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)

Presentation Goals

Reason for program changes

Description of GAIN-Q Screener

Description of MET/CBT5 intervention

Discuss Implementation Issues

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 - YouthDeveloping Community Treatment OptionsSCY

2001

2002

Bloomington, IL

Oakland, CA Harlem, NY

Tucson, AZ

Iowa City, IA

St. Louis MO

Phoenix, AZ

Mobile, AL

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

Why the GAIN-Quick?

Provides a standardized screening for all students referred to the SAP counselorWanted consistency with other measurement in continuum of careCan be completed in 20 minutes or soAlso evaluates need for mental health screening

Why MET/CBT5?

For Quality Control, we felt it was important to train and supervise staff in one ‘known’ interventionFound to be effective in CYT studyManual-guidedCould be adapted for school settings (i.e. all individual sessions)Approach is designed to increase motivation for treatment, non-confrontational, and brief

Chestnut Health Systems’ Student Assistance Program

(SAP)Central Illinois Region

Current Chestnut Service Structure

Recruitment, Assessment, & Treatment

Early Intervention

Outpatient & IOP

Day Treatment

Residential Treatment

Continuing Care

Outpatient Offices & Residential Treatment

School and Recreation Services

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

M cDonoughHancoc

k

Adams

Schuyler

Brow n

Pike Scott

G reene

Jersey

Calh

ou

n

Cass

M ason

M enard

DeW itt

P iatt

M oultrie

Shelby

Christian

Logan

T azew ellFulton M cLean

M acon

Sangam on

M organ

M acoupin M ontgom er

y

Fayette

Effingham

Cham paign

Verm ilion

Douglas Edgar

Coles

ClarkCum berlan

d

Jasper

Craw ford

Ford

Iroquo is

LakeM cHenr

yBoone

W innebago

CookDu

Page

KaneDe

KalbO gle

Lee

LaSalle

Kendall

W ill

G rundy

Kankakee

Livingston

M arshall

Putnam

W oodford

M arion

Clay Richland

Law rence

Wab

as

hW ayne

Ed

war

ds

Je fferson

Ham ilton

W hiteFrankli

n

SalineG allati

nW illiam so

n

Hard inPope

M assac

Johnson

Pulask

i

Alexan

de

r

Union

Jackson

PerryRandolph

W ashington

Clinton

Bond

St.C lair

M adison

M onroe

He

nd

erson W arre

n

M ercer

Knox

Henry

Rock

Island

W hiteside

Bureau

Peoria

Stark

Carro ll

Jo Daviess Stephenson

M cLean County

C hicago

Bloomington/Normal

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.

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

Number of Hours in Schools

12

7

56

0

2

4

6

8

2 4 8 16 35

# of schools

Funding

Combination of four primary sources:• School Districts • McLean County

Health Department • Office of Alcoholism

and Substance Abuse (OASA)

• Federal Funds (SCY Project)

$130,000

$130,000

$250,000

$93,000

Schools Health Dept. OASA SCY

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

Staff Characteristics:Certification

32

9

20

2

4

6

8

10

LCPC LCSW CSAP Teacher

Staff Characteristics:Educational Level

32

7

2

0

1

2

3

4

5

6

7

M.S. M.S.W. B.S. B.S.W.

Program Marketing

Distribution of SAP flyers throughout community and school district

Send SAP flyers home as part of registration

Present as part of School Staff Orientation

Meetings with teachers, Superintendents, PTO, School Board

Monthly newsletter, “FYI”, distributed to all school personnel

Classroom presentations on what SAP is and how to refer

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

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

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

Types of Services (Continued)

Education with students related to drug or mental health concerns

Brief intermittent intervention MET/CBT5 as appropriate

Prior to Implementation of GAIN measures and

MET/CBTPossible 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

Global Appraisal of Individual Needs

Quick (GAIN-Q)Developers: Mike Dennis, Janet Titus, et al.,

Can be Administered via Computer or Paper

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

Background of GAIN-QGAIN 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

When/Where is the GAIN-Q used?

The GAIN-Q can be used for:

Screenings at juvenile detention

Screenings at court services

SAP screenings at school

Screenings at other agencies/groups

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

Taking a closer look at the GAIN-Q

Distribute copy of GAIN-Q

Description of GAIN-Q Instrument

Fifteen pages in lengthCan be Interviewer- or Self-administeredLength of time to administer instrument is 20 to 30 minutesMost items written in a “yes/no” format

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

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

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

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

After completing the GAIN-Q what direction or

step should you take?

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

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

Can Produce the Personalized Feedback

Report Used during MET

Training & Monitoring ofStaff 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

9%

91%

Referred for GAIN-I

Only GAIN-Q

Percentage of students completing GAIN-Qs referred for GAIN-Is (N=

271)

n=24

14%

86%

Began MET/CBT5

Percentage of students participating in MET/CBT5 at schools where

available (N=140)

Ohh…the Possibilities15 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/CBT2 were referred for further assessment, refused, but did enroll in MET/CBT3 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

Emotional and Behavioral Health

Internal Behavior Index (Depression, Suicide risk and Anxiety)

50%44%

6%

57%

4%

39%

0%10%20%30%40%50%60%70%

Per

cen

t

Rural District (n=106)

Urban District

Motivational Enhancement Therapy/Cognitive Behavior Therapy 5

(MET/CBT5)

Can

nabi

s Yo

uth

Trea

tmen

t

Expe

rimen

t

CYT

Treatment Series

Volume 1

Sampl, S., & Kadden, R. (2001)University of Connecticut Health CenterFarmington, CT USA

CYTCannabis 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, ILUniversity of Miami, Miami, FLUniversity of Connecticut Health Center, Farmington, CT

Sites:Univ. Conn. Health Center, Farmington, CTOperation PAR, St. Petersburg, FLChestnut Health Systems, Madison County, ILChildren’s Hospital of Phil., Philadelphia, PA

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

Av

era

ge

Da

ys A

bs

tin

en

t p

er

Qu

art

er

0

10

20

30

40

50

60

70

80

90

Intake 3 6 9 120%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nt

In R

ec

ov

ery

Days Abstinent

Percent in Recovery

Figure 1: General Pattern of CYT Clinical Outcomes

Figure 2. Effectiveness of CYT Therapies Across Sites

200

210

220

230

240

250

260

270

280

290

300

Tot

al d

ay a

bstin

ent

over

12

mon

ths

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Per

cent

in R

ecov

ery

at M

onth

12

MET/CBT5 (n=102)

MET/CBT12 (n=95)

FSNM (n=102)

MET/CBT5 (n=99)

ACRA (n=100)

MDFT (n=99)

Trial 1 Trial 2

Total Days Abstinent

Percent in Recovery

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

The Stages of Change ModelProchaska & DiClemente, 1986

Permanent Exit?

Precontemplation

Contemplation

Determination

Action

Maintenance

Relapse

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

Five Strategies of MET & MI

1. Express Empathy

2. Develop Discrepancy

3. Avoid Argumentation

4. Roll with Resistance

5. Support Self-Efficacy

MET Session 2

(see page 41)

Review of Progress- 15 min.

Goal-Setting- 20 min.

Functional Analysis- 20 min.

Preparation for Group- 5 min.

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.

3 CBT Sessions

Drug/Alcohol Refusal Skills

Increasing Social SupportSupplement—Increasing Pleasant Activities

Planning for Emergencies & Coping With Relapse

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

Implementation Issues:

TrainingOngoing Individual supervision Group supervision Used a certification process that includes tape reviews and rating formsAdapted forms for use in the schools

Certification Process

Helps to ensure that intervention is being delivered as outlined in manualVideo or audio tape sessionsSupervisor reviews several random tapes initially and rates performance by using TSSUse of TSS, Global and Individual procedure checklistsConsistent 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

Use of Audio and/or Video Tapes

Obtain release from studentUse in individual or group supervisionLearning tool for role-playsSelf-monitoring Track progressAdherence and competency related to manualized treatmentMonitoring therapist drift

Case Review Tracking Form

CASE

No. Open Date Status Date to Close

Weeks

in Tx #client #parent #together PFR

FA-

Use FA-PS GOC

A 2/13/2001 E 5/8/2001 13 12 4 3 1 1 4

B 2/15/2001 D 5/10/2001 13 6 1 1 1 2

C 2/26/2001 E 5/21/2001 11 9 1 1 1 2

D 3/13/2001 E 6/5/2001 9 7 1 1 2 1 1 2

E 3/19/2001 E 6/11/2001 8 7 2 1 2 1

F 3/19/2001 E 6/11/2001 8 6 2 1 1 1

G 4/19/2001 N 7/12/2001 4 2 1 1 1

H 4/27/2001 N 7/20/2001 3 2 1 1 1

I 4/26/2001 N 7/19/2001 3 2 1 1 1

Columns with procedures

Group/Team Supervision

Provides support, feedback, problem-solving, sense of team/decreases isolation, increases cohesivenessActivities 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 encouragementFoster/stimulate supportive positive environmentHelps convey same information at same time

Figure 9. Substance Use for MET/CBT5N=14

79% 79%71%

8%

86%

64%

86%

15%

0%10%20%30%40%50%60%70%80%90%

100%

% 1+ Days Alcohol Use % 1+ Days Heavy Alcohol Use % 1+ Days Marijuana Use % 1+ Days Other Drug Use

Pre

Post

ImplementationIssues

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

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

Implementation Issues: Referral Sources

Who are they?

What information needs to be sharedwith school boards?with administrators?with school counselors?with teachers?

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…

How will the new intervention fit with existing SAPprocess?

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

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)

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

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 sentPosters for providing CBT sessions need to be made.Provide a site specific Paperwork Flowchart Provide cheatsheet for use in initial sessions

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, BKD384Can download from:

http://www.chestnut.org/LI/bookstore/index.html

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