Etty Matalon Clinical Training Manager (02) 9385 0262 04111 94568 - - PowerPoint PPT Presentation

Etty Matalon Clinical Training Manager

(02) 9385 0262 04111 94568 etty@unsw.edu.au

• utline

learning outcomes

• To provide participants who treat individuals

presenting with cannabis use disorder and mental heal heath issues with a brief and efficacious intervention based on Motivational Interviewing

• To familiarise participants with the material

related to the delivery of a brief intervention

• bjectives for today

By the end of the workshop participants will be: * familiar with a brief intervention aimed at reducing cannabis related harms for clients suffering from anxiety and/or depressive disorders * familiar with resources and materials related to the brief intervention

Quik Fix is a Brief Intervention

• Targets:
• Depression/Anxiety
• Substance use
• Treatment attendance/adherence
• Any other presenting issue
• 1 to 4 sessions (usually 45-60 minute

individual sessions)

• Screening
• Personal Feedback
• Psychoeducation
• Motivational Interviewing
• Brief Coping Skills Training

Quik Fix uses ……

the spirit and principles of MI to :

• Engage the young person
• Conduct a brief assessment
• Provide assessment feedback and

Psychoeducation

• Build readiness to change and commitment to

make a change

• Assist the young person to develop a plan for

making a change (if willing)

• And provide brief coping skills to manage the

presenting issues (if willing)

Quik Fix aims …

Use the spirit and principles of MI in order to :

• Engage the young person
• Help them identify and develop an understanding
• f their presenting issues
• Provide them with relevant information on the

issues

• Increase their motivation and commitment to

make a change in their presenting issues

• Develop a plan for making a change
• Enhance their ability to cope with their presenting

issues

• Motivate the young person to attend further

treatment or follow-up

Motivational Interviewing

• W. Miller and S.Rollnick

1991, 2002 edition, Guilford press Treatment Approaches for Alcohol and Drug Dependence Jarvis,Tebbutt and Mattick 1995, 2004 edition

what is a Brief Intervention? (BI)

• “A time-limited, patient-centred counselling strategy

that focuses on changing patient behaviour and increasing patient compliance with therapy” (Fleming & Manwell, 1999: 129)

• “Any therapeutic or preventative activity of short

duration undertaken by a healthcare professional” (Aalto et al, 2000: 372)

stages of the Quik Fix (p11)

STAGE 1: Conduct a Brief Assessment and provide Assessment Feedback STAGE 2: Offer Psychoeducation STAGE 3: Explore Motivation to Change STAGE 4: Assess Importance and Confidence to Make a Change STAGE 5: Explore Options for Change STAGE 6: Negotiate a General Change Plan STAGE 7: Offer Brief Coping Skills Training STAGE 8: Summarise the Change Plan & Rate Confidence to Implement the Plan

Motivational Interviewing

“Motivational Interviewing is a client- centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” ~Miller & Rollnick, 2002~

what is motivation?

• Ready: a matter of priorities
• Willing: the importance of change
• Able: confidence for change

limitations

• Client
• The client may want longer term treatment
• ?Effectiveness among clients with severe mental

health and substance use problems

• Who will deliver it?
• Availability of training
• Perception BI isn‟t „enough‟ treatment
• How will it be funded? - Compatibility with

Medicare funding

advantages

• Some YP may prefer short term

treatment

• Increases number of YP who can access

treatment

• Easily disseminated to a range of allied

health professionals across multiple settings

• May be used as a first step in stepped

care interventions for mental health and substance use problems

intervention philosophy

There is no confrontation regarding the participants‟ use, There is the provision of a non-judgmental atmosphere in which questions may be asked.

motivation relates to ambivalence

• Ambivalence – feeling two ways about something
• Ambivalence is normal
• Getting stuck in ambivalence can intensify problems
• Exploring ambivalence is to work at the heart of the

problem

spirit of MI

Source: Miller & Rollnick, 2002

Fundamental approach of MI Mirror-image opposite approach to some counselling Collaboration: Create an atmosphere conducive to change by developing a partnership that honours the client‟s expertise and perspectives Confrontation: Counsellor imposes their „reality‟ that the client cannot see or will not admit to Evocation: The resources and motivation for change are presumed to reside within the client. Education: The client is presumed to lack key knowledge necessary for change to occur. Autonomy: The counsellor affirms the client‟s right and capacity for self- direction and facilitates informed choice. Authority: The counsellor tells the client what he or she must do.

general principles of MI

• 1. Express Empathy
• 2. Develop Discrepancy
• 3. Roll with Resistance
• 4. Support Self-Efficacy

principle 1: Express Empathy

• One of the most important elements of MI
• Acceptance facilitates change
• Skilful reflective listening is fundamental
• Ambivalence is normal

Miller & Rollnick 2002

principle 2: Develop Discrepancy

• Motivation is a function of the discrepancy

between present behaviours and values

• Discomfort can enhance motivation to change
• The client presents the arguments for change
• Change is motivated by a perceived

discrepancy between present behaviour and important personal goals or values

principle 3: Roll with Resistance

• Avoid argumentation
• Avoid direct confrontation of resistance
• New perspectives are invited, not imposed
• The client is the primary source of „solutions‟
• Resistance is a signal to respond differently

Miller & Rollnick 2002

principle 4: Support Self-Efficacy

• Nurture the clients‟ belief in the possibility
• f change – Build hope & optimism
• Counsellor believes in the client‟s ability

to change & communicates this to the client

Miller & Rollnick 2002

methods for eliciting change talk - OARS

Open questions Affirming Reflective listening Summarising

STAGE 1: ENGAGEMENT, BRIEF ASSESSMENT & ASSESSMENT FEEDBACK

gather information

• Establish rapport
• Undertake assessment
• Find out how the client sees their

situation at present

principles of effective feedback

• Be understandable
• Be accurate
• Be positive
• Be collaborative
• Be appropriate
• Be responsible
• Undertake assessment

feedback

• The provision of assessment feedback can raise

the clients awareness of their presenting issues

• Aim is to help the client to understand the

assessment results and develop a discrepancy between how things are and how the YP wants them to be

• Avoid using the results to “prove” anything or to

pressure the client to accept a diagnosis or prescribed course of action

• Describe results and provide information needed

to understand what the assessment means

feedback

• Present results within a context that allows clients

to form own conclusions and allows freedom of choice, for example

• “I don‟t know what you will make of these

results, but…”

• Avoid “scare tactics”; this style may diminish

the client‟s openness to feedback

• Solicit and reflect the client‟s reactions to the

feedback, for example:

• “What do you make of this?”

feedback

• Summarise the feedback in terms of:
• The risks and problems that have

emerged from assessment findings

• The client‟s own reaction to the

feedback, including self-motivating statements that have been made

• An invitation for the client to add to or

correct the summary

consider barriers to engagement

• External obstacles to treatment attendance
• “even when people want help, it can be hard to do so. What

things might get in the way of you coming to treatment?”

• Psychological obstacles
• “If we could magically solve these practical issues, what

else might get in the way of you coming?”

• Quick fix, stigma
• Cultural obstacles
• “Sometimes it is difficult for YP to come to treatment because

their friends or family do not believe they need treatment or see the value of treatment. Do you have any concerns like these?

STAGE 2: OFFER PSYCHOEDUCATION

what is Psychoeducation? Steps ….

• 1 acknowledge the YP‟s knowledge about

their symptoms and substance use

• 2. ask permission to provide information
• 3. provide appropriate psycholeducation
• 4. enquire about the YP‟s reaction to the information
• 5. provide take home resources (p20)

Search for „mental health‟ on

• ur website to download PDF

Psychoeducation

• Information should be delivered in

a understandable & acceptable language and format

• Include info on the common

symptoms of depression/anxiety & substance misuse & the links between them

STAGE 3: Explore motivation to change (focus on strategies to elicit change talk)

motivation to change

Recognise that current behaviour is a concern or a problem

• increase awareness e.g. self-

monitoring

• assess pros and cons of behaviour

change Believe that they will be better off if they change

• personalise the benefits for the client
• provide information about the

advantages of change

• provide context and opportunity for

change Believe that they are able to change

• set achievable goals
• foster self-efficacy
• identify support
• learn strategies to deal with high risk

situations and relapses

explore motivation to change

• 1. Focus on change in general
• 2. Identify and explore the presenting issue using
• 3. Explore the impact of the presenting issue on

MH & SU and the relationship between them

• 4. Explore ambivalence about making change to

SU or MH

eliciting change talk

• Involves building intrinsic motivation to

change

• Change talk helps to resolve

ambivalence

• Client provides argument for change

self motivational statements

• Four types of these can be identified

(p21)

• Problem recognition: “I guess this is

more serious than I thought…”

• Expression of concern: “I‟m really

worried about this…”

• Intention to change: “I‟ve got to do

something about this…”

• Optimism about change: “I think I can

do this…”

methods for eliciting change talk - OARS

Open questions Affirming Reflective listening Summarising

DARN leads to C statements

Preparation talk:

• Desire: I want to change
• Ability:

I can change

• Reasons: It would help me if I changed
• Need:

I need to change Preparation talk  Commitment talk

commitment talk

““I‟m not planning to…” “I might …” “I will now …”

Increasing intensity of commitment talk  Action

change talk (p23)

• 1. Elaborating Change Talk
• 2. Reflecting Back Change Talk
• 3. Summarising Change Talk
• 4. Affirming Change Talk

The Decision Balance

 Good things

about use

 Benefits of

status quo

 Not-so-good

things about use

 Benefits of

change

Decisional Balance

Good things about… Imp Not so good things about… Imp Good things about changing. Imp Not so good things about changing. Imp

STAGE 4: RATE IMPORTANCE & CONFIDENCE IN MAKING A CHANGE

Importance Ruler

Circle how important it is for you to change your mental health symptoms/substance use?

1 2 3 4 5 6 7 8 9 10

Not Important Somewhat Most Important

questions to explore importance

• What would have to happen for it to become more

important for you to change?

• What stops you from moving from X to 10?
• If you were to change, what would it look like?
• What are the things you take into account that makes you

give yourself the score of X?

• Unless the person is scoring 8‟s on importance

scale…do not move on to Phase 2 i.e. stage 5:

• ptions for making a change!!!

Confidence Ruler

Circle how confident you are that you could change your mental health symptoms/substance use?

1 2 3 4 5 6 7 8 9 10

Not at all Confident Somewhat Most Confident

questions to explore confidence

• What would make you more confident about

making these changes?

• What would need to happen to take your score

from X to Y?

• How can I or others help you to make a

change?

• What have you learned from previous attempts

to change?

• What are the steps you need to take to achieve

your goal?

Readiness Ruler

• Page 27
• Questions to assess and explore

readiness to attend treatment

STAGE 5: Explore options for making a change

explore options

• Check in with the client how they‟re feeling

about what has been discussed

• Summarise issues raised so far – separate

MH and SU issues

• Acknowledge ongoing ambivalence
• Explore readiness to change

question to ask

• “What do you think?”… Would you like to make

a change in your substance use? …”How would you like it to change”?

• “What do you think it would take for your

symptoms to improve?”, “What would things be like for you in the future if your symptoms stayed the same?”, “ Would you like to make a change in your depression/anxiety?”, “How would you like it to change”?

roadblocks to change

• Underestimating ambivalence
• Prescribing a plan that is unacceptable

to the young person

• Insufficient direction
• Important to summarise client‟s current

situation and perception of problem when moving from Stage I to II

if the young person is not receptive to change . . .

• Explore the young person‟s life style and what

things are important to the client (e.g., family, work, friends) and how MH and/or SU impact “How does your substance use fit in with spending time with your family” “How does your anxiety impact on your school/work”

• If client still resistant to making changes offer

information and go back to Phase I strategies

signs of readiness to change

• Decreased resistance
• Waiting for the next step
• Change talk increases
• Questions about change
• Experimenting with possible changes

STAGE 6: DEVELOP A GENERAL CHANGE PLAN

develop a change plan

• What are the client‟s goals regarding

change?

• What are the most important reasons for

making a change?

• What can the client do to work towards their

goal of change (including coping skills)?

• What can others do to help support the client

regarding their goals?

• How will the client know if their plan is

working?

develop a change plan

• 1. Set some change goals
• 2. Brainstorm Change Options
• 3. Arriving at a Plan
• 4. Offer coping strategies

STAGE 7: OFFER COPING SKILLS STRATEGIES

some basic strategies that can be offered to the client

• Learning about coping styles -
• Increasing Positive Feelings
• Stress Less/Belly breathing
• Thought Management
• Sleep hygiene (optional) ………….

coping styles

• Think about a time when you have had to

deal with a problem or difficult emotions

• Without disclosing the problem or

emotion, brainstorm the strategies you have used to cope

• In pairs share your responses
• In a group list these strategies in the

categories of helpful or unhelpful

review current coping skills

• Ask: “How do you usually use when you‟re dealing

with problems or difficult emotions?”

• Distinguish between:
• Helpful Coping: Actively deal with problems/emotions
• Unhelpful Coping: Do not address problems/emotions (e.g.,

denial, avoidance, substance use, aggression, impulsivity)

• Ask “Which of your coping styles are helpful and

which are unhelpful”

• How effective is it in helping me manage my problems or

emotions?; How long does it work for?

review current coping skills

• If the young person is using unhelpful coping skills
• ffer the following information:
• The more you attempt to avoid or deny problems or emotions the

more you‟ll think about them and the more upset you‟ll feel, this will

• nly make you feel better in the short term & can make things

worse

• State: “Would you like to learn some alternative ways
• f coping with [presenting problem]?

improving mood

• Balance eating
• Treat physical illness
• Be active (exercise at least 3 times

weekly)

• Balance your sleep

Increasing positive feelings

Do at least 1 thing that makes you feel good each day.

• 2 people you would like to spend more time with
• 2 activities you would like to do more often
• 2 places where you would like to spend more time
• 2 things you don‟t own but would like to (make sure

you can afford them)

• 2 of your favorite foods

Schedule pleasant activities in advance –

• Set days to do them

increasing positive feelings

• Turn to the Good Vibes Worksheet
• Look at the Increasing Positive Feelings

section

• Complete the pleasant activities list and

schedule which days you will do them

• Make sure you are doing at least one

pleasant activity per day.

relaxation

• Reduces negative feelings as well as

cravings for substance use

• Aim: Reduce physical and mental tension
• Can include:
• High energy activities
• Gentler activities.
• Key: find which activity or combination of

activities works best for an individual

stress less

• 1. Exercise 3+ times a week.
• Identify preference for high energy or

gentler activities (or combo)

• Identify 3 activities
• Encourage the YP to do the activities 3+

times/week to lift their mood

stress less

• 2. Ssttrreettcchh your body
• Stretching reduces muscle tension by

increasing blood flow to these muscles

• Ask the young person to stand up and

work your way through the stretches

• Ask the YP to reflect on whether they feel

any different

stress less

• 3. Give yourself a mini massage!!
• Massage can also reduce muscle tension
• Ask the YP to give themselves a mini-

massage using their own hands.

• Ask the YP to reflect on whether they feel

any different

stress less

• Use the Stress Less Worksheet
• Working in pairs, have a go at doing the

stretching and mini massage activities

• Take turns being the counsellor and the

YP

stress less

• 4. Self soothe
• Relax by soothing each of your 5 senses
• Ask the YP to identify their 5 senses
• Then, ask the YP what kind of things

soothe each of their 5 senses

• Encourage the YP to do self soothing

activities

stress less

• 5. Take a short holiday
• Take a short holiday from the world
• If it all get‟s too much

OR

• Just to spoil yourself
• Ask the YP, what kind of things they

could do to take a short holiday

stress less

• 6. Listen to music mindfully

Being mindful of the present moment helps us to feel more relaxed and calm Ask the YP what their favourite song is or what kind of music they like Ask them to try and listen to the music mindfully

most importantly just DO SOMETHING to help you STRESS LESS

belly breathing

• Belly breathing, is a „deep breathing‟

technique

• Designed to be used at the first sign of

negative feelings

• It is important to practice this skill

belly breathing

• Working in pairs: One person is the

counsellor, the other the client

• Present a rationale for using belly

breathing

• Train the client in how to do the belly

breathing technique

• Swap roles

belly breathing

• Can be used as a Quik Fix for reducing

mental and physical tension

• REPEAT the belly breath in and out at

least 3 times to quickly reduce feelings

• f anxiety or anger

cognitive coping skills

• Simple skills for managing negative thoughts

that are causing the YP distress

• Individuals are taught to be receptive to and
• bserve their thoughts in a non-judgmental

way - as just thoughts not facts

• Reduces the impact and influence of negative

thoughts on the individual

• This is just one way of managing negative

thoughts and there are a range of other strategies available

cognitive coping skills

In summary the steps are:

• 1. NOTICE and OBSERVE the thought in a non-

judgemental way

• 2. Remind yourself: „This is just a thought‟;

„Thoughts are just thoughts, they are not facts” OR say to yourself: „I‟ve had the thought that….‟

• 3. Refocus your attention on what you are doing in

the present moment

• 4. Finally, take a moment to see if your feelings

change.

cognitive coping skills

• Use the Be Mindful NOT Mindless

Worksheet

• Participants: Generate a recent example
• f a negative thought (keep it simple)
• Facilitator: Present the rationale for

thought management and the steps for managing thoughts

things to consider when developing the plan

• Don‟t overwhelm the young person with

too many strategies

• Tailor strategies to current concerns
• Offer and demonstrate in a collaborative

manner

• Only provide strategies if client is

agreeable

STAGE 8: Summarise the Change Plan and Rate the Young Person’s Confidence to Implement the Change Plan

review the change plan

• Summarise what has been discussed regarding MH

and SU issues

• On a scale from 1 to 10 how confident are you that

you will implement this change plan?

• If low: What would it take to improve you confidence?
• Address any concerns regarding the plan & revise

accordingly

• Elicit a commitment in implementing the change plan

& re-rate the scales

Confidence Ruler

Circle how confident you are in your ability to implement the plan? 1 2 3 4 5 6 7 8 9 10

Not at all confident Somewhat Highly Confident

Treatment Ruler

Circle how likely it is that you will attend further treatment of your substance use/mental health symptoms after completing Quik Fix? 1 2 3 4 5 6 7 8 9 10

Not at all likely Somewhat Highly Likely

change plan

• Turn back to the change plan devised for

earlier in the training

• How confident do you think your client is

in implementing the plan

STAGE 1: Conduct a Brief Assessment and provide Assessment Feedback STAGE 2: Offer Psychoeducation STAGE 3: Explore Motivation to Change STAGE 4: Assess Importance and Confidence in Making a Change STAGE 5: Explore Options for Change STAGE 6: Negotiate a General Change Plan STAGE 7: Offer CBT Coping Strategies STAGE 8: Summarise the Change Plan & Rate Confidence in Implementing the Plan

Thank you