Brief Interventions: What’s Motivation Got to Do with It?

1. Brief Interventions:What’s Motivation Got to Do with It? Ken Winters, Ph.D. Department of Psychiatry University of Minnesota winte001@umn.edu 5th Annual Georgia School of Addiction Studies Savannah, GA August 30, 2011

2. Introductory Notes • Quote from a prominent research book: • “Assessment and treatment of adolescent substance use disorders are complex clinical and practical processes, requiring a professional workforce with specialized training.”

3. Introductory Notes • Collective wisdom from countless youth-serving workers • Adolescence may be the age group that is the most resistant to the therapeutic process.

4. Introductory Note • Collective wisdom from research and the views of countless youth-serving workers • At the risk of being over-simplistic, the keys to treating drug-abusing youth: • Develop a strong yet caring relationship with the young person. • Help him/her to break the functional value of the drug use.

5. Youthin the Lifespan average of marriage = ~26 years Young Adult Teen years Adult Child Middle Age Fetus Youthis the period between the onset of puberty and the attainment of stable adult roles and responsibilities. Dahl, 2002 Senior

6. Youthin the Lifespanearlier generations ? average of marriage = ~22 years Young Adult Teen years Adult Child Middle Age Fetus Senior

8. Adolescence is a period of profound brain maturation. • We thought brain development was complete by adolescence • We now know… maturation is not complete until about age 25!!!

9. An Immature Brain = Less Brakes on the “Go” System

10. Maturation Occurs from Back to Front of the Brain Images of Brain Development in Healthy Youth (Ages 5 – 20) Earlier: Motor Coordination Emotion Motivation Later: Judgment Blue represents maturing of brain areas Source: PHAS USA 2004 May 25; 101(21): 8174-8179. Epub 2004 May 17.

11. Seven Implications of Arrested Development for Adolescent Behavior • Preference for …. • physical activity • high excitement and low effort activities • activities with peers that trigger high intensity/arousal • novelty • Less than optimal.. • balance of emotion and logic when making decisions • consideration of negative conseq. • Greater tendency to… • take risks and show impulsiveness

12. Seven Implications of Arrested Development for Adolescent Behavior • Preference for …. • physical activity • high excitement and low effort activities • activities with peers that trigger high intensity/arousal • novelty • Less than optimal.. • balance of emotion and logic when making decisions • consideration of negative conseq. • Greater tendency to… • take risks and show impulsiveness

13. ADHD Oppositional Defiance Disorder Depression Drug Abuse Conduct Disorder PTSD Anxiety

14. Drug Abuse Outcomes and Co-Existing Disorders(Steling & Weisner, 2005) % Patients Abstinent 6 months after beginning tx

15. Spectrum of Intervention ResponsesAdapted from Broadening the Base of Alcohol Treatment (IOM) Primary Prevention Brief Therapy/Intervention Intensive Approaches Thresholds for Action Dependence Abuse Misuse Infrequent use Drug Involvement Abstinence

16. Source: Linda Sobell

17. Adolescent Drug Abuse Treatment • Opportunities for Motivational Enhancement (ME) approach • Their problems are not as deep-rooted.

18. Estimates of Mutually Exclusive Drug Abusing Adolescent Groups, Ages 12-18-year-old (based on data from SAMHSA, 2005) BI? (24.7%) % Spc Tx group? (5.2%) Heavy, Binge, and Light Drinkers: prior 30 days Dependence, Abuse only, Illicit Drug Use and No Drug Use: prior year

19. Adolescent Drug Abuse Treatment • Opportunities for ME approach • Their problems are not as deep-rooted. • Multiple applications in the continuum of response.

20. Response OptionsAdapted from Broadening the Base of Alcohol Treatment (IOM) MET is typically used in BI Primary Prevention (Intensive for High Risk) MET has several applications within intensive tx Brief Intervention Intensive Treatment Referral Challenges Dependence Abuse Early abuse Infrequent use Drug Involvement Abstinence

21. Adolescent Drug Abuse Treatment • Opportunities for ME approach • Their problems are not as deep-rooted. • Multiple applications in the continuum of response. • Commitment to lengthy and intensive interventions can be difficult at this age. • Client centered approach is appealing to young people.

22. Stages of ChangeProchaska and DiClimente Precontemplation Action Preparation Contemplation

23. Adolescent Drug Abuse Treatment • Cautions of ME approach • Empirical work with teenagers and college students is limited. • Ideological barriers to consider given goals of brief interventions include harm reduction/risk reduction. • Not sufficient tx dosage for • co-morbid cases or where family dysfunction is severe • Not sufficient tx dosage for very low motivated youth.

24. ME Tools Counseling skills

25. Challenges of Adolescent Recovery Keenly aware of the unique challenges for most adolescents when trying to stay sober.

26. Challenges of Adolescent Recovery • Adolescents generally can not choose where to live after treatment; they often return to pretreatment home & school. • These environments can pose several difficulties….

27. Challenges of Adolescent Recovery • home occupied with parents and/or siblings who use • home may be source of conflict • school a source of drugs and drug-using friends • community a source of drugs and drug-using friends

28. ME Tools Counseling skills Assessment

29. Brief Intervention as a Response Option Primary Prevention (Intensive for High Risk) Brief Intervention Intensive Treatment Assessment Challenges Dependence Abuse Early abuse Infrequent use Drug Involvement Abstinence

30. Assessment Model Evaluation Methods Sources Client Brief Screening Short Qx Client Drug use severity (5-10 min.) Screening Short Qx Client Drug use severity (30-60 min.) Brief Interview Parent Biopsychosocial Urinalysis Comprehensive Compreh. Qx Client Drug use severity (2-3 hours) Detailed Interv. Parent Biopsychosocial Observation Archival Comorbidity Problem recog. Faking

31. Assessment Resources Screening and Assessing Adolescents for Substance Use Disorders (1999)TIPS #31, SAMHSA-CSATwww.samhsa.gov/csat/csat.htm Assessing Alcohol Problems: A Guide for Clinicians and Researchers (2004) NIAAA Treatment Handbook, Series 4www.nih.gov/silk/niaaa1/publication

32. CRAFFT Questions(Knight et al., 2002) C Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?” R Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? A Do you ever use alcohol/drugs while you are by yourself, ALONE? F Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use? F Do you ever FORGET things you did while using alcohol or drugs? T Have you gotten into TROUBLE while you were using alcohol or drugs? 2+ endorsements = red flag

33. ME Tools Counseling skills Assessment ME strategies

34. Enhancing Motivation 1. Take stock of client’s stage of change; respond accordingly 2. Non-confrontational interviewing 3. Five principles of motivational interviewing 4. Decisional Balance exercise

35. Ready to Change Worksheet Here is a scale that will help us determine how ready you are to change your use of drugs. Place a number on the scale that indicates how you feel right now about this. 1 2 3 4 5 6 7 8 9 10 Not ready Very ready

36. Enhancing Motivation 1. Take stock of client’s stage of change; respond accordingly 2. Non-confrontational interviewing 3. Five principles of motivational interviewing 4. Decisional Balance exercise

37. Contrasts Between Confrontational and Motivational ApproachesMiller & Rollnick, 1991 Confrontational Motivational Heavy 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

38. 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

39. Enhancing Motivation 1. Take stock of client’s stage of change; respond accordingly 2. Non-confrontational interviewing 3. Five principles of motivational interviewing 4. Decisional Balance exercise

40. Five principles of motivational interviewing • Express empathy • Avoid argumentation • Develop discrepancy • Roll with resistance • Support self-efficacy (Miller and Rollnik)

41. Express Empathy • Attitude of “acceptance” (≠ approval !!) • Understanding the client’s perspective • Reflective listening

42. Express EmpathyExample “I can understand that it is tempting to use drugs given that you do not like school.” ___________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

43. Avoid Argumentation • Arguments are counter-productive • May promote defensiveness • Try “light confronting”

44. Avoid ArgumentationExample “Okay. It looks like we do not agree on this issue. Let’s move to another topic.” ___________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

45. Roll with Resistance • In the face of arguing, reframe • Offer different perspective “Yes, but…..” • Invite new view, but do not impose

46. Roll with ResistanceExample “It sounds like there are individuals in your life that really care about you, that are very concerned.” ___________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

47. Support Self-Efficacy • Client is responsible for change • Instill faith that client can do it • Change is more self-rewarding when its source is internalized

48. Support Self EfficacyExample “If you want to change, it really comes down to you wanting to make changes. I will help.” ___________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________

49. Develop Discrepancy • Amplify discrepancy between the present and future (aim short-range future with youth) “where he/she is; where he/she wants to be” • Explore important goals • Emphasize how continued drug use will interfere

50. Develop DiscrepancyExample “If you keep driving while under the influence, you risk getting into legal problems.” ___________________________________ ________________________________________ ________________________________________ ________________________________________ ________________________________________