Addressing Teen Substance Use:A Clinical Perspective on

Adolescent Brain Development

Ken Winters, Ph.D.Department of PsychiatryUniversity of Minnesota

winte001@umn.edu

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 winte001@umn.edu

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! winte001@umn.edu