Complexities for Clinical Tx Majority of adolescents presenting for tx with more than just substance use problems… Psychological co-occurring (trauma, depression, anxiety, etc.) histories Delinquent/legal court/probation issues School drop-out/academic failure issues Family dysfunction
Clinical Risk Differs Clinical Risk Differs
Understanding Problem Severity Screening is essential To determine RISK - the actual problem severity– where are they along the clinical risk continuum of use? Standardized Screeners CRAFFT: Eng/Span Knight et al. 2002
Client Screening Activity
Responsibility element Coping element – use moves beyond pleasure Isolation/Social Withdraw element Impairment element Problem Use recognized by others Consequences of use*
Interviewing for interconnected problems e M s U e n e t a c n l H a t e s a b l u t h S Medical 46
Children’s Forms – Being Revised?
48 Los Angeles DMH Assessment Mental Health SUD
Los Angeles DMH Assessment Medical Mental Health Considerations Considerations Cirrhosis Depression Gastroenteritis Anxiety Abscess Anhedonia Diabetes Psychotic Thinking High Blood Pressure Trauma/PTSD HIV/HCV Confusion Cardiac Problems Memory Issues TB … … 49
The Spectrum of Interventions Prevention/ Education Brief Advice *Brief Interventions *Brief Treatments Formal Specialized Treatments 51
Continuum of Adolescent Substance Use
Turn Our Attention to: Treatment Effectiveness Studies Tell us about the effectiveness of different treatment models for adolescents with substance use disorders Includes studies with programs deemed “evidence-based” Proven to be successful through research methodology and have produced a consistent pattern of positive results.
CYT EBP Brief Treatment Series Cannabis Youth Treatment 1. Motivational Enhance Treatment/Cognitive Behavior Therapy (MET/CBT5) Trials 2. Cognitive Behavior Therapy 7 (CBT7) 3. Family Support Network (FSN) 4. Adolescent Community Reinforcement Approach (ACRA) 5. Multidimensional Family Therapy (MDFT) Treatment Series
s s e n d a S r SUD SUD e e P Physical Problem Negative Negative Family Emotions Emotions Mental Health
Difficult Clients are Categorized as… Main problem: AOD/SUD contributes to their MH issues The client perception of the issue: XXX B/C Disconnect & Mismatch Resistance Distrust Poor Insight/Awareness Low motivation
5 Manualized Tx Protocols Treatment manuals available from National Clearinghouse for Alcohol and Drug Information (NCADI) or www.chestnut.org/li
Motivational Enhanced Treatment/ CYT Cognitive Behavior Therapy 5 Cannabis Youth Treatment (MET/CBT5) Sampl, S., & Kadden, R. (2001) University of Connecticut Health Center Trials Farmington, CT USA Treatment Series Volume 1
Individual MET (MI) Sessions 1 & 2 (50-75 min) 1. Assessment Feedback (Review PFR), Rapport- Building, Orientation to Treatment 2. Review of Progress, Functional Analysis, Personalized Goal Setting, and Orientation to the Group Sessions
Group CBT Sessions 1-3 (50-75 Min) 1. Drug/ETOH Refusal Skills 2. Increasing Social Support and Pleasant Activities 3. Coping with Emergencies and Relapse Client Preparedness Plus 2 Random Urines over six weeks
CYT Cognitive Behavior Therapy Cannabis Youth Treatment 7 Supplement (CBT-7) Webb, C., Scudder, M., Kaminer, Y., Kadden, R., & Trials Tawfik, Z. (2002) University of Connecticut Health Center Farmington, CT USA Treatment Series Volume 2
7 Supplemental CBT Sessions: 6. Problem-Solving Skills 7. Anger Awareness 8. Anger Management 9. Communication Skills: Assertiveness and Criticism 10. Coping with Cravings 11. Managing Negative Moods 12. Managing Thoughts about Using
Stages of Change Prochaska & DiClemente
How you talk to the adolescent matters You are singing off key if you find yourself… • Challenging • Shaming • Warning • Labeling • Finger-wagging • Confronting • Moralizing • Being Sarcastic • Giving unwanted • Playing expert advice
Five Strategies of MET 1. Express Empathy 2. Develop Discrepancy 3. Avoid Argumentation 4. Roll with Resistance 5. Support Self-Efficacy
Facilitating the Risk/Reward Analysis What to focus on: Decisional balance scale Elicit pros and cons of use and change Emphasize client choice and responsibility Elicit self-motivational statements, and summarize them (they are hearing what they just said)
How do you avoid argumentation with a teenager? Resistance should be a CUE to modify your approach Treat ambivalence (mixed feelings) as normal Bring the focus back on their concerns: Elicit the client’s perceptions of the problem and providing feedback
Video Demo: Goal Setting (MET) & Increasing Social Support/Pleasant Activities (CBT) & Coping with Emergencies
CYT Family Support Network Cannabis Youth Treatment (FSN) Hamilton, N., Brantley, L., Tims, F., Angelovich, N., & Trials McDougall, B. (2001). Operation PAR St. Petersburg, FL USA Treatment Series Volume 3
I mportance of the Family! I mportance of the Family! Intraclass Substance Use Correlations Correlations w 3-month 6-month 9-month 12- 95% C.I. month Family conflict .56 .48 .47 .43 .58 (.53, .62) Family cohesion .56 .50 .46 .50 .54 (.50, .59) Social support .42 .38 .45 .44 . 50 (.45, .54) Recovery environment risk .42 .42 .37 .24 .43 (.39, .48) Social risk .28 .34 .24 .21 .37 (.32, .42) Substance use .36 .30 .19 .27 .50 (.45, .54) Substance-related problems .43 .35 .31 .31 .46 (.42, .51)
A Closer Look at the Family Issue… Family Support: less family conflict and greater family cohesion corresponded to reduced risk for poor treatment outcomes Although families play a pivotal role, they vary in their ability and willingness to help…
How do you facilitate Parental Attendance?
CYT Adolescent Community Cannabis Youth Treatment Reinforcement Approach (ACRA) Godley, S. H., Meyers*, R. J., Smith*, J. E., Godley, M. D., Titus, J. Trials M., Karvinen, T., Dent, G., Passetti, L., & Kelberg, P. (2001). Chestnut Health Systems Bloomington, IL USA, and *University of New Mexico Albuquerque, NM USA Treatment Series Volume 4
CYT Multidimensional Family Cannabis Youth Treatment Therapy (MDFT) Liddle, H. A. (2002). University of Miami Trials Miami, FL USA Treatment Series Volume 5
2010 Meta-Analysis Study of studies conducted to identify treatment effectiveness of various EBP treatment approaches that maximize treatment outcomes (JMATE presentation) 48 studies that included 79 treatment approaches for adolescents
Treatment Approaches Family therapy (k = 25, n = 88) Individual counseling Generic GROUP counseling Cognitive behavioral therapy (CBT) Motivational interviewing/enhancement therapy (MET) MET + CBT (MET/CBT) Psychoeducational therapy (PET) Contingency Management Vocational counseling Drug court Pharm. treatment No Treatment
Results Effect sizes were close and not statistically meaningful to make definitive statements about superiority…BUT Family therapy & CBT/MET combo had stronger effects (on abstinence outcomes) than all compared treatment conditions Individual counseling was less effective than all other treatment conditions with which it was compared
Recovery The Post-Treatm ent Period Factors Factors In-Tx In-Tx
Treatment Effectiveness Studies Important to note: studies have NOT established a superior treatment approach They all have equally effective results in terms of producing positive outcomes… Reducing use Improving mental health/wellbeing, and Repairing social relations Happy Ending?
Treatment Outcome Studies Treatment Outcome Studies Although treatment is working… Less than half of adolescents leave treatment with a positive discharge (still using) Relapse continues to be fairly common: ~65% relapse during first three months after tx completion (Brown et al., 1989) and longer-term (12 mos; Dennis et al.,2000) Lack of continuity of care: less than 10% participate in aftercare after formal tx
Been called many things… … Been called many things McKay (2008) Aftercare Extended interventions Continuing care Disease management Stepped-down care
Continuing Care Service Barriers Limited funding for services in the addiction field Limited availability of services Hence, not a standard “clinical” practice Why pay when we have – 12 step model? Been referred to as “the perfect aftercare” (White, 2007)
Em pirical Support for CC Evidence suggests clients who get continuing care have better outcomes than clients who do not receive CC services (McKay, 2009). Evidence mainly established for adults; less clear for adolescents Very few continuing care studies of adolescents in the scientific literature Godley et al. 2002 – home visits with youth after residential tx (Assertive Continuing Care)
Brief Intervention FLO
85 Avoid Warnings! (that’s it) W Warn The 3 Tasks of a BI O Options Explored L Listen & Understand F Feedback
86 How does it all fit together?
87 O Options Explored The 3 Tasks of a BI L Listen & Understand F Feedback
The First Task: Feedback Your job in F is only to deliver the feedback! Let the consumer decide where to go with it. Ask for Permission explicitly There’s something that concerns me. Would it be ok if I shared my concerns with you? Provide direct feedback The results of your screening form suggest that… 88
The First Task: Feedback Handling resistance… • Look, I don’t have a drug problem • I just like to party with my friends • I can quit using anytime I want to • I just like the taste • I’m young, what’s the big deal? What would you say? 89
The First Task: Feedback To avoid this… LET GO!!! 90
The First Task: Feedback Easy Ways to Let Go… • I’m not going to push you to change anything you don’t want to change… • I’m not hear to convince you that you’re partying too much… • I’d just like to give you some information... • I’d really like to hear your thoughts about… • What you do is up to you…. 91
Feedback: Content Areas for Adolescents Alcohol Use Marijuana Use Prescription Medication Use Club drug use Always ask this question: “What role, if any, do you think (substance) played in (problem) ? 92
The First Task: Feedback Let’s practice F: Role Play Giving Feedback ONLY 93
94 O Options Explored The 3 Tasks of a BI L Listen & Understand F Feedback
The Second Task: Listen and Understand Listen for the change talk… Maybe drinking did play a role in what happened If I wasn’t partying, this would never have happened I don’t want to be in this mess again The last thing I want to do is hurt someone else I know I can quit because I’ve stopped before Summarize, so they hear it twice! 95
The Second Task: Listen and Understand Dig for change talk… • I’d like to hear your opinions about… • What are some things that bother you about your use? • What role do you think drugs/alcohol played in ________________? • How would you like your drinking to be 5 years from now? 96
The Second Task: Listen and Understand Tools for Change Talk • Pros and Cons • Importance & Confidence Scales • Readiness Ruler 97
The Second Task: Listen and Understand Strategies for weighing the pros and cons… • “What do you like about drinking?” • “What do you see as the downside of drinking?” • “What Else?” Summarize both pros and cons… “On the one hand you said.., and on the other you said…. 98
The Second Task: Listen and Understand Importance/Confidence/Readiness On a scale of 1–10… • How important is it for you to change your drinking? • How confident are you that you can change your drinking? • How ready are you to change your drinking? For each ask… • Why didn’t you give it a lower number? • What would it take to raise that number? 99 1 2 3 4 5 6 7 8 9 10
The Second Task: Listen & Understand Let’s practice L: Role Play Listen & Understand Using Completed Screening Tools • Pros and Cons • Importance/Confidence/Readiness Scales • Develop Discrepancy • Dig for Change • Create movement in Consumer’s Stage of Readiness for Change 100
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