2. Using the GAIN-Q Screener and MET/CBT5 in Student Assistance Programs Funded by: The Center for Substance Abuse Treatment (CSAT) Substance Abuse and Mental Health Services Administration (SAMHSA) U. S. Department of Health & Human Services (DHHS)

3. Presentation Goals Reason for program changes Description of GAIN-Q Screener Description of MET/CBT5 intervention Discuss Implementation Issues

4. Sponsored By: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (DHHS) Strengthening Communities - Youth Developing Community Treatment Options SCY 2001 2002 Bloomington, IL Oakland, CA Harlem, NY Tucson, AZ Iowa City, IA St. Louis MO Phoenix, AZ Mobile, AL

5. Strengthening McLean County for Youth (SCY) GAIN Screening Assessment at Juvenile Justice/JDC GAIN Screening & Manual-Based Intervention at Schools Coordination with Other Human Service Agencies Evaluating Manual- Based Intervention in OP Evaluating Aftercare Following OP MIS Development for Continuum and System of Care

6. Why the GAIN-Quick? Provides a standardized screening for all students referred to the SAP counselor Wanted consistency with other measurement in continuum of care Can be completed in 20 minutes or so Also evaluates need for mental health screening

7. Why MET/CBT5? For Quality Control, we felt it was important to train and supervise staff in one ‘known’ intervention Found to be effective in CYT study Manual-guided Could be adapted for school settings (i.e. all individual sessions) Approach is designed to increase motivation for treatment, non-confrontational, and brief

8. Chestnut Health Systems’ Student Assistance Program (SAP) Central Illinois Region

9. Current Chestnut Service Structure Recruitment, Assessment, & Treatment Early Intervention Outpatient & IOP Day Treatment Residential Treatment Continuing Care

10. Outpatient Offices & Residential Treatment School and Recreation Services

11. General Information:  Established in 1985  Initially in one school in McLean County (the largest geo. county in Illinois)  Currently 14 staff in 34 schools throughout the county

13. The students we see:  Eleven high schools/junior high schools  Ten elementary schools  In 2002-2003, staff saw nearly 1300 individual students  Staff ran over 125 different groups on grief, COA, depression, bullying, etc.

14. Referral process (typical) Concerned person (school staff, student, parent) Fills out referral form Staff meets with student, goes over nature of services, HIPAA, confidentiality Staff gives student GAIN-Q, then develops Service Plan with student based upon results Refer, discontinue, or continue to meet

15. Number of Hours in Schools

16. Funding  Combination of four primary sources: School Districts McLean County Health Department Office of Alcoholism and Substance Abuse (OASA) Federal Funds (SCY Project)

17. Quality Assurance/Evaluation  Number and timeliness of SALs  Number of GAIN-Q’s and when given  Number of students seen  Number of MET/CBT initiated/completed  Student Descriptors  School Personnel Satisfaction  Pre-Post GAIN-Q in selected schools

18. Staff Characteristics: Certification

19. Staff Characteristics: Educational Level

20. Program Marketing Distribution of SAP flyers throughout community and school district Send SAP flyers home as part of registratio n Present as part of School Staff Orientation Meetings with teachers, Superintende nts, PTO, School Board Monthly newsletter, “FYI”, distributed to all school personnel Classroom presentations on what SAP is and how to refer

21. Reasons for Referral:  Declining school performance, absenteeism, truancy  Depression, grief, loss  Suspected of or known substance abuse (self or family member)  Self-mutilation, eating disorder, other mental health concern  Other

22. Types of Services Provided  Crisis Intervention and Referral  Screening of students using the GAIN-Q  Referral assistance to community based agencies  Assistance obtaining more extensive evaluation using the GAIN-I  Assistance obtaining OPT and residential services if needed

23. Types of Services (Continued)  Conducting small groups on topics as needed: COA, grief, etc.  Doing classroom presentations as needed on wide range of topic areas, including substance abuse, depression, grief, family roles, etc.  Consult with teaching staff and parents about concerns

24. Types of Services (Continued)  Education with students related to drug or mental health concerns  Brief intermittent intervention  MET/CBT5 as appropriate

25. Prior to Implementation of GAIN measures and MET/CBT Possible SASSI Possible referral for a GAIN-I evaluation Possible referral to center for treatment If refuse treatment, then intervention in school varied by SAP counselor

26. Global Appraisal of Individual Needs Quick (GAIN-Q) Developers: Mike Dennis, Janet Titus, et al.,

27. Can be Administered via Computer or Paper

28. What is the GAIN-Q? It is an instrument designed to efficiently and effectively identify adolescents or adults in need of referral for a more detailed assessment on substance use and/or mental health problems

29. Background of GAIN-Q GAIN family of measures has evolved from over a half dozen grants from CSAT, NIAAA, NIDA, and the Interventions Corp. since 1993 (Dennis & colleagues, 1993, 1995, 1996, 1998) In use by over 50 researchers/clinical groups across the country Scales have developed excellent consistency and ability to reliably predict initial level of treatment

30. When/Where is the GAIN-Q used?

31. The GAIN-Q can be used for: Screenings at juvenile detention Screenings at court services SAP screenings at school Screenings at other agencies/groups

32. When to proceed to a full GAIN-I? Collaborative reports suggest use, despite the adolescent NOT self- reporting any use The GAIN-Q report indicates a need for further assessment

33. Taking a closer look at the GAIN-Q Distribute copy of GAIN-Q

34. Description of GAIN-Q Instrument Fifteen pages in length Can be Interviewer- or Self- administered Length of time to administer instrument is 20 to 30 minutes Most items written in a “yes/no” format

35. Description of Instrument cont. Organized into 12 sections: Background General Factors Sources of Stress Physical Health Emotional Health Behavioral Health Substance-Related Issues Service Utilization End Case Disposition Reasons for Quitting Optional Study Questions

36. Overview of Sections First four sections (Background, General Factors, Sources of Stress, Physical Health) provide background and formative indices of factors that are related to behavioral health problems

37. Overview of Sections cont. Next four sections (Emotional Health, Behavioral Health, Substance-Related Issues, Service Utilization) contain the core behavioral health indices The core symptom scales cover behavior during the past year and each concludes with an item on whether these problems have occurred in the past three months

38. Overview of Sections cont. End—Misc. questions about setting, type of administration, time Case Disposition—Referral Source, Issues, Placement, Add. Comments Reasons for Quitting—Used if plan to provide MET Special Study Section--Optional

39. After completing the GAIN- Q what direction or step should you take?

40. GAIN-Q Recommendation and Referral Summary (Q-RRS) Narrative-based for easier interpretation Provides a recommendation for each section Reports the range of urgency according to the appropriate index for each subscale within each larger section Distribute Copy of Q-RRS

41. GAIN-Q Recommendation and Referral Summary (QRRS) cont. List the symptoms endorsed for each section List the days and/or times a particular problem occurred during the past 3 months (90 days) Lists days during past 3 months that services were utilized for each area May range in length from 2-6 pages depending on the severity of the individual

42. Can Produce the Personalized Feedback Report Used during MET

43. Training & Monitoring of Staff in GAIN-Q Training by a certified trainer Required certification in the Q by all staff who would be using it. Required role play Tapes that are evaluated for certification using a certification form Continued to review tapes on a random basis after certification

44. Percentage of students completing GAIN-Qs referred for GAIN-Is (N= 271) n=24

45. Percentage of students participating in MET/CBT5 at schools where available (N=140)

46. Ohh…the Possibilities 15 were not referred for further assessment, but enrolled in MET/CBT at the school 5 were referred for further assessment, refused and were not enrolled in MET/CBT 2 were referred for further assessment, refused, but did enroll in MET/CBT 3 were referred for further assessment, completed the GAIN-I (2 recommended for OP and 1 recommended for IOP but none were admitted to Chestnut), and enrolled in MET/CBT

47. Emotional and Behavioral Health

48. Motivational Enhancement Therapy/ Cognitive Behavior Therapy 5 (MET/CBT5) Cannabis Youth Treatment Experiment CYT Treatment Series Volume 1 Sampl, S., & Kadden, R. (2001) University of Connecticut Health Center Farmington, CT USA

49. CYT Cannabis Youth Treatment Experiment: A Collaborative Study of the Effectiveness of Treatment for Cannabis Use Disorders Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services Coordinating Center: Chestnut Health Systems, Bloomington, IL, and Chicago, IL University of Miami, Miami, FL University of Connecticut Health Center, Farmington, CT Sites: Univ. Conn. Health Center, Farmington, CT Operation PAR, St. Petersburg, FL Chestnut Health Systems, Madison County, IL Children’s Hospital of Phil., Philadelphia, PA

50. Purpose What are the characteristics and needs To evaluate the relative effectiveness, cost and cost-effectiveness of 5 interventions To provide validated models of these interventions to the treatment field

51. Average Days Abstinent per Quarter 0 10 20 30 40 50 60 70 80 90 Intake36912 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percent In Recovery Days Abstinent Percent in Recovery Figure 1: General Pattern of CYT Clinical Outcomes

52. Figure 2. Effectiveness of CYT Therapies Across Sites 200 210 220 230 240 250 260 270 280 290 300 Total day abstinent over 12 months 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Percent in Recovery at Month 12 MET/CBT5 (n=102) MET/CBT12 (n=95) FSNM (n=102) MET/CBT5 (n=99) ACRA (n=100) MDFT (n=99) Trial 1Trial 2 Total Days Abstinent Percent in Recovery

53. Introduction to MET A style of intervention based on the premise that people are most likely to change when the motivation comes from themselves, rather than being imposed by the therapist Based on a trans-theoretical model: 1) stages of change theory 2) client-centered approaches 3) clinical research A strengths-based approach

54. The Stages of Change Model Prochaska & DiClemente, 1986 Permanent Exit? Precontemplation Contemplation Determination Action Maintenance Relapse

55. MET Session 1 (see page 32) Rapport-building & orientation to treatment- 20 min. Review of the Personalized Feedback Report (PFR)- 30 min. Summarization & preparation for next session- 10 min. Distribute sample PFR report

56. Five Strategies of MET & MI 1. Express Empathy 2. Develop Discrepancy 3. Avoid Argumentation 4. Roll with Resistance 5. Support Self-Efficacy

57. MET Session 2 (see page 41) Review of Progress- 15 min. Goal-Setting- 20 min. Functional Analysis- 20 min. Preparation for Group- 5 min.

58. CBT for Adolescents Cognitive Behavioral Therapy aims to help adolescents identify triggers for substance use, and to learn & practice coping strategies as an alternative to substance use.

59. 3 CBT Sessions Drug/Alcohol Refusal Skills Increasing Social Support Supplement—Increasing Pleasant Activities Planning for Emergencies & Coping With Relapse

60. Structure of CBT Group Sessions Intro’s & Rapport Building Review of Progress Introduction & Teaching of Coping Skill In-Session Practice Exercise Assign Real-Life Practice Exercise Closing

61. Implementation Issues: Training Ongoing Individual supervision Group supervision Used a certification process that includes tape reviews and rating forms Adapted forms for use in the schools

62. Certification Process Helps to ensure that intervention is being delivered as outlined in manual Video or audio tape sessions Supervisor reviews several random tapes initially and rates performance by using TSS Use of TSS, Global and Individual procedure checklists Consistent ratings of 4 and above on a standard scale are necessary for certification, as well as, a demonstration of implementing the intervention in a competent and consistent manner

63. Use of Audio and/or Video Tapes Obtain release from student Use in individual or group supervision Learning tool for role-plays Self-monitoring Track progress Adherence and competency related to manualized treatment Monitoring therapist drift

64. Case Review Tracking Form CASE No.Open DateStatusDate to Close Weeks in Tx#client#parent#togetherPFR FA- UseFA-PSGOC A 2/13/2001 E5/8/2001131243114 B 2/15/2001 D5/10/20011361112 C 2/26/2001 E5/21/20011191112 D 3/13/2001 E6/5/200197112112 E 3/19/2001 E6/11/2001872121 F 3/19/2001 E6/11/2001862111 G 4/19/2001 N7/12/200142111 H 4/27/2001 N7/20/200132111 I 4/26/2001 N7/19/200132111 Columns with procedures

65. Group/Team Supervision Provides support, feedback, problem-solving, sense of team/decreases isolation, increases cohesiveness Activities depend on needs: case reviews/presentations (new and active), tape reviews, peer feedback/interaction, role-playing, on-going training, etc. Promote team problem-solving, assistance, support, praise and encouragement Foster/stimulate supportive positive environment Helps convey same information at same time

67. Implementation Issues

68. School Year 02-03 Implemented GAIN-Quick Screenings in 2 schools Implemented the MET/CBT5 intervention for youth screened as having substance abuse issues in same two schools Implemented follow-up GAIN-Q interviews by research assistants with all students seen 3 or more times who signed an informed consent

69. School Year 03-04 Implemented GAIN-Quick Screenings in all 10 schools Implemented the MET/CBT5 intervention for youth screened as having substance abuse issues in 5 schools

70. Implementation Issues: Referral Sources Who are they? What information needs to be shared with school boards? with administrators? with school counselors? with teachers?

71. Data Collection & Monitoring Set up system to track what happens with every referral—GAIN-Q helps Type of referrals—what are the possibilities? Track important student descriptors Track referral sources—what are yours? Track reasons for referral…

72. How will the new intervention fit with existing SAPprocess?

73. How will you do these things? Initial Training On-going Training Use of Audio and/or Video Tapes Certification Process Individual Supervision Group/Team Supervision Tools to assist with Supervision Process Assistance/Support for Supervisors

74. SAP Implementation Issues What is your access to students CBT in groups vs. individual sessions # of sessions How will you assess needs? Confidentiality How is the SAP person identified in the school? Parental permission & involvement Making materials user friendly (see page. 42- 50)

75. More Considerations Space—plays into confidentiality How to handle crises when using manual-based intervention? What about after MET/CBT5? Check-in sessions—review procedures Clinical supervision/support

76. Implementation Issues: Materials Some handouts are focused primarily on marijuana and can be adapted to reflect a broader range of drugs & alcohol. Electronic copies of more generic hand-outs can be sent Posters for providing CBT sessions need to be made. Provide a site specific Paperwork Flowchart Provide cheatsheet for use in initial sessions

78. For more Information: On GAIN-Q: http://www.chestnut.org/LI/gain/index.html MET/CBT Manual: Can order a free copy from NCADI—phone 800-729-6686, BKD384 Can download from: http://www.chestnut.org/LI/bookstore/index. html

79. Contact Information Susan H. Godley, Rh.D. Senior Research Scientist Chestnut Health Systems 720 W. Chestnut St. Bloomington, IL 61704 309.829.3543 ext.83343 sgodley@chestnut.org Bruce Boeck, M.S. Associate Director of Early Intervention Chestnut Health Systems 720 W. Chestnut St. Bloomington, IL 61704 309.829.3543 ext. 3627 bboeck@chestnut.org