Externalizing Youth 2005-11-24 Sunday

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Approach to the Externalizing Youth

Collaborative Mental Health Care Network’s ‘Weekend of CME’

Sun, February 5, 2006, 1000-1230 hrs

Dr’s Michael Cheng, Sharon Cirone, Helen Spenser

Attention Teenagers!

Tired of being hassled by your stupid parents?

Act immediately!

Move Out – Get a Job – Pay Your Own Bills

Start now while you still know everything!

Disclosures

• No competing interests identified

Externalizing Youth: Schedule (1030-1230 hr)

1200-1230 Question Period (30-min)

1030-1200•Principles of Forming Alliance •Stages of Change and Motivational Interviewing •Specific negative behaviors

–Substance Use–Out-of-control, rule-breaking behaviors–Self-cutting

Goals

• We will present an Approach to the Youth with Externalizing problems, involving: – Principles of Forming Alliance

• Agreement on Goals, Task, Bond

– Stages of Change and Motivational Interviewing

– Specific negative behaviors• Substance Use• Out-of-control, rule-breaking behaviors• Self-cutting

The Therapeutic Alliance


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Therapeutic Alliance

• A good therapeutic alliance is the key to working with all patients

• A therapeutic alliance can be more challenging with certain types of patient problems, and patient populations

• Easier to form alliance when the patient is distressed by the problem, e.g. broken leg

• Harder to form an alliance with problems where 1) patient doesn’t think there is a problem, or 2) others are distressed by the problem more than the patient, e.g. drug use

Therapeutic Alliance: Components

• Agreement on goals (desired outcome), i.e. you and patient agree on the desired outcome

• Agreement on tasks (steps that will lead to goals), i.e. you and patient agree on what to do to get to the goals

• Bond– Patient-focus/Altruism – Consistency / Reliability – Empathy / Attunement

Case/Role Play

• As the family physician in a busy practice, you glance through your schedule, you note a 30-minute visit to see a 15-yo youth with ‘out of control behavioral problems’

• You can hear parents and teen arguing in the waiting room, “I don’t need to be here!”

Unsuccessful Clinician Role Play

• Role play showing an interview, in which the clinician is not successful (or ‘not yet successful’) in forming an alliance with the youth (3-5 min)

• As you listen to this role play, pay special attention to the alliance (goals, tasks, bond)...

Unsuccessful Clinician Role Play: Debrief

• In this role play:– How did you find the clinician?– Any positives?– Any negatives?– What would you recommend the

clinician do differently for the future?

Unsuccessful Clinician Role Play: Debrief

• There was nothing wrong per se about prescribing the task of seeing an addictions counselor

• However, in this case telling the youth what to do was unsuccessful, because the youth did not even agree with the physician’s goals in the first place

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Stages of Change, and Motivational Interviewing


Stages of Change

Precontemplation

Contemplation

Action

Maintenance

Nah…..

Hmm…

Doing it

No Problem

What is motivational interviewing?

• An extremely powerful way of establishing a working alliance (agreement on goals, tasks) with difficult, negative behaviors

• Originally developed for substance use and addictions, but can be used for other conditions where patients think that they don’t have a problem with their behavior

• E.g. – Self-Cutting – Eating disorders– Chronic conditions (e.g. diabetes, asthma, heart

disease treatment, etc)

Prochaska’s Stages of Change

Contemplation Contemplation (towards agreement (towards agreement on goals and tasks)on goals and tasks)

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PrecontemplationPrecontemplation(no agreement on goals (no agreement on goals

and tasks) and tasks)

MaintenanceMaintenance

Action Action (agreement on goals, (agreement on goals, and possibly goals) and possibly goals)

Precontemplation

• Patient is not considering change, and does not recognize the need for change

• I.e. the person does not agree with the clinician’s goals for change

• Example– Patient: “Yes, I use weed. I like using weed. I

definitely don’t have a problem – its makes me feel better.”

Contemplation

• Patient is considering change, but the person is NOT ready to commit to change

• I.e. the person is considering the clinician’s goals for change, but there is still not yet agreement on goals (and hence not tasks)

• Example– Patient: “Yeah, I’ve thought about not using weed,

but I’m going through a tough time these days and I’m not ready to give it up right now.”

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Action

• Person is actively wanting to change, and wanting to take action as well

• I.e. there is agreement on the goal of change, and (there is the potential for) agreement on tasks

• Example– Patient: “I really need to stop using. Who can

I call for help?”

Maintenance

• Person is adjusting to change, and acquiring and practising new skills and behaviors that support the change

• Example– Patient: “Its hard to not be smoking weed,

but I’m doing my best. I’m hanging around with a different group of friends these days.”

Spiral of Change

MAINTENANCE

relapse action

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action

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precontemplationcontemplation preparation


Theory of Change and Motivation to Change

Self Change

• Most people who change their addictive behaviors do so on their own, with no formal treatment

• Self changers: “just decided”• Same sequence of change stages, whether

or not they received help• Resistance arises from strategies that are

inappropriate to the client’s stage of change

Readiness to Change

• On a scale of 1 to 10 where 1 is where you are only willing to hope and pray that things improve and 10 is where you are willing to do anything to change, how ready are you to make changes?

• “What would help to move you from a 6 to an 8?”

• “What would have to happen to make you more ready?”

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Helping a Teenager Change


The Motivational Interviewing Approach

• In motivational enhancement, or motivational interviewing, the key is to – Figure out where the youth is – Make your intervention based on where the

youth is at• Timing is key• Telling the youth to see a counselor can be a super

intervention, but it must be timed correctly

Confidence to Change

• Ability to change depends on one’s confidence in one’s ability= “self efficacy”

• Clinician– “On a scale of 1 to 10, where 1 is not

confident, and 10 is completely confident, how confident are you that you will be able to make these changes?”

• If patient says, “6”, then clinician can ask– “What would help you to move from a 3 to a

6?”



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Dialogue with the Precontemplative Teen

• Goal: – To get the patient thinking about change

• Clinician– “What do like about smoking?” “What don’t you like

about it?”– “What warning signs would let you know that your

drinking is a problem?”– “Have you tried to change in the past?” “Why?”– “The door is always open if you want to talk about

this later”• Since there is not yet agreement on goals, don’t

tell the patient to stop smoking at this stage, or what to do to stop smoking at this stage

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Q. What happens if you tell the patient to stop smoking?

• Clinician: “You should stop smoking”...

“Given a choice between changing and proving that it is not necessary, most people get busy with the proof.”

John Galbraith

Principles of working with Precontmeplation

• A decision to change does not have to be the goal

• Any time expressing concerns is time well spent• Summarize the progress of the discussion• Emphasize freedom of choice• Offer willingness to provide further support• Provide information and referrals if appropriate



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Talking with the Contemplative Teen

• Help the patient examine benefits and barriers to change

• Examples:– “In what way do you want things to change?”– “Why do you want to change at this time?”– “What is your goal?”– ”What would be some of the good things

about making a change?” “What would you miss if you made this change?”

– “What would keep you from changing at this time?”

– “What might help you with that aspect?”

Talking with the Contemplative Teen (cont’d)

• “It sounds like things can’t stay the way that they are now, what are you going to do?”

• “How would you like for things to turn out for you, ideally?”

• “What are your options?”• “What things have helped in the past to

change?”• “what change could you make before your next

visit?”

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Principles of Working with Contemplation

• Ask Open-Ended Questions• Listen Reflectively• Affirm• Summarize• Elicit Self-Motivational Statements• Support harm reduction

Working with Change Preparation and Plans

• “What supports do you have in place for this change?”

• “Have you set a quit date?”• “How do you see things in 1 month, 3

months?”• “Where will you be going for counselling?”• “Would you like to come back in a week to

tell me about the program?”



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Approach to Action Stage

• There is agreement on the goal of change, but remember to collaborate on coming up with the tasks

• Examples– Clinician: “Its great that you want to stop using

marijuana. How would you like to go about doing that?”

– Clinician: “Its great that you want to find some other ways to cope. What other ways have you thought about?”

– Clinician: “How can I be helpful and support you in this?”

Externalizing Problems



• Externalizing Problems refer to problems where youth’s problems typically cause more distress to others than the youth directly, such as: – Substance Use – Behavior Problems – Rule-breaking behaviors– Self-Cutting – Eating Disorders– Parent-child relational problems

• Forming a therapeutic alliance is tough, due to disagreements in goals, tasks, and poor bond

• Patients resemble the ‘involuntary’ rather than the voluntary patient

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• Externalizing problems are like garlic and bad breath...

• They cause more distress to others than the person

Examples of Externalizing Problems

• Common things that we hear from patients with externalizing problems...– “I don’t need to be here. My parents need help, not

me.” (disagreement about the goal or the problem)– “I’m not seeing any stupid shrink, and I’m definitely

not going to stop cutting.” (disagreement about tasks)

– “You can’t stop me from smoking pot, so don’t even try.” (disagreement about tasks)

– “I’ve already seen a few shrinks, and none of you understands and you can’t make me talk.” (poor bond)

Q. What do doctors dread to hear from their patients and their families...?

• Parents telling the doctor – “Your meds aren’t working”– “You need to fix my child”– “You need to hospitalize our child for a 30-

day evaluation.”– “You need to use this particular

medication/treatment because I read about it on the Internet.”

• Children/youth telling the doctor– “I’m smoking pot but you can’t tell my

parents.”

Q. What do doctors dread to hear from their patients and their families...? (continued)

• In other words– As physicians, we don’t like others telling us

what to do (in other words, having our control taken away)

– (and Physicians don’t like situations we feel unskilled with)

What do teenagers dread hearing from adults?

• “You should (do this) and (do that)...”• “I’m taking you to the doctor – she’s going

to tell you that smoking pot is bad for you.”

• “We’re taking your privileges away.” • In other words

– Teenagers ALSO don’t like others telling them what to do (in other words, having their control taken away)

Q. Thus, what should doctors do to ally with their teenaged patients?

• As much as possible, find a way to give back as much healthy, reasonable amounts of control to teenagers as possible

• This will happen naturally by forming a therapeutic alliance (agreement on goals, tasks and bond), and/or by paying attention to the Stages of Change model

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Normal Developmental Goals for Teenagers

Agency / Autonomy

Activity (as opposed topassivity)

Affiliation / Relationships

Agreement on Goals

• Eliciting the youth’s goals– Goals for coming to therapy– ‘Goals’ for their negative behavior

• Eliciting the parent’s goals• Example

– “What would make this a helpful visit? / What would you like to get out of coming here?”

– “How will you know if today’s visit was helpful?”

Changing unhealthy goals/tasks into healthy ones

• Ensuring the goals are healthy• If unhealthy goals/tasks are given, then

elicit the underlying healthy task• Role play

– “I just want to smoke pot.”– “I just want to party all night with my

friends.”

“Successful Clinician” Role play

• In this role play, a “good (enough) clinician” will interview the Youth/Parents (3-5 min)

“Successful Clinician” Role play: Debrief

• In this role play:– How did you find the clinician?– Any positives?– Any negatives?– What would you recommend the

clinician do differently for the future?

“Successful Clinician” Role Play: Summary

• Alliance formed by agreement on goals, tasks, bond

• Negative behavior was seen as a coping strategy for underlying healthy

• Pros/cons of behavior explored• Tentative, collaborative approach with

teenager about what to do (as opposed to simply directing the teen what to do)

• (Being directive okay, but first need teen’s permission)

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Substance Use: What are Youth Using?

Alcohol

• stimulant, sedative• store purchased- methanol and ethylene

glycol• rarely used IV• often used in combination with drugs of

abuse (ecstacy and cocaine)

Cannabis

Cannabis

Long term effects of chronic use: • bronchitis• can exacerbate depression and anxiety

disorders• can exacerbate psychotic symptoms• may precipitate latent schizophrenia in

predisposed patients

Ecstasy

• The empathy stimulant – in fact, almost called ‘Empathy’, but ‘Ecstasy’ was a ‘sexier’ name

OTCs

• Make sure you ask about: – Gravol– benadryl– Tylenol#1 – Dextromethoraphan

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Cocaine

Crack

Stimulants

• Prescription: – Methylphenidate (Ritalin)– Dextroamphetamine (Dexedrin)– Ephedra and Pseudoephedrine

• Illicit: – Cocaine– Amphetamine– Methamphetamine– Methylenedioxymethamphetamine (MDMA, i.e. Ecstasy)– Cathinone and Cathine (Khat)

Methamphetamine

Heroin

Prescription Opioids

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Prescription Opioids

• Short acting (immediate release)– Tylenol #1,2,3,4 , percocet, dilaudid,

morphine

• Sustained release– Codeine contin, oxycontin,

hydromorphonecontin, MS Contin

• Long acting– methadone, buprenorphine

Substance Use: How Family Physicians Can Make

a Difference


Talking to Teens

• Establishing an alliance• Trust is your currency• What are your values?• Youth friendly environment• Barriers to treatment• Confidentiality

Raising the Issue of Alcohol and Substance Use

• Do – Establish an alliance (agree on goals, tasks,

form bond)– Proceed at the client’s own speed– Use open-ended questions– Find a “way in”

• E.g. CRAAFT• E.g. Asking about substance use while doing

medical review of symptoms

Raising the Issue of Alcohol and Substance Use

• Don’t– Label– Confrontation– Lecture

CRAAFT Screening Tool

• C - Ever ridden in a Car driven by yourself or someone else who was “high” or had been using alcohol or drugs?

• R - Ever use alcohol or drugs to Relax, feel better about yourself, or fit in?

• A - Ever use alcohol or drugs while you are by yourself, Alone?

• F - Do family or Friends ever tell you that you should cut down on your drinking or drug use?

• F - Ever Forget things you did while using alcohol or drugs?

• T – Ever gotten into Trouble while you were using alcohol or drugs?

TWO or more positives indicates possible problem.

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History Taking

• Consider family history, parenting issues• Ask about lifestyle and stresses• Ask about risk factors and protective factors• Ask about health, then substance use• Ask about substance use in more detail• Ask about substance use in the past and now• Ask about a typical day of use• Explore concerns and interest to change

Resources for Substance Use Problems in Ontario

• Contact the Drug and Alcohol Registry of Treatment (DART) for information about drug and alcohol treatment services in Ontario

• For patients or professionals, 24-hrs a day, 365 days a year

• Tel: 1-800-565-8603• Web: http://www.dart.on.ca

Self-Cutting (and other Self-Injurious Behaviors)


Approach to Self-Cutting

• Self-injurious behaviors (such as cutting) also simply represent an example of a negative behavior, but presumably with an underlying healthy goal underneath

• As with the same approach to all other negative behaviors, use the same principles of forming an alliance

• Find out the teen’s underlying healthy goal, so that we can ally with it, and show a healthier way or task to get to that same goal

Virtual Role Play

• 15-yo teenager dragged into your office by his parents because they have noticed that he is cutting his arms and they have found razor blades in his room

• After meeting with parents and teenager together, you have met alone with the teenager, and completed your suicide screen

• Your goal is to gain an alliance...

Virtual Role Play

• You say to the youth: “Your parents have told me that you are cutting, and that they’re very concerned.”

• How will you continue? Choose 1) or 2)1) “I’m really worried about you, and I think

things would be easier for you if we could stop the cutting. What do you think?”

2) “Your parents seem worried about the cutting. What do you think?”

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Virtual Role Play

• In response, your teenaged patient says nothing. At next visit, he fails to show up.

• Perhaps it was premature telling the patient what to do, when there wasn’t yet an alliance (i.e. not yet agreement on goals...)

• Try again

Virtual Role Play

• You decide to say: “Your parents seem worried about the cutting. What do you think?”

• Youth responds: “Everybody’s cutting nowadays, its no big deal.”

Virtual Role Play

• How do you continue? Choose 1) or 2)1) Clinician: “I’m really worried about you,

and I think things would be easier for you if we could stop the cutting. What do you think?”

2) Clinician: “I’m guessing that things must be pretty stressful for you to have to be cutting. What stresses are you under?”

Virtual Role Play



• Try again

Virtual Role Play

• You have decided to ask more about stresses leading to the negative behavior (cutting)

• Youth: “I don’t know.”• Clinician: “Well, the usual ones for most teens

are stresses with school, family and friends, especially boyfriends/girlfriends.”

• Youth: “Well, my best friend has been all depressed, and my boyfriend’s been acting like a jerk lately.”

Virtual Role Play

• How do you continue?1) Clinician: “I’m really worried about you,

and I think things would be easier for you if we could stop the cutting. What do you think?”

2) Clinician: “Okay, I really respect that you’re trying to cope with things by cutting. What problems does cutting cause you?”

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Virtual Role Play



• Go back

Virtual Role Play

• You have asked about the pros of cutting, and now have just decided to ask about the cons of cutting

• Youth: “Well, I feel real really guilty afterwards, and I don’t want others at school to think I’m psycho or something.”

• Clinician: “And I guess the cutting leads to a lot of the fighting with your parents too.”

• Youth: “Yeah...”

Virtual Role Play

• How do you continue?1. “Clinician: “I’m really worried about you, and I

think things would be easier for you if we could stop the cutting. What do you think?”

2. Clinician: “What if we could find a way for you to cope with your stress, without causing you all these problems with feeling guilty, the others at school, or without causing fighting with your parents?”

Virtual Role Play

• Youth: “Yeah, that’d be nice, but its not gonna happen.”

Virtual Role Play

• Clinician: “Would you be open to hearing talking together to explore some options?”

• Options would include– Treating underlying psychosocial stresses– Treating underlying conditions (e.g. ADHD,

learning disabilities, mood/anxiety disorders)– Referral

Management of Self-Cutting

• Immediate Issues – Safety assessment to ensure self-cutting is not

active suicidal ideation– If acute medical concerns referral for

acute medical care, e.g. stitches– If acute psychiatric concerns referral to

emergency psychiatry services

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Management of Self-Cutting

• Longer term issues – Alliance and motivational interviewing

strategies– Consider harm reduction approach

suggesting less harmful ways of cutting; have teen take first aid course

– Consider referral to mental health services

Some Practical Advice for Parents Includes:

• “First, based on what your child has told me, she is not feeling suicidal. The good news about the cutting is that your child is actually trying to cope with things. The usual stresses for teens are school, family and friends. The key is for us to make sure we have good communication with her, and support her in coping with the stress.

• In an emergency, you can take her to the ER to get her stitched up, but I wouldn’t make the cutting a power struggle

• You might say to your child: “I love you very much, and it scares me that you are cutting. I want to support you to deal with this. What can I do to support you?”

Problem-Solving and Distraction Strategies

• Using a Socratic, collaborative problem-solving approach, collaborate together on strategies that might include: – Problem-solving the underlying problem

• What is the problem?• What are possible solutions?• If the problem is conflict with someone else

figure out what each person wants, negotiate/compromise

• Try out a solution

Problem-Solving and Distraction Strategies

• Using a Socratic, collaborative problem-solving approach, collaborate together on strategies that might include: – Distraction strategies

• Relaxation strategies• Listening to music, watching TV, playing video

games • Exercising • Communicating with others• Being creative• Sensory replacement for cutting sensations

– Elastic Band Technique– “Cutting” with ice

Referral to Mental Health Resources

• Refer to mental health services for complex cases, or when youth/family not responding to current treatment

• Future online directories of mental health resources will be available at – http://www.mentalhealthinfo.on.ca for

adults and families– http://www.onthepoint.ca for children/youth– http://www.ementalhealth.ca for Ottawa

Handouts in Your Package

• For self-injury– Self-injury handout for parents – Self-injury handout for youth

• For Substance Abuse– Sharon will give websites with information– ? ARF’s “A guide for helping professionals:

Alcohol and Drug Treatment in Ontario”

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Review of Goals

• We have presented an Approach to the Youth with Externalizing problems, involving: – Principles of Forming Alliance

• Agreement on Goals, Task, Bond

– Stages of Change and Motivational Interviewing

– Specific negative behaviors• Substance Use• Out-of-control, rule-breaking behaviors• Self-cutting

Questions and Discussion

EXTRA SLIDES

Precontemplation

ContemplationRelapse

Determination

Maintenance Action

J. Prochaska,C. DiClemente: Six Stages of Change


BONUS TOPIC

Dealing with the “Oppositional” Youth

Parenting Styles over the Lifespan

• Don’t wait for a problem• Address parenting styles as part of

understanding family dynamics as soon as a child enters the family

• Continue to address parenting styles across age groups

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Interpersonal Circle

•Connected to people•Affiliative•Friendly•Engaged

•Hostile•Disengaged•Disconnected from people

Autonomous, In Control, Assertive

Submissive, No control, Unassertive

CONTROL

CONNECTION

Kiesler

Four Basic Parenting Styles: Parenting Circle

Authoritarian –parents have control but no connection with children

Controlling –Has Control / Rules

Permissive –No control / rules

Authoritative – parents have healthy rules, healthy connection with children

Neglectful –parents have no control, nor connection with children

Indulgent – parents have no rules/control, but do have healthy connection

Peggy Patton

Validating / Connected

Invalidating / Disconnected

What is the ‘Aggressive, Out of Control’ Teenager

• Parent complaint: “S/he doesn’t listen or obey any of our rules anymore! We’ve had it up to here!”

• Teen behaviors may include – Opposes parental authority– Breaks house rules– At extreme, breaks laws– Substance use

DDx of ‘Aggressive, Out of Control’ Teenager

• Diagnoses overlap, but may include– Parenting issues, e.g. permissive

parenting– Psychiatric diagnoses

•ADHD / Conduct / Oppositional Defiant •Depression / Anxiety Conditions (e.g.

Trauma such as Abuse) / Bipolar•Psychosis

– Medical disorder – Substance Use Disorder

Typical Features of Out-of-Control Youth and Families

• Typically, out-of-control youth have families where there is – Youth / parent conflict– Disagreement over home expectations,

chores/responsibilities – Lack of (positive or negative) consequences or

limit setting from parents

Working with the Out of Control Youth

• Out of control behaviors are an example of negative behaviors, but usually there is some positive goal underneath

• Typical healthy goals are – Autonomy/Control/Power – Affiliation/Connection with Others/People

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Working with the Parents of Out of Control Youth

• Get a sheet of paper, and have parents write down their parenting – Expectations (negotiable/non-negotiable)– Consequences

•Positive consequences / privileges: what child gets when expectations are met

•Negative consequences: what child gets when expectations are not met

– Schedule for spending time with child for 1) having fun, and 2) for working out conflicts

Parenting Plan / Behavioral Contract: Elements

• Expectations (Mandatory, Non-negotiable)– Safety

• Permission to go out, inform parents of whereabouts, return by curfew

– Respect for one another • I.e. No verbal aggression (no insults, putdowns,

swearing) / No physical aggression

• Consequences if expectations unmet– Loss of privileges for period of time– If severe breaches contacting crisis services,

physician, mental health resources

Parenting Plan / Behavioral Contract: Elements

• Negotiable expectations – Chores must be done – the time they are done

is negotiable– Homework must be done

• Positive consequences– Computer, internet, television, telephone

time will be given each day when expectations are met

– Allowance given when expectations met

Allying with Parent and Youth over “Contract”

• Parents usually support written “contract”• Allying with youth’s goals

– “You told me that in the future, when you move out, you want to make lots of money and have your own place.”

– “When you’re making lots of money in the future, you’ll probably have some ‘contract’ with your record producer or agent or whatever.”

Allying with Parent and Youth over “Contract”

• Allying with youth’s goals (cont’d)– “So having a contract now with your parents is

just like the real world, and helps get you to that future.”

– “I agree, it would be nice if your parents could just give your allowance no matter what, but what type of a person will that make you?”

– “Are you going to make it to your future if you’re not responsible?”

Documents

Externalizing Youth 2005-11-24 Sunday