?

52. 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

53. 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

54. 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

55. 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.

56. Specific Measurable Achievable Realistic Timeframe
Goal Setting
Specific Measurable Achievable Realistic Timeframe

57. Shaping Behaviors Toward Goals
Help the person set a series of goals that move him or her ahead in small steps to reach a distant point;
Help the person find ongoing rewards for achieving these steps to help them want to keep the change process going.

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

59. RESISTANCE
The quality of not yielding to a force or external pressure “Push Back”.

60. 1. “Roll” with resistance.
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 clarification 7.  Minimize defocusing and keep them in the middle of the process 8. Bring in a “compassionate friend”/ third party 9. Frequently utilize the most useful words in clinical interventions -
"tell me more" 10. Focus on impetus for change- emotional laden “teachable
moments”

61. Contact Information:
Jim Matney, SBIRT Clinical Director Phone: Steve Mason Phone:

62. THANK YOU!