1. Brief Intervention with Middle/High School Students Scott Caldwell, MA CSAC Wisconsin Department of Public Instruction Safe and Supportive Schools and AODA Grantees Technical Assistance Conference, December 8, 2011

2. Presentation overview: Part I – BI background: What, Why, When, and How Part II – BI in practice, training, lessons learned

3. Wanted! An intervention model which is… Evidence-based and student friendly Developmentally and culturally relevant Efficient and flexible Compatible with existing paradigms Simple to deliver with feasible training

4. Brief Intervention A student-centered yet structured approach that addresses a target behavior through developing a student’s intrinsic motivation for change. Delivered in an empathetic, collaborative and respectful manner, student ambivalence for change is explored and resolved.

5. Underlying principles: Motivation is a key to change State (not trait) Ready, willing, able Dynamic and fluctuating Interpersonal

6. Underlying principles: Motivation is a key to change Ambivalence can be a barrier Pros/Cons Normal to change What happens when we champion the side of change?

7. Something You Feel Two Ways About Identify a change you are considering. Something about yourself that you… – Want to change – Need to change – Should change In other words, something you’re ambivalent about

8. Speaker: Identify the change you are considering Counselor: Do these four things, in this order… 1) Explain why the speaker should make the change 2) Provide at least two specific benefits that would result from the change 3) Tell the speaker how he/she could make the change 4) Emphasize how important it is to make the change

9. Underlying principles: Motivation is a key to change Ambivalence is a significant barrier Practitioner skill drives effectiveness

10. In Brief Intervention the practitioner is… Collaborative Evocative with open questions Supportive of student autonomy Reflectively listening Affirming Motivational Interviewing

11. A Taste of Motivational Interviewing Speaker: discuss the same change you were considering Counselor: Listen carefully with the goal of understanding the dilemma; give no advice Ask these three questions: –Why would you want to make this change? –How might you go about it in order to succeed? –What are the two best reasons to do it? Offer a short summary of the speaker’s motivations for the change, then ask, “so what do you think you’ll do” and just listen

12. Brief Intervention (the vehicle) Motivational Interviewing (the engine)

13. Why Brief Intervention? 1)Multiple uses

14. few many most

15. Level of AOD Involvement Risky, Subclinical Use Experimental, infrequent use or Abstinence Abuse or Dependence ≈ 10% ≈ up to 30% ≈ 40% + ?

16. Type of AOD Services Risky, Subclinical Use Experimental, infrequent use or Abstinence Abuse or Dependence Treatment BI Prevention BI (1 session) (2-3 sessions) Referral to Multiple Uses of BI

17. Why Brief Intervention? 1)Multiple uses 2)Fits within PBIS

18. SECONDARY PREVENTION PRIMARY PREVENTION TERTIARY PREVENTION Specialized Individualized Systems for students with high risk Specialized group Systems for students with at-risk behaviors School-/Classroom-wide systems for all students, staff, and settings PBIS Paradigm BI

19. Why Brief Intervention? 1)Multiple uses 2)Fits within PBIS 3)No problem recognition required! Meets teens where they’re at Ambivalence is normalized Harm reduction goals are acceptable

20. Why Brief Intervention? 1)Multiple uses 2)Fits within PBIS 3)No problem recognition required! 4)It works

21. #1 Brief Intervention #2 Motivational Enhancement Meta Analysis of Adult Alcohol Treatment Outcome: Rank Order Source: Miller & Wilbourne (2002, p. 272) What does not work: #41 Standard treatment #43 Confrontational counseling #46 Education

22. Efficacy of brief AOD interventions with teens: Clinical studies consistently show that… Brief intervention > No treatment Brief intervention = More extensive treatment Listed in reviews of effective adolescent treatments Deas (2008); Tripodi et al. (2010); Winters et al. (2009)

23. BI with teens in multiple settings: Aubrey (1998): AODA treatment * Monti et al. (1999): hospital ED * Breslin et al. (2002): 4-session treatment McCambridge & Strang (2004): school * Baer et al. (2004): homeless Spirito et al. (2004): hospital ED * Knight et al. (2005): primary care Stein et al. (2006): juvenile detention * Walker et al. (2006): school * Monti et al. (2007): hospital ED* Winters & Leitten (2007): school * D’Amico et al. (2008): primary care* Martin & Copeland (2008): community* * Randomized Clinical Trial

24. 1) Small but growing literature 2) Teen outcomes: AOD use AOD consequences self-efficacy 3) Effective with racially diverse teens 4) Abstinence not typical, however, effects are rapid and durable 5) High satisfaction ratings by teens What the research suggests:

25. Beyond AOD? School attendance Homework completion Self harm Classroom conduct Fighting

26. When BI (stand alone) may not be appropriate: Substance dependence Daily marijuana use Existence of significant co- occurring problems

27. Part II BI in practice Training Lessons learned

28. Brief Intervention Structure Leads with a brief screen Typically 1-3 sessions Focuses on a target behavior Protocol driven

29. 1. Opening strategies 2. Decisional balance 3. Readiness ruler 4. Change plan 5. Confidence ruler BI Procedures:

30. BI procedures MI Skills MI Spirit

31. 1. Opening strategies 2. Decisional balance 3. Readiness ruler 4. Change plan 5. Confidence ruler BI Procedures:

32. MI Behavior Counts Practitioner behaviorBenchmark for basic MI proficiency Open Questions 50% of total questions Complex Reflections 40% of total reflections Question to Reflection ratio 1:1 MI Adherent behaviors (e.g., ask permission, affirmation, emphasis on choice) At least 90% MI Non-adherent behaviors (e.g., info. without permission, advising, warning, confronting) No more than 10%

33. BI Training

34. 1.Exposure Background Concepts Share with leadership 2. Adoption Decision by leadership 1-2 day training Fidelity checks 3. Implementation Set up data collection Fidelity checks On-going learning activities Implementation Stages

35. Since 2006… 19 Adoption trainings, including 4 CESAs and 7 school districts 375 student services staff involved 440 tapes submitted, reviewed, and coded with feedback

36. Observations from the tapes: Student services come with talent and skills Demonstrating Motivational Interviewing proficiency is not easy –Giving up the “educator” role –Asking fewer questions –More and deeper listening –Acknowledging student choice –Resisting tangents (i.e., sticking to the target behavior)

37. Observations from the tapes: Student services come with talent and skills Demonstrating Motivational Interviewing proficiency is not easy Self-reported competency doesn’t correlate with actual practice Skills develop quickly with dedicated practice, feedback, and involvement in on- going learning activities

38. Implementation Lessons Leadership support is crucial Identify the champions Adoption training with entire student services team Get data collection system into place Establish peer group or other on-going learning activities

39. Summary BI is evidence-based and “teen friendly” Fits within PBIS Provides structure and focus, with flexibility Readily adaptable to school settings Maximizes limited resources

40. Thank you! Scott.Caldwell@wisconsin.gov