A Motivational Response to Contemporary Youth Health Issues

1. A Motivational Response to Contemporary Youth Health Issues Bonnie Malek MS QMHP CDS III

2. A Snapshot of Youth Health Status • In 1988, 5% of American youth were overweight • In 2008, 30% of youth between the ages of 6-11 are overweight • Among adolescents 30% are overweight and 16% are obese • In 1969, 80% of youth played sports every day • In 2008, 20% of youth play sports every day • If a teen is above the 85th percentile in BMI they have a 95% chance of becoming obese (America’s Children in Brief, Key National Indicators of Wellbeing, 2006

3. A Snapshot of Tobacco Abuse • In 2005, the rates of daily tobacco use for youth were: • 4% for 8th graders (6% decline since 1995) • 8% for 10th graders (10% decline since 1995) • 14% for 12th graders (11% decline since 1995) (America’s Children in Brief, Key National Indicators of Wellbeing, 2006 • Exposure to second hand smoke in children between the ages of 4 and 11 as measured by blood cotinine levels has been declining since 1995 as well.

4. A Snapshot of Alcohol Abuse • In 2005, the following percentages of youth reported having 5 or more drinks at one time in the past 2 weeks: • 8th graders-11% • 10th graders-21% • 12th graders-28% • Heavy drinking by race and ethnicity has remained relatively stable since 2001 with higher prevalence rates among white and Hispanic youth (America’s Children in Brief, Key National Indicators of Wellbeing, 2006

5. A Snapshot of Prescription Drug Abuse • In 2005, 9.9% of females and 8.2% of males between 12 and 17 reported non-medical use of prescription pain relievers, benzodiazepines and muscle relaxants. (2005 National Survey on Drug Use and Health) • Initiation of prescription drug use among youth now exceeds initiation of marijuana use. • A substantial percentage of youth (between 21-62%) see prescription drug use as safer, cheap, easy to obtain and less stigmatizing than using street drugs with fewer health, parental and social consequences. (2005-PATS Partnership Attitude Tracking Survey)

6. A Snapshot of Illicit Drug Use • In 2005 the reported rates of illicit drug use in the past 30 days were: • 9% for 8th graders (3% decline since 2001) • 17% for 10th graders (6% decline since 2001) • 23% for 12th graders (3% decline since 2001) (America’s Children in Brief, Key National Indicators of Wellbeing, 2006

7. A Snapshot of Youth Mental Health Issues Many of the following mental health issues predate the onset of substance use in adolescents: • Depression • Anxiety • ADHD • Oppositional Defiant Disorder • Conduct Disorder • Gambling

8. Adverse Childhood Experiences and Long Term Health Consequences • The Kaiser Study-Turning Gold Into Lead • 17,421 “typical” middle class adults with a mean age of 57. • Screened for 8 categories of childhood abuse and household dysfunction. Defined as “adverse childhood experiences” yielding an ACE score of 0-8. • Abuse categories=recurrent physical abuse, severe emotional abuse and contact sexual abuse.

9. Gold Into Lead • Household dysfunction=growing up in a home: • With a parent/close family member in prison. • Where the mother was treated violently. • With an alcohol or drug abuser. • With someone that was chronically depressed, mentally ill or suicidal. • Where one biological parent was lost to the person regardless of cause.

10. Gold Into Lead-Key Findings • Slightly more than half of the participants had an ACE score of at least one. • There is a powerful & long-lasting relationship between trauma and serious health problems-heart disease, hypertension, obesity, diabetes, injuries, addiction and mental health problems. • The higher the ACE score, the greater the health consequences:

11. Gold Into Lead-Key Findings • A person with an ACE score of 4 is 260% more likely to: • have chronic obstructive pulmonary disease (COPD); • 240% more likely to have hepatitis; • 250% more likely to have a sexually transmitted disease; • 460% more likely to suffer from depression; and • 1,220% more likely to attempt suicide. • At higher ACE scores the suicide risk increases 30-51 fold-3,000-5,100%). • A person with an ACE score of 6 is 4,600% more likely to be an IV drug user.

12. Suicide Most people that complete suicide: • Have a substance disorder, mental disorder or both. • Have a depressive illness. • alcohol abuse is related to 25-50% of all suicides. • strong relationship between alcohol abuse and suicide for young people. • Co-occurring substance abuse and gambling increase suicide risk. (TIP 42, pg.214)

13. Common Factors Outcome Research Replicated with a variety of populations in numerous settings with multiple practices-describes essential ingredients for successful behavioral health outcomes • 40% is dependent on client factors or what the person brings to the table in terms of motivation, skills and resources • 30% is dependent on the therapeutic alliance between the helper and the person being helped (agreement on goals and tasks) • 15% is dependent on the change model being used • 15% is dependent on expectancy (positive beliefs about getting better) hope, and the placebo effect) (Miller, S., Duncan B. 2001)

14. Why Mention It? Because Motivational Interviewing impacts all of these areas by: • Making the most of what the person brings to the table (client factors) • Guiding helpers through the process of creating a therapeutic alliance (agreement on goals/tasks) • Utilizing a change model that a broad range of people will experience as respectful, supportive and culturally sensitive • Fostering hope and the expectancy of a positive outcome through active listening, empathy and supporting self-efficacy

15. Why Motivational Interviewing? • Motivational Interviewing (MI) improves engagement and it brings people back, which improves outcomes. • MI is more likely to produce accurate matching between the person and a specific change process. (Miller, W. 2006 NIDA Conference) • MI is an important “cross-over” practice that is applicable to physical health, behavioral health and a variety of other areas where change is desired and/or needed

16. Core MI Philosophy • MI is not a way to coerce people into changing. It is designed to facilitate change through: • Collaboration in the relationship and change process • Evocation in drawing out the person’s feelings, needs, wants and motivation for change • Autonomy through safety and support and the absence of persuasion or confrontation • Rolling with resistance through acceptance, invitation, shifting approach and respect. (Motivational Interviewing Assessment Protocol; Section E. Pg. 2,3)

17. Stages-of-Change Theory • Is trans-theoretical and describes core elements of change as opposed to psychopathology (Prochaska & Diclemente, 1984) • It allows helpers with different training and theoretical orientations to share a common perspective and approach to change • It facilitates congruency for the person receiving help(Motivational Interviewing Assessment Protocol; Section E. Teaching Tool No. 5)

18. MI and Stages-of-Change • Motivational Interviewing is designed to facilitate movement through the stages of change in a reliable way • It is “issue” specific, not disorder specific • Movement through the stages-of-change is generally not a linear process. Ambivalence is a normal and expected part of change • The important thing is to stay with the person in whatever stage they are in (Motivational Interviewing Assessment Protocol; Section E. Teaching Tool No.5)

19. Stage-of-Change Definitions Pre-contemplation-The person is not seeing a need for change (May be due to lack of awareness, ambivalence or resistance) Contemplation-The person is considering change but is still undecided Preparation-The person has decided to change and is considering how to do it Action-The person is actively involved in the change process (Motivational Interviewing Assessment Protocol; Section E. Teaching Tool No.5)

20. Stage-of-Change Definitions (cont) Maintenance-The person is working on maintaining the change(s) and integrating them into their lifestyle Relapse-May involve small lapses or more serious ones. In most cases it can be a valuable learning experience and serve as a catalyst for renewed commitment (Motivational Interviewing Assessment Protocol; Section E. Teaching Tool No.5)

21. The MI Dialogue • Express Empathy-an accurate understanding and acceptance of another’s perspective and feelings from a “neutral” position. (empathic detachment-not necessarily agreement or approval) • Develop Discrepancy-(where MI becomes more strategic than a strictly client-centered approach) Develops cognitive dissonance between the way things are and the way the person wants them to be (always connected to the individual’s needs, wants and perceptions) (Motivational Interviewing Assessment Protocol; Section E. pg. 7,8)

22. MI Dialogue Continued • Roll with resistance- Do something else-when in doubt express empathy. Practice “psychological judo” by getting out of the way of resistance. (Jay Haley and other strategic family therapists) • Support self-efficacy-conveys belief and support for the person’s ability to change successfully (confidence, skills and past successes with change can form the foundation for this)(Motivational Interviewing Assessment Protocol; Section E. pg. 9)

23. OARS To Row the Boat With • OARS are a way to remember how to stay on track with MI skills and more importantly, the MI spirit • Open-ended questions-encourages the person to talk through through setting an interested, open and collaborative tone (what, how, when, and where questions) • Affirmations-genuine & direct statements about something specifically positive (conveys a deeper understanding and appreciation)(Motivational Interviewing Assessment Protocol; Section E. pg. 11,12)

24. OARS To Row the Boat With • Reflective listening-a way to convey empathy and to check on the accuracy of our active listening (reflects the essence of what the person is saying-goes beyond the words) • Summaries-a reflection that is inclusive of the whole conversation to this point. Helps us to stay close to pertinent issues and provides us the opportunity to selectively emphasize certain things (another area where MI is more strategic) (Motivational Interviewing Assessment Protocol; Section E. pg. 12,13)

25. Gnarly, Hairy MI Traps • Question/answer trap-sets the expectation that the helper asks the questions and the person answers. • Labeling trap-diagnostic and other labels that may become an obstacle/source of resistance. • Premature focus trap-when our process gets ahead of the person’s process. (we’re in action and they’re not there yet or have a different idea about what to do) (Motivational Interviewing Assessment Protocol; Section E. pg. 3)

26. Other Gnarly, Hairy MI Traps • Taking sides trap-when you detect some information that suggests a problem and you begin to tell the person how serious it is or what they should do about it, you have taken sides (fosters resistance and arguments) • Blaming trap-a common defensive response. Helpful to diffuse it • Expert trap-fosters a passive role. The person is the content expert on their life (Motivational Interviewing Assessment Protocol; Section E. pg. 3,4)

27. An “MI Snack”? • What we’re going to focus on next is a modified version of the “MI Sandwich”, which is part of a NIDA Blending Initiative on the Motivational Interviewing Assessment Protocol. The protocol is designed to work with other assessment and intake processes already in place in various clinical settings. The goal is to build rapport and engagement prior to the assessment and to promote retention after the assessment by using MI skills and micro-skills or OARS.

28. Making an MI Snack At your table, pick 1 person to be a student and 1 person to be a teacher/coach/counselor. The role of the rest of the group is to observe and provide supportive coaching on the following micro skills. • Open-ended questions • Affirmations • Reflections • Summaries (Motivational Interviewing Assessment Protocol; Section E, pg. 5, 11-14)

29. A Scenario A student comes in to see you about a poor grade on his last test. You have had some ongoing concerns about possible marijuana use. Using the MI Skills (expressing empathy, developing discrepancy, rolling with resistance and supporting self-efficacy) and the micro skills or OARS, see how far you can go with developing trust and increasing the likelihood of having future conversations on more personal matters.

30. Where’s the Cheese? • Putting MI to work: • Work to truly understand the context of “the issue” from the youth’s perspective • Expect to find more than you anticipated • Expect adverse childhood experiences and expect to be seeing the early health consequences associated with them (opportunities to educate, to develop discrepancy and to support self-efficacy) • With multiple issues, expect trauma • Match your pace to the youth’s pace…have patience and expect setbacks

31. And Here are the Crackers • The Clinician MI Self Assessment tool is an evidence-based tool for clinicians to self-evaluate their use of MI skills in a given counseling session • The tool is not restricted to clinicians and can be helpful for anyone working towards proficiency or solving a communication/trust problem • Try practicing with low intensity problems first and more complex problems as skills increase • Form a study group and practice using an MI framework for problem solving student issues • Anything worth doing takes time and mindfulness

32. REFERENCES • Filetti, V.J. The Relationship of Adverse Childhood Experiences to Adult Health. Turning Gold Into Lead, San Diego. Kaiser Permanente. • Fixsen, D.L., Naoom, S.F., Blasé, K.A., Friedman, R.M., & Wallace, F. (2005). Implementation Research: A Synthesis of the Literature (No. Louis de la Parte Florida Mental Health Publication #231). Tampa, Florida: University of South Florida. • Glasgow, R.E., Lichtenstein, E., & Marcus, A.C. (2003) Why don’t we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition.American Journal of Public Health, 93(8), 1261-1267. • Maxwell, J.C. Trends in the Abuse of Prescription Drugs (2006) Austin, Texas. Addiction Technology Transfer Center Network.

33. REFERENCES • Miller, W.R., Zweben, J.E., & Johnson, W. (2005). Evidence-Based Treatment; Why, What, Where, When and How? Journal of Substance Abuse Treatment, 29, 267-276. • Miller, W.R. (2006) What Defines Evidence-Based Practice?: and What Does it Mean to Implement Evidence-based Treatment? NIDA Blending Conference. • Miller, W.R., Rollnick, S. (2002) Motivational Interviewing-Preparing People for Change-2nd Edition. New York. Guilford Press. • Zweben, J.E. (2006) Defining Evidence-Based Practices and Treatment Interventions: A Clinician’s Perspective. NIDA Blending Conference.

34. HELPFUL WEBSITES • http://www.nichd.nih.gov/publications/pubs/upload/americas_children_brief_2006.pdf • www.cdc.gov/genomics/ (genetics) • www.nida.nih.gov/CTN/home.html (info on clinical trials) • www.drugabuse.gov/Blending (info on free products produced through clinical trials) • www.nattc.org/resPubs.html (training info on blending products like the MI Assessment Protocol) • www.nfattc.org (Information on evidence based practices in mental health and addiction current research…also has the MI Protocol) • www.drugabuse.gov