Teens R’ Us and the SBIRT Model

Teens R’ Us and the SBIRT Model


Hello everyone! My name is Meg Brunner and
I am guest webinar-hosting today while your regular host, Dr. Bia Carlini, is out.
I’m very excited to welcome you to this month’s Northwest ATTC webinar, Teens R Us and the SBIRT Model, and before we get started I have just a couple of
notes for you. There we go. Okay, first, the slides from today’s
webinar will be coming to you in an email this afternoon along with a link
to a survey about the webinar that we would love for you to fill out for us. In
fact we would love it so much if you filled it out for us that if you
complete and submit that survey you’ll get a $5 gift card to Starbucks or
Amazon, you get to pick, and we’ll also be sending you a second survey in 30 days
that has the same bonus, so that’s two lattes on us which is a great deal. Second, a recording of this webinar is being made and will be up on our website
early next week. And then finally if this is your first webinar with us we use the
chat box function in Zoom for questions and you can type a question into chat
any time during the webinar and then at the end I’ll be reading as many of those
as we have time for to Dr. Winters to get his answers for you. So let’s get
started Dr. Ken Winters is a senior scientist at the Oregon Research
Institute and adjunct faculty at the University of Minnesota Department of
Psychology. His primary research interests include the assessment and
treatment of adolescent drug abuse. Dr. Winters is on the editorial boards of
several prominent journals in the field and has received numerous grants from
NIH and various foundations over the years. He’s published over a hundred and
twenty five peer review articles, which is incredible, and over the past 10 years
he’s been researching brief interventions and the SBIRT model. So
welcome to the webinar, Dr. Winters. I’m gonna transfer control over to you in
just a sec, we’ll see if we can get this to work. Okay, all right. Thank You Meg and hello everyone. Appreciate the opportunity, also
thanks to Bia for helping make this happen.
I appreciate the opportunity. I’m not going to try to take all the time by
talking; I want to leave some time for Q&A. And also feel free to email me, you
see my email there, if you have a follow-up question that can’t be
addressed today. So some of you, I assume, know what SBIRT is. This has
been around for a while, it’s getting more popular with teenagers, I’d make a
case, and the model isn’t, at least its components, aren’t new — people have
screened and done brief interventions and figured out how to refer teenagers
for more treatment for decades. But this has been put into an interesting model
and formalized over the last few years. So, let’s get a disclosure for you: I do
have a personal commercial interest with one of the brief intervention programs
that will briefly be noted as background material. And I have a personal
disclosure — I’m hoping that actually this is not your reaction or part of your
evaluation of the talk when it’s done — I’m borrowing from the famous physicist
Enrico Fermi when he said, or heard, from a participant, “Before I came here, I was
confused about this subject. Having listened to your lecture, I am still
confused — but on a higher level.” I’m hoping I don’t bloviate so much and get
too confusing that you have that reaction afterwards. Before we get into
the SBIRT model, a couple thoughts on when counseling any teenager who might
have a substance abuse problem, and I’m being a little simplistic here, but I
think there’s plenty of interesting research over decades that have made a
case that the stronger your therapeutic alliance with the teenager, the more
likely you are to have great outcomes. And as people have looked inside what
does it mean to have therapeutic alliance, you know, how well you connect
with a teenager looks like, has a lot to do with that client, that teenager’s
seeing you as a credible person and someone who is using
a credible and a meaningful or believable strategy or approach. It’s one
reason why I like SBIRT models because I think they’re very teen friendly. And
then another feature that’s important when we’re working with teenagers who
have a problem with substance use is the key to try to help him or her understand
what the functional value of that use may be and how you can help him or her
figure out a way to break those connections. You’ll see how SBIRT tries
to do that quite soon. Then there’s another feature, the having to understand
the dynamics of motivation. I think that’s important in counseling. And
motivation is a complex term and it reflects you know more than one
direction. So on one hand, we can talk about you as a therapist being a
motivator — you’re trying to convince a person to to recognize they may have a
problem or recognize they may need to change their behaviors and you want to
help him or her steer their their life down a healthier path. And so to some
degree as a counselor you want to be an excellent or a great motivator. So I
thought I’d just bring up a couple examples. I’m a sports fan so I found two
examples of so-called “great motivators” from the sports world and the first one
I picked is Vince Lombardi. He’s quite famous, as you may know, for being able to
bring many teams, football teams to great success. He’s known for a lot of great
quotes. One of them is, “Confidence is contagious. So is lack of confidence.” And
to some degree, you’re trying to build confidence in your client and make that
a contagious part of their personality, a part of their motivation
to change. Someone with a very different path towards being a great motivator
is Jill Costello — probably no one has heard of her. She was highlighted in a Sports Illustrated article back in 2010.
She was the caller of the elite championship rowing team at the
University of California, so she wasn’t a rower but she was the key person in
the rowing boat that motivated all the others, and the article spent a lot of
time talking about how special she was, how she used unique features to motivate,
and our personality just exuded motivation among her teammates, and how
she struggled with a chronic illness, didn’t let that get in the way of her
working as a wonderful teammate. Now motivation also is something we have to
understand from the perspective of our client, and when we’re dealing with
individuals that have a substance use problem to some degree we are having to
deal with triggers and cravings and motivate that person to not let those
triggers and cravings influence their behavior. And psychologists have talked
about this phenomenon with many constructs. One of them is self-control,
and you may know about the the so-called marshmallow test that is a way to look
at how well somebody can handle self-control. I thought I would show you
this very brief YouTube video that shows how children are trying to handle the
temptation of resisting a marshmallow and having to exert self-control. Let’s
see if this pops up for you. So are we getting volume, Meg? Yep here we go. Yeah, no volume for me, Meg. hear it fine, but it may be that it’s not gonna
transfer over via Zoom, so we may have to just describe the video. Oh okay yeah
sorry no problem. So throughout this video, these youngsters are are trying to
resist the challenges. They’re told to not eat the marshmallow, and in about two or
three minutes the adult will come back and if they haven’t eaten it, they’ll get
a second one and then the adult leaves the room and they don’t know they’re
being videotaped. So this is a montage of how kids are trying to handle it and
they’re poking, they’re prodding, they’re trying to come up with strategies like
ignore, or here’s the identical twins, so, looking like they’re using similar
strategies, and some of them succeed in holding off, some of them have a little
tougher time, most of them do touch it or pretend to eat it, even maybe pick at it a
little, bit but the the theme of this is that there is variability in
self-control, the so called self-control trait, and it may even be a trait that is
fairly stable throughout life, although there’s nothing that says self-control
behaviors you show as a young person are fate, and that surely is something that
can be shaped, and people can be taught how to either improve or show less
self-control, and context is gonna play a role. Now this girl didn’t wait too
long — she started eating even while given instructions. She perhaps didn’t care
about waiting around for the second
reward. And here’s at the end where the the moderator comes in and
congratulates the young boy for for hanging in there and he gets his reward
of the second one. The so-called marshmallow test — there are people who
studied this and looked at how young people are doing with this task over the
years and there’s some data to suggest actually kids are doing a better job
with it than they have in the past, so maybe we’re teaching better self-control
with better parenting and perhaps our education system is doing that. Okay
the SBIRT model: it has three main components: screening, brief intervention,
referral to treatment or referral the services, because often we’re
sending youngsters on for for more services than formal treatment. I’m going
to go through each of these components in some detail. But first some resources. This slide has some free ones, I see, maybe at the bottom, we’re missing the
website, but the top first three are our free resources that cover drug abuse
treatment in general, so they would have some chapters or sections that deal with
SBIRT. But the fourth and the fifth are two resources specifically about SBIRT and if you go to those websites you’ll see a lot of information ranging
from the S all the way to the RT. For cost items, there are four I have here. The first two are generic — they are our manuals about adolescent
drug abuse and textbooks, both of them are edited, and they’ll have some SBIRT-specific features as well as a lot co-occurring disorders and treatment
approaches across the span of disorders. The third is a great book on
motivational interviewing with adolescents; this is an edited book, but
drills neatly into how to use this approach for youngsters. And then the
fourth is a product from a group at a Kognito. This is an interesting multi-component training module for how
to learn SBIRT and it includes avatar technology, so you can watch simulated
examples and learn from that. It’s a cost item but I think just an excellent
resource. I think of SBIRT as just very clinical-friendly and, so I’m showing you a Swiss Army knife — the metaphor for me is SBIRTis like the Swiss Army knife. It’s handy, you can use it in multiple settings, and it has a
lot of different tools in it for a range of purposes. And so why might we like it
as a model for teenagers? I think it has many teen friendly features. In general
the SBIRT model is going to be done in in what I call brief counseling or in a
very brief time frame, so there’s a minimal commitment by the teenager. At
least the BI component usually focuses on using motivational interviewing and
cognitive behavior therapy strategies and these approaches, which we’ll get
into in more detail, I think are very accommodating when working with
teenagers. A wide range of professionals can learn SBIRT,
it is not heavy lifting technology, and it can be done in many different
settings– I call them opportunistic settings such as schools, school health
clinics, pediatric clinics, juvenile detention centers, juvenile drug courts,
etc. Another reason I like the model is that it fills the need for indicated
prevention and there aren’t a lot of really evidence-based programs that fit
that portion of the prevention continuum. A little bit more about indicated
prevention with the help of Tammy Cheung: this figure tries to show you how we can
categorize somewhat simplistically various levels of severity of substance
use, and you can see that there’s six categories and they vary a little
bit on how much they’re… based on substance use frequency as as well as
how many symptoms you might have from the DSM-5 diagnostic manual. But if you
start at the bottom and then work your way up, you’re seeing the least severe
group all the way to the most severe. All right, so at the low and the top end,
at the two extremes, the two bookends, you actually are probably addressing or
thinking of teenagers that don’t fit the sweet spot of the SBIRT model. So for
teenagers that have no past year substance use or are infrequent
substance users, they’re not likely going to need any clinical services, they might
benefit from prevention but not clinical services, and estimates put roughly about
70% of teenagers, depending on age and many other variables, fit that
definition. At the very severe end, roughly 5% might meet the substance use
disorder “severe” level which means they have several of the substance use
disorder criteria, and for those individuals they might need more than
SBIRT, something more intensive. But we could think of a sweet spot somewhere in
the middle that ranges from those that are starting to use regularly as well as
those that are starting to show mild or moderate substance use disorder symptoms,
and they seem to be the most appropriate as suitable, and they’re probably early
in their substance use admittedly some of them may grow out of the problem but
to at least address the issues and see if the teenager can
recognize that they might not be on a healthy pathway can make a lot of
clinical sense and surely it meets the public health need of helping teenagers
negotiate the teenage adolescent years without adding extra risk by using
drugs. Estimates put the size of this so-called sweet spot at roughly 25% of teenagers. A little bit more — SBIRT looks to be showing some early
effectiveness. I point people to a very good meta-analysis by Tanner-Smith and
Lipsy in 2014 — there are others out there as well and they do a good job of
providing an overview of what’s already been studied, the rigor of those
investigations, and to what extent we can say that we’re looking at promising,
emerging, or definitive effectiveness. The RT part of the model hasn’t been
studied much, though. It’s an important component but right now it looks like
it’s we’re relying on clinical knowledge and not empirical findings. The model has
been endorsed by many professional organizations; the most prominent would
be the American Academy of Pediatrics. It’s also getting recognized in the
reimbursement world by having CPT codes associated with it and the opportunity
for you to be reimbursed for your efforts. So next up let’s look at the
three components with some detail. Start with screening. I want to distinguish
screening from assessment, and one way to do that is tolook at the depth of
information and the type of decision made from a screening. So the notion is that a
screening process — you’re really just assessing the probabilistic nature if
there is a problem or what problems exist or not, and thus the decision from
that is either more assessment, or, as many people
now suggest, it can make sense to do a brief intervention. Because brief
interventions do not force definitive goals and work with a teenager on
negotiating behavior change, I agree with those that say even
though you might not be sure if there’s a definitive problem, it can make sense
to talk to a teenager about their health behaviors. That’s to be contrasted with
assessment. So with a full assessment that often can take two to three hours
or perhaps even longer, the depth of information is more definitive. You’re
nailing down if there’s diagnosis or diagnosis or not, and from there the
clinical decision typically is: should there be formal treatment or not. And if
there is decision for treatment, you would probably start to make some
determinations of what type or what setting. There are a lot of tools
available in the screening arena. I have listed seven of them here. Some of them
are cost items and some of them are public domain. Even the cost items, let’s
see which, the fourth one, the GAIN-SS and the PESQ and the SASSI-Adolescent– those
three are cost items but they’re relatively inexpensive. But there are
others, four of them up here, that are not at cost and public domain, and all of
these have been tested on adolescents, have a lot of psychometric rigor working
with this population. Let me focus on two of them. Many of you have probably heard
of the CRAFFT, but I also want to show you a little bit about the HEADSS. This is the
standard CRAFFT — the six items. Each item represents a letter from the acronym. Take a moment and just read those. I think you’ll, if you think about the
items, you hopefully come to conclusion that they’re basically face-valid. There’s nothing subtle about them. If the teenager wants to deny they have a
problem, it’d be easy for them just to say no to all of those even though they
might have a problem. So it’s not going to detect someone who
is trying to to fake good. But they work quite well — it’s amazing how six
items are very predictive. There’s a question of so what do you do with a cut
score, because you can get scores all the way from zero to six — zero meaning
you said no to all of them and six meaning you said yes to all of them. And this is
a recommended breakdown but it’s open for for interpretation and
adjustment. But if somebody says no to all of them or maybe yes to just one, they
they might not need a formal brief intervention. Perhaps assessing later or
recommending that if they are using that they they pull back. But the brief
intervention sweet spot is thought to be somewhere in the two to five range, If
you get a six that might lead to several options — you could do a brief
intervention because you might think of it as the first step in a stepped care
approach, trying to open the door for the teenagers — try something that’s not a
full commitment and if it looks like they really do have a severe problem you
could convince perhaps the teenager to get more services later. Another option would be just do a formal and a full diagnostic workup and really
get the details. We’ll talk later about how it’s likely a teenager with a severe
form or severe level of substance use also has co-occurring problems, and if so
more assessment is needed for sure along those lines. And then I thought I would mention a little bit about the HEADSS. H-E-A-D-S-S. Each letter stands for a key word in the assessment. You can see how it’s broken
down across a range of life functioning areas relevant to teenagers, not just
drugs. If you Google HEADDS, you will see how you can download for free structured
and semi-structured interviews that help you with these six categories. And so if
you’re interested in a little bit more than screening for just substance abuse
you have, I think, an interesting public domain option with some rigor behind it if you choose the HEADDS. There are several strategies and techniques you
can do to optimize getting a good quality self-report from a teenager. It’s
not just that the teenager might have a certain mindset that might be a barrier
to good self-report, but there’s things you can do or there’s setting
considerations that can also help optimize that you get high quality
information from a teenager. I’ve got a list here and this is not an exhaustive
list and all of them have a lot of details behind them, but I wanted to show
you this to remind you that there are things you can do such as building good
rapport, establishing confidentiality, reinforcing the benefits of good
assessment, as well as choosing a standardized test. Some standardized
tests have scales to measure invalid responding that can help you then detect
whether you think you’re getting a good report or not. You surely could
repeat testing — you might not think that you’re getting a good accurate reading
and you could repeat it some time later. Urine tests can be of value on some
level you got to keep in mind if you’re going to go down that road. They, the
tests, often have short time detection windows for various drugs and it only tells you if the person has that substance in their system for that time window and it
doesn’t tell you anything else about about severity or problems resulting
from use. So it has limited value. But in some settings it can be important to
backup self-report with a biometric reading. The core of SBIRT is brief
intervention, so we’ll spend a lot of time on this. Good news is there’s
several available brief interventions that are manualized and in the
literature and meet the definition of evidence-based. The five that I
have found in the literature are these, with the first one focused on on college
students, and then there’s the Brief Strategic Family Therapy, MET-CBT 5,
the Brief Negotiated Interview, and Teen Intervene. For the sake of time I’m gonna
just briefly highlight these three. And so for each of these, I have websites
that you can go to and I have more information about all of them if you’re
interested. So CBT combines I think the two wonderful components that are key
elements to effective counseling with teenagers: motivational interviewing and
cognitive behavior therapy. The MET part blends motivational interviewing with
normative assessment feedback — that’s where the the client and you as the
counselor go through a procedure where you evaluate or get a reading
of the teenager’s view of their use and how normal it is, and then you
compare their perception to what are norms for that youngster. And you see if you can get the teenager to gain some insight because the likelihood is
teenagers think that the heavy or high-end use that they’re engaged in is
just normal and they’re surprised when they see with
that perhaps that is not the case. And these sessions also use a lot of good
CBT strategies, and these include wonderful approaches to convince a
teenager to solve specific problems. So it’s personalized at that level, and also
it works on the theme that you’ve got to have goals that are practical that can
have immediate feedback to the teenager and that are meaningful to him or her. So
there’s a negotiation process that goes on with that. So you make sure that your
addressing something that’s relevant to the youngster. The Brief Negotiated
Interview is is a single session, 60-minute format. It’s organized around
these four structured steps. The first two are really organized around this
personal feedback approach, but you have to start that by by engaging the
youngster as to what what their view is about risk of substance use and what
their use levels are, then you compare that to what might be considered a
normative and what might be considered harmful or not harmful. And of course the idea there is to have the
teenager gaining some insight that they may be overusing and engaging in more
harmful behavior than they think they are. Then there’s the use of the decisional balance exercise in a readiness ruler to
help improve motivation. We’ll delve into them in a few minutes. And then the last
step is where you negotiate a plan for change and these changes are an effort
to get the person either for harm or risk reduction or abstinence and the
idea is to encourage them to be the captain of their change and that the
change has to come from within and that you as the counselor is not the one
that’s going to affect a change but he or she, the youngster, has to be
responsible for it. Often these plans for change can address
co-occurring problems as well, particularly when you’ve been able to
link what might be an underlying issue in the teenager’s life, behavioral or
emotional for example, that might be driving the drug use, and that
information comes from the decisional balance exercise. So steps three and four
are also quite useful because what you learn in step three with the decisional
balance tool, you can use to help shape a relevant plan for change. Soon we’ll
we’ll get into that a little bit more. The last one I wanted to emphasize is
the Teen Intervene program. This has three sessions so it’s a little
bit more than a brief negotiated plan but it’s also a little bit less than the
the five session MET-CBT. Two of the sessions are focused just with a
teenager and then there’s a third session that’s just with the parent.The
role of a parent session is to help support the teenager’s goals and this has
the full expert model in its revised form and included the CRAFFT as a
screening tool, and it has a guide for the counselor for the referral to
treatment component. Okay these evidence-based brief intervention
programs have some common elements. I have four that I’m going to just briefly
summarize. Decisional balance exercise to me is the the most effective component
of any brief intervention. If you just had five or ten minutes with somebody
and wanted to try to get them to look at their drug use habit in a little
different light and maybe even then use that information to leverage a plan of
action for him or her in such a very brief amount of time, I would just do a
decisional balance interview with him or her. Here’s examples of how this is done. I’ve got you know the two basic halves of
decisional balance exercise: the pros and the cons, and sample questions and
inquiries within each. You always start with the pros and then you follow with
the cons. The pros are important because they they help you get a ballpark read
of the functional value that may be driving the individual’s drug use. For
teenagers I think it’s … the research tells us that
social recreational value, social benefits, and coping strategies, or
psychological benefits, are the three driving pathways that are the
functional motives underlying adolescent drug use. Of course they can vary among
teenagers. Some teenagers it’s all of those, for some you find dominance of the psychological benefits and that often are those that are have an
underlying depression or anxiety problem. For teenagers with the cons, you might
not be getting much, that’s okay. Given what it’s like for a teenager
these days and the fact they might have not have been using that much and
might have been clever enough not to have been caught, or maybe they have been
caught and there’s consequences and they don’t care, so they might not be
admitting too much. But that’s alright. You’re usually going to get some
great information on the pro side and you can use that when you’re setting up
goals. Motivational interviewing is a second common element. You may know about
the value of this strategy as an effort to move a client’s attitude about change
from the the low level pre-contemplation, where the individual isn’t thinking
about change, all the way to preparation and action, where then you have a
client ready to change and your goal is to help him or her towards those changes. So in pre-contemplation, you’re raising doubt,
increasing the client’s perception of risk. If you can move or have them in
contemplation, you want the teenager then to start to talk about the value of
their thinking, of change, and how they can improve their life, and make some
important health improvements by agreeing to some changes. And when
they’re in preparation, action, you’re really getting specific with a teenager
about where they’re going to go with their changes. The notion is that if you
can move a client even one stage to the right, you’ve doubled the chance that the
individual will eventually get to action within a short amount of time. So you are
going to get a lot of clients in pre- contemplation, and just if you can move
and shift that person’s attitudes towards contemplation, you’re making some good progress. This is my facetious slide about the stage of progression for
teenagers. I’m just showing this because in many ways you may not move a teenager
all that far out of pre-contemplation, if you even if you can nudge him or her
theoretically into once in a while thinking about change, you might have
made some decent progress. That’s why I don’t want to get too frustrated when
you’re doing brief counseling with a teenager, because you don’t have a lot of
time to work with him or her and you might not be thinking you really don’t
have much commitment from the youngster. That’s all right. Hopefully you’re planting mustard seeds. Motivational interviewing works, I think,
on two levels. One it helps promote this client-centered approach, as opposed to
therapist-centered, which means you’re de-emphasizing labels, you’re emphasizing
personal choice, you’re focusing on getting the client’s concerns, you’re
you’re acting as a mentor and a coach with those concerns in helping him or
her set goals. You might have some important goals in mind, you may want to
nudge your client towards those goals, but the notion is that you’ve really got to
get buy-in from the teenager and not over-force how you may see goals.
Here’s some sample sound bites from a good motivational sentence: “I can see why
you see many benefits of using.” That’s recognizing in the pros. “Describe a time
when you’re with your friends and you did not use or you used less than you had
planned to.” It’s a good statement because maybe you’re going to get some examples
and you can use that as leverage, see if the teenager can find value in repeating
that the last one. “Okay it looks like we do not agree on this topic, let’s move on.”
Many times you have to roll with the resistance you’re receiving and agree to
disagree at that point and you can always come back to an issue later. The
second key to effective motivation interviewing is that you’re eliciting
change talk. I’ve got some examples of here of what might be the kind of thing
you’re trying to get from a client by asking questions — that “plant mustard
seeds of change” — and so it’s just saying things like: what personal strengths you
have that will help you succeed, what encourages you that you can change if
you want to. So you might not be getting the client interested in change but if you
can just get them to talk about the possibility of change, the potential that
they can change, that’s still moving the behavior change ball forward. Third
element is cognitive-behavioral therapy. As you may know, this approach is used in
a range of treatment strategies to address all kinds of behavioral and
emotional problems in adolescents and adults. So the notion is, you focus on
immediate and relevant and specific problems and you design the treatment
plan and the goals around things that are realistic and action-oriented. You’re changing either the person’s way of thinking about something, their
behavior, or both. And then the final is negotiating goals. There’s a range of things. You might not get a teenager who’s interested in any
drug use-related goals — maybe they don’t want to change their their substance use
patterns. They may not be interested in in any harm or risk reduction. That’s
fine. I think the one idea is to get them to agree to some goal. Now, that could be
just to get them to think and learn more about their triggers — so everyone has
some either internal or external triggers for their drug use, and just
getting them to gain some insight about that and to monitor that can be of value.
Some counselors use the brief intervention and realize: I don’t have a
teenager at all interested in changing their substance use but they have
expressed other kinds of problems in their life and so I’ll jump on that and
see if I can get some progress along those lines. So I might have an issue
with their friends, with school, with their parents, issues with anxiety,
depression, etc., and building some goals around that can get them started, can get
them to feel like you’re credible and that the counseling process is favorable
and rewarding. And maybe you can work in drug use goals later. I’m also a big fan
of having youngsters just focus on what their personal assets are and encouraging them to to build those and focus more on them and do more things to
promote those assets as a goal. So this slide is a reminder that it’s not common
for most brief interventions to focus on the parent, but if you do find that you
have an opportunity for that, one way to look at the kinds of things you want to
do with a parent is to improve both their discipline or monitoring behaviors
and their support behaviors. So teenagers that have parents that are on top of
those teenager’s lives, have rules and expectations, and do a good job of
monitoring if the teenager’s meeting those expectations — you find that those
are parents that are quite good at at the so called “disciplining and
monitoring” skills, and the support component is just as important, and
that’s where the parents are providing emotional and environmental support to
the to the youngster, where many instances a teenager will say: I can
least turn to one parent to share or talk about a personal problem. And
parents that are good with supportive behaviors find that teenagers agree to
that. The last component is referral to treatment or services. It’s the least
studied, as I mentioned. People have applied their clinical common-sense to
this portion of the model. Usually this is met with several barriers: what
services are available, if more services are needed, and what kind of things might
get in the way of my teenager or the teenager’s family from seeking those
services, including is there insurance coverage for stepped-up services, is
there anyone with expertise that’s local that I’m hoping he or she can can be
referred to it etc. So it’s a very challenging situation. Some use the RT
component to add sessions and so they might actually decide to conduct booster
sessions and so with your own skill you could perhaps provide these extra
services: more assessment or dealing with the additional problems. This is a model
that we’ve shown others where you can figure out what kind of outcome you’re
getting with your brief invention and then that can lead you to perhaps some
suggestions of where you want to go with the referral to treatment. So favorable
outcome: you support the continued favorable behavior, all the way from from
the minimal change, needing some booster, down to you may have a problem that’s
worsening or you’ve realized with the screening you have multiple problems, and
you need to refer for more assessment. Would you like to be part of an SBIRT
research project? I’ve been made available this interesting project funded by a
grant with the Conrad Hilton Foundation called Project Amp. Now this is a four
session brief intervention designed to reduce and prevent substance use in
adolescents who are at risk. So it’s indicated prevention model. The delivery
of it is by young adult peers who are in recovery and that are trained to
deliver a brief intervention. The study officials are hoping to see how this
works in school sites, and they’re in a Phase Two
portion of the project, which means they’ve already designed Project Amp and
done an initial pilot study and found it reasonable and favorable early results
and so now want to implement a rigorous full-fledged investigation. If you’re
interested there’s the contact site at the bottom. Project Amp. And so I have a five
minute sidebar topic and then we have plenty of time for Q&A. A major
limitation of SBIRT is represented by this slide. As I mentioned a little bit
and as you are well aware of if you work with teenagers, usually substance use
does not occur in a vacuum and multiple other problems typically occur in
teenagers who have a substance use problem, even those that have a mild
problem. This a noisy slide but I put a red box around the two bars that are of
interest to our discussion. They represent two groups that are labeled
mild or moderate and you can see below it
how many symptoms are present and the colors of them. The inside of these two
columns represent how many other co-occurring problems are present in
individuals within these two groups and the lighter colors mean either none or
or a few problems and the darker colors mean a lot of problems. You can
see that even with youngsters who are showing mild or moderate substance use
disorder levels which range from two to five symptoms, they show several other
problems. You can see in contrast with the no substance use disorder group
looks like as well, to the far right, the severe. But the point is there’s, you know, it’s pretty common have two, three, four, even five co-occurring problems, even when
you’re at the mild, moderate level. So one notion is that perhaps downstream, we’re
going to look at SBIRT as a great first step. But for individuals in settings
that have the ability to expand it and be a bit more ambitious, they might be
able to enhance it. And I think you could enhance it on two levels: one would be at
the screening and at the brief intervention level. So this slide
represents my thinking along these lines. The screening enhancement would mean you
find a multi-problem screening tool that does more than just screen for drug
abuse and hopefully there you could use a screen that might have ability to
screen for the the most common co- occurring problems among teenagers. So
there are a lot of problems, you could make a list, twenty to thirty forty fifty,
but I think it’s rational to talk about a core set. There are somewhere in
the five to ten range that I would call common co-occurring problems. Not all of
them are are diagnosable-level problems But some of them are important problems.
We call them subclinical but still important. And then the notion behind the brief
invention is that it wouldn’t just focus on the drug use, but you would
additionally focus on what might be the biggest co-occurring or the most salient
co-occurring problems. So if you’ve screened for several you might
prioritize and figure out, okay I’ve got, I’m going to do two or three more
sessions, and I’m going to prioritize this list of screening issues, this
list of co-occurring problems, and I will take some time and address each of them
with some evidence-based cognitive behavior therapy approaches. And then the arty
part would be where you have to figure out after you do the full model, this
enhanced model, what would be the next steps. It’s like with the regular SBIRT
if I got improvement, do I do a booster or do I really see there’s significant
other problems and I want to intensify specialized treatment to address those
problems? So I’m not sure where this will go,
I offer just as a look into the future. There isn’t anything formally in the
literature along these lines. There’s people writing about it, I know there’s
people applying for grants to see if they can develop and test this model, but
you can see there are several challenges. There are multi problems screening tools but it means you have to spend more time — it’s more than just two or three minutes, it might take 10 or 15. You got to have a
little bit more sophisticated scoring staff in mind, and some of them are not
public domain, but the multi screening tools do exist and one could put
together a personalized brief intervention package by taking modules that already
address anxiety or depression, delinquency, they exist, and you could
package those and you know use the ones that make the most sense for a teenager. So I’m going to summarize: I think the SBIRT approach is emerging but a very
promising set of tools that can help address a wider range of adolescents
with early or mild moderate drug use problems then we’re already doing with
our existing strategies, which tend to be too intensive. So it doesn’t make
sense to offer intensive inpatient or outpatient therapy or 12-step
approach to a teenager with a mild/ moderate problem and the SBIRT approach
though is a rational clinical strategy or toolbox to apply in such situations. The field is starting to show evidence-based and evidence-informed
programs and models, and I spent a little time just talking about perhaps
the future will expand this where we can formalize a way to screen for multiple
problems that typically exist in teenagers and provide tools for
counselors that can help address those multiple problems. Well thank you for
this opportunity, you’ve got ten minutes, and we surely can use that time if
people have some questions. [Meg] Okay so before we do questions just a quick
reminder that you’ll be getting the slides in about an hour and also a
survey asking you about the webinar. And if you have any questions, please type
them in the chat box and if not, I have a couple to get us started with. So Ken are
there settings in which the SBIRT model works best for adolescents or
settings in which it might work the worst? [Ken] The conversations that I’ve
had with professionals along these lines is that the biggest barrier is a setting
that doesn’t have the time to really at least do a one-hour brief intervention. I
know there are examples of the five to ten minute conversation but I’m not
optimistic that those are going to work at a in a very favorable level. No
if you only had five or ten minutes say like I said earlier, I think the
decisional balance exercise would be hit. So that’s why I’m more encouraged that
you know school health clinics, juvenile detention centers, juvenile drug courts,
and you know outpatient counseling programs and settings all could
find, I think, a home for the SBIRT model. Pediatric clinics and general health care settings: they’re more challenged
because they often have a difficult time allocating time and resources and staff
to something that’s, I’d call it the lengthier version of an SBIRT. [Meg]
Interesting. How much training is needed to implement SBIRT? [Ken] So I don’t think a
lot of training is needed — this will vary on your background and your skill in
working with young people. A counselor who is good with teenagers probably has
a lot of skill in talking to young people in general and that might be more
important than how much classroom training you’ve received. So there’s a
lot of great youth-serving professionals that don’t have formal training but are
just outstanding with young people. And fortunately there’s a lot of
training you can get online for either very low cost or for free. [Meg] Great, wow,
that’s great. Another question from the group is: should the teen and parent
do family sessions on top of the teen receiving their own services? [Ken] Yes if that
would be ideal and the brief family therapy program that was in one of those
slides that is the basic model that requires more training, it can be more
complicated, there’s a lot of things you’ve got to watch out for, you’ve got
to be careful of all the different perspectives, and it can it can really be
a challenge to meet the teenager’s needs but not also turn off the parent. And
then you got the other side where you’re trying to meet the parent’s needs and
you’re perhaps creating a barrier with the teenager. My view of that expanded SBIRT would… that would be, could be, one of the
modules. So you might realize with your screening that it’s really a family
systems problem, and one of the modules might be then, “Okay, we’re gonna actually
have, you know, a couple sessions. It’s a, it’s a form of family therapy. [Meg] Interesting. How successful is this model for teens with addiction problems? Ccan
you talk a little bit more about the evidence for the effectiveness of SBIRT? [Ken] So unfortunately most of the literature
doesn’t go out more than six months or one year outcome. It’s reasonable when
you look at at the 1 year and 6 months outcome data, in part because I
think you’re getting nice results even though they were very non intensive
approaches. One of the things we found when we studied is that we had a slight
advantage when the parent was involved for more access to community services
after the brief intervention and so keep in mind your SBIRT model might be
just moving the momentum forward a bit for the teenager and/or the family to
seek more services, so you might be at the front end providing a little push,
and downstream there might be additional help. And the more significant
outcomes will unfold and so we did find a little bit of that when we compared
just the version of the brief intervention that was just the teenage
sessions only versus the teenage sessions with that third parent. So the
third parent probably didn’t change parenting practice as much, what
are you going to do in one session, but it it looked like it acted to alert the
parent that maybe that we should take these issues more seriously and
and let’s take advantage of some of local resources for additional help. [Meg] Interesting. Did anyone else have any other questions? Doesn’t look like it. Do
you have any last advice you want to offer the listeners on how maybe they can get
started with SBIRT, Dr. Winters? [Ken] Oh well definitely go to the slide that has the
the websites for free resources, the Children’s Hospital and the IRETA
group. Both of them have websites with a lot of free free tools. [Meg] Great,
thank you so much and thank you all for attending today have a rest good rest of
the week! You see, thank you Dr. Winters!


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