View from the Middle of the System–

Indicated Prevention with Adolescents DHCS Substance Use Disorders Conference

Garden Grove CA August 23, 2018

WilliamW.Harris,MPS,CCPS,CADC-IIJanRyan,MA,PPSJimRothblatt,MFT,PPS

SUD Conference Goals 1.  Support Coordination and

Integration for SUD Services 2.  Explore Opportunities of SUD

Services 3.  Focus on What Works to Effect

Change 4.  Provide training opportunities

Indicated Prevention with Adolescents: View from the Middle of the System

•  …ideal time to undo any perception that substance use and mental health services begin with treatment.

•  Indicated prevention providers work one-to-one to strengthen and heal the family and the county system from the middle…

•  Listen to and discuss lessons learned from Riverside County…about how to help adolescents and families to navigate the system successfully.

Thinking aloud together about the Continuum of Services

•  Where does the Continuum of Services start?

•  Does it matter who you ask?

CA. ADP CONTINUUM OF SERVICES

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History of “IOM”•  In January 2006, the National Institute of

Medicine (IOM) recommended a Spectrum of Prevention focused on serving the different needs of each of the three categories of prevention population:

1.  Universal 2.  Selected 3.  Indicated - (Individual) Substance Abuse

Prevention addresses the gap between prevention and treatment

Institute of Medicine: definition Indicated Preventive Interventions

Targeted to high-risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing mental, emotional, or behavioral disorder, or biological markers indicating predisposition for such a disorder, but who do not meet diagnostic levels at the current time.

9

Community

Family

School

Individual/Peer

P

Much Commonality in Risk Factors for Behavioral Health Problems

P

P

MuchCommonalityinProtectiveFactorsforBehavioralHealthProblems

Protective Factors

Substance

Abuse

Delinquency

Safe S

exual B

ehavior

School D

rop-O

ut

Violence

Depression &

A

nxiety

Individual            

CognitiveCompetence ü ü ü ü ü üEmotionalCompetence   ü        Social/BehavioralCompetence ü ü ü   ü üSelfEfficacy     ü      BeliefintheFuture ü ü ü   ü üSelf-determination     ü      Pro-socialNorms ü ü ü   ü üSpirituality ü ü ü      Family, School and Community            

OpportunitiesforPositiveSocialInvolvement ü ü        RecognitionforPositiveBehavior ü ü     ü üBondingtoProsocialOthers ü ü ü ü ü ü

If our theory doesn’t match reality then…

•  What have been the consequences so far?

•  What happens if Indicated Prevention is marginalized?

•  What happens if people think the system begins with treatment?

Brief Risk Reduction Interview and Intervention Model (BRRIIM) =

“prevention conversation” in three stages

Welcome

2.Engage

3.Enlist,Plan

1.Explore

Three-stage BRRIIM Process: Problem Identification and Referral + Education

1.  Engage: –  Greeting/welcoming to setting, goals;

begin questions to surface strengths, resources, and needs

2.  Explore and Energize: –  Individual gets time alone with the staff to

identify strengths/needs 3.  Enlist and Extend:

–  Creating a Prevention Services Agreement

Prevention Services Agreement (PSA) •  One person at a time •  Customized •  Strength-based •  CSAP Strategy = Education •  Linkages •  Coaching •  Open door to return for service

Family Sessions •  Family and significant others are encouraged to

be allies in the prevention process through education

•  They may request their own sessions with Prevention Specialist to facilitate this process

•  Utilizes CSAP strategy of Education

•  No confidential information is shared between family members and participant - focus is totally on education

Basic flow of BRRIIM Process

Referral

BRRIIM Interview: Screening and Brief Intervention

Prevention Agreement Referral to Diagnostic Assessment

Prevention: reverses harmful behavior

No Improvement: referral to assessment

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BRRIIM and Indicated Prevention –IS NOT

•  A questionnaire or quick “screen” •  An unstructured discussion •  Focused on only one problem •  Just a step before automatic referral to treatment •  An assessment or diagnosis •  Used for the creation of a Treatment Plan •  Designed to be after-care service

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What makes BRRIIM different

As a model of Indicated Prevention: •  Serves the individual and family •  Scope is comprehensive, •  Opportunity to learn family’s culture •  Empowers people to prioritize, create own

prevention plan and outcomes •  Keeps door open to return

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Brief

Risk

Red

uction

Int

erview

and

In

terv

ention

Mod

el (BR

RIIM

)

Readiness to Change Summary Table (N=139)

Substance/BehaviorBefore/AfterSession

AverageReadinessRating

AverageChangeRating

%WhoseReadinessIncreased

%ReadyorTryingtoChangeBefore

%ReadyorTryingto

ChangeAfter

Tobacco*(N=31)

Before 3.0+1.6 61% 23% 48%

After 4.6Alcohol*(N=57)

Before 4.5+1.5 61% 47% 84%

After 6.0Marijuana*(N=75)

Before 4.7+1.7 67% 53% 87%

After 6.4RxorOTCDrugMisuse(N=6)

Before 4.7+2.0 67% 50% 83%

After 6.7OtherDrugs*(N=17)

Before 4.1+2.8 71% 41% 88%

After 6.9HarmfulBehavior*(N=66)

Before 4.2+2.3 71% 48% 88%

After 6.5

*Indicates a statistically significant increase in readiness to change (p<0.05).19

SummaryofEvaluationFindingsü  Increased protective factors

ü  Increased readiness to change AOD-involvement or use

ü  Decreased risk factors for developing more serious AOD problems

ü  Developed a Prevention Services Agreement

ü  Followed a Prevention Services Agreement

ü  Identified participants who need to be referred to diagnostic assessment

ü  Increased family involvement in participants’ lives

ü  Prevented/reduced the onset of participants’ AOD use and related behaviors

ü  Increased use of community resources

ü  Sustained outcomes resulting from participation in BRRIIM

ü  High Levels of Overall Satisfaction

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•  “Staying clean has been cool…and I am able to concentrate better at school.”

•  “The counseling helped change me. You don’t listen well when it’s your family or friends.”

•  “The plan lets you know that someone has faith in you and makes you want to follow through.”

Participant Comments from Pre-Post Survey Findings

Prevention Specialists – View from the Middle?

WhatisaPreventionSpecialistinRiversideCounty?Whataretheylearningabouttheservicesthey

provide,howitfitsintotheContinuumofServices,andhowitischangingthemasproviders.

Indicated Prevention Implementation Challenges

RiversideCountyongoingchallengesandsolutions.

SAPT Funded Primary Prevention

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Information

Dissemination

Education

Alternatives

Problem Identification & Referral

Community-Based Process

Environmental

CSAP strategies for allowable use of SAPT BG funding

7/30/18 25

Primary Prevention Services by Strategy

InformationDissemination,

$10,909,753.00,20%

Education,$7,546,550.00,14%

Alternatives,$6,694,093.00,12%

ProblemIdentificationandReferral,

$849,483.00,2%

Community-BasedProcess,

$18,763,722.00,35%

Environmental,$3,503,175.00,6%

SynarAmendment,$2,000,000.00,4%

ResourceDevelopmentandTechnicalAssistance,

$1,351,442.00,2%

State-levelAdministration,

$2,700,000.00,5%

ExpendituresbyStrategy InformationDissemination

Education Alternatives

ProblemIdentificationandReferral Community-BasedProcess

Environmental SynarAmendment

ResourceDevelopmentandTechnicalAssistance State-levelAdministration

SAPT Primary Prevention -Individuals Served FY 2012-13

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Services by Strategy

Information Dissemination Education

Alternatives

Problem ID and Referral

Community-Based Process Environmental

19059

42309

SAPT Primary Prevention – Individuals Served FY 2012-13

CSAP Strategy Individuals Served in 2012-13 Community-based Processes 42,309 Education 34,919 Information Dissemination 30,764 Alternatives 19,059 Environmental 17,125 Problem ID and Referral 5,257

Based on pie-chart from DHCS 27

IP: amplifies impact of Prevention & Tx

•  To identify individuals who are exhibiting early signs of substance abuse and other problem behaviors

•  To address risk factors and increase protective factors •  To reduce first-time substance abuse and/or to delay

onset of substance abuse •  To reduce the length of time the signs and symptoms of

use continue and/or to reduce the severity of substance abuse

•  To increase access to prevention and referrals to diagnostic assessment for Tx services

Why IP might be challenging

•  History of professional and institutional tension.

•  Unintended competition for funds within the prevention field

•  Relatively demanding to deliver •  IP is a critical discussion between Prevention

and Treatment. Source:TheInstituteofMedicineFrameworkandItsImplicationsfortheAdvancementofPreventionPolicy,Programs,andPracticeByJ.FredSpringerandJoelPhillips

BreakthroughinRiversideCounty

Why IP is a valuable asset for both Prevention and Tx

IP offers the highest probability of getting services to those:

– who will experience the greatest individual harm, and

– create the greatest social harm, as a result of substance abuse.

Source:TheInstituteofMedicineFrameworkandItsImplicationsfortheAdvancementofPreventionPolicy,Programs,andPracticeByJ.FredSpringerandJoelPhillips

Referral Sources for Riverside County Clinics

County Clinics •  Self-referral •  Substance Use Community Access, Referral, Evaluation,

and Support (SU CARES) line •  Clinic Tx. Staff referral •  Schools •  Family Law •  Probation •  Senior Programs •  Parenting Programs •  Dept. of Social Services •  Employer

Referral Sources for Schools ü Students who violate a school policy ü When staff worry about their students:

•  notices abnormal behaviors or trends •  excessive absences •  signs of drug or alcohol use •  poor hygiene •  excessive fatigue/sleepiness

6-PreventionSpecialistFocusGroupFindingsfromKeyEvaluationFindingsofBRRIIMwithintheRCIndividualPreventionServices(IPS)fromShannelleBoyle,Ph.D.

PreventionSpecialistChallenges&Recommendations

PreventionSpecialistFocusGroupFindings#1

Indicator Challenge Recommendation

TimePreventionSpecialistsfeelrushedduetotimeconstraints/treatmentresponsibilities

ReducetreatmentdutiesandincreasetimeallocatedtoBRRIIM

PerceptionsatClinics

Preventionisperceivedas“co-located”attheclinicsratherthananintegralpartoftheclinicsservices

Conductadditionaltrainingdepartment-wideonhowpreventionfitsintotheContinuumofServices

AwarenessaboutBRRIIM

Sometimestherearechallengesreachingalloftheyouthandadultsover55inthecommunitythatcouldbenefitfromBRRIIM

Increaseawarenessthroughacommercial,publicserviceannouncement,video,website,orapp;gettheUnifiedSchoolDistrictandmoreoutsideagenciesonboard

IsolatedatClinics

PreventionSpecialistssometimesfeellonely/isolatedattheclinics

ContinuetoholdMonthlyTrainingsandcoordinatearetreatfortheentireBRRIIMteam

Indicator Challenge Recommendation

BRRIIMInterviewGuide

AcoupleofBRRIIMquestionsarehardforpeopletounderstand;someoftheadolescentquestionswouldbehelpfulforadults;somehavedifficultiestranslatingtheguidefromEnglishtoSpanishduringtheBRRIIMinterview

ReviewtheBRRIIMinterviewguidetoidentifywaystoimproveit(e.g.,rewordquestionsparticipantsdonotunderstand;determinewhichadolescentquestionswouldbeagoodfitfortheadultguide;considerdevelopingaSpanishversion,etc.)

DifficultParents

SometimesPreventionSpecialistsencounterparentswhotrytotakeovertheBRRIIMinterview,makingitchallengingtostayontrack

PreventionSpecialistsshouldbedirectwiththeparentandmakeitclearthattheywanttheyouthtoanswerthequestionsandrepeattheprocessstepssohe/shegetstoalltheinterviewquestions

NoiseandInterruptions

Noisefromotheractivitiesattheclinicandinterruptionssuchasknockingatthedoor,phonecallsandpagesovertheloudspeakerinterferewithBRRIIMsessions

Althoughpreventionhaslittlecontroloverthenoise,andinterruptionissuesvarybyclinic,thePreventionSpecialistscantrytacticssuchasputtingthephoneondivert,placinga“donotdisturb”plaqueontheirdoor,directingstaffnottopagethem,etc.

Self-CareSomePreventionSpecialistsmentionedputtingoffappointmentsandneedingmoretimeforself-care

ThePreventionSpecialistssaidtheywouldlikeadditionalvacationtime

Contact Information William W. Harris, MPS

Riverside University Health System – Behavioral Health Substance Abuse Prevention and Treatment Program

(951) 955-3306

Jim Rothblatt MFT, PPS Prevention Consultant

(760) 534.8340 redleafresources@gmail.com

Jan Ryan, MA, PPS Prevention Consultant

(760) 333-6102 janryanprevention@mac.com

SpecialThankstoRCIPSPreventionSpecialistsandtoourvideospecialistandAdministrativeAssistant:NhanPham

Handouts Provided Online •  PowerPoint for this presentation •  QuickLook at Brief Risk Reduction Interview

and Intervention Model (BRRIIM) Flow Chart

Pleasecallformoreinformationortoextendthis

discussion.

More Information about School-based Implementations can be found online

•  California Department of Education Student Assistance Programs – https://www.cde.ca.gov/ls/he/at/sap.asp

•  Murrieta Valley BreakThrough Student Assistance Program video with program overview and interviews with students and parents: https://www.schooltube.com/video/1d2deca67f9b2ee16da7/Breakthrough%20SAP

•  Conejo Valley BreakThrough Student Assistance Program: http://www.venturacountylimits.org/en/prevention/school-based-initiatives/breakthrough-student-assistance-program

ManyCaliforniaCountyPreventionCoordinatorsareimplementingIndicatedPreventiontoreachthoseathigherrisk–callformoreinformationandwecanlinkyoutotheirprograms.