|
Young people who score more than 2 on the AME Screen will benefit from both support for their positive behaviour and at least one brief intervention session using motivational interviewing techniques to help them make changes to reduce their drug-related problems.
Tip: In choosing the point of intervention, it is helpful to understand the level of motivation within the young person. This is less about identifying a particular fixed stage than a general awareness.
If a youth has no intention to change or is just beginning to consider change, your goal may be to
- explore reasons for change, and
- explore problems associated with not changing, including risks related to their current behaviour.
If a youth is preparing or attempting to make changes, you may seek to
- cement their decision to change,
- enhance their confidence in their ability to change, and
- help them plan realistic change.
If a youth has recently made positive changes, you’ll likely want to
- enhance their belief in their ability to maintain healthy patterns, and
- help them identify and plan for situations that pose a risk of relapse.
Depending on the situation and your goals, the following panels provide suggestions on how to proceed.
Supporting positive behaviour includes raising a young person’s awareness of their developing strengths and the role these can play in their health and well-being.
If a young person scores below 2 on the AME Screen, chances are they’re at minimal risk of having an issue with alcohol or other drugs. But they may still require support for their positive behaviour and healthy lifestyle choices.
Youth who score 2 or more on the AME Screen are at greater risk of developing drug-related problems and perhaps need even more recognition for the good choices they’re making, even if for now the only good choice has been in showing up for their meeting with you.
Note: Pointing out their strengths doesn’t mean ignoring the risks related to their weaker moments. Instead, it helps you build a deeper bond with the youth and lays the groundwork for later discussions about potential changes they could make. In short, your role is to help them both see their strengths and use them to build motivation, confidence and self-efficacy for changing any problematic drug use behaviour.
|
In supporting positive behaviour, you can:
It’s important to provide young people with positive feedback about their AME Screen score. For those who score below 2, this might mean praising them for their low-risk behaviour and reinforcing the responsible choices they’re making. For those with a score of 2 or more, this could mean giving them credit for the sections on the screen where they scored 1 or 0.
Ask them how they plan to maintain their positive behaviour. And help them identify strengths that they can use to increase their health and handle high-risk situations. You can do this using a Strength Meter or Circle of Courage. You can also offer self-help resources that might help them stay on track.
Here is one example of giving positive feedback:
YPO: It’s great that you’re making responsible and safe decisions about your substance use. What helps you maintain your low level of use?
Youth: My parents really disapprove of drugs. Alcoholism runs in my family so I try not to drink that much. But it’s hard because my friends are into drinking and stuff.
YPO: What could you do with your friends instead of drinking alcohol?
Youth: I don’t know.
YPO: Well, what are some of the things that you like to do for fun?
Here is another example:
YPO: You’re doing a good job steering clear of alcohol. Let’s talk about what else you’re good at. Tell me what some of your strengths are.
Youth: What do you mean?
YPO: What are some of the things you like to do?
Youth: My friends and I like to play basketball on the weekends down at the park.
YPO: What is it that you like about playing basketball?
Youth: It’s fun, and I like hanging out with my friends.
YPO: That’s great. Basketball is great exercise and a great way to stay healthy. Have you thought about joining the school basketball team?
You can ask young people to rate their confidence level, or use the Change Scales tool to assess their confidence in their ability to maintain a minimal-risk level of drug use (or in their ability to reduce their risk). Help them identify their network of support for both now and in the future when they might face pressure to use alcohol or other drugs. Help them brainstorm strategies they can use to identify and deal with high-risk situations. Here’s an example of a conversation about confidence:
YPO: On a scale of 1-10, how confident are you that you could walk away from a situation where you felt uncomfortable and call someone to help you?
Youth: Maybe a 5.
YPO: Okay, so you think you might be able to do it. Is that right?
Youth: Yeah, I think I could do it sometimes.
YPO: Let’s think about some situations where you might feel uncomfortable, and how you might handle them. Does that sound good to you?
Express your confidence in their ability to achieve their goals and overcome challenges they’re likely to face. Emphasize your support for them and provide them with self-help resources that may help them be successful. Let them know your door is open and that they can come back for help at any time. You could say something like:
“I think you have a lot of strengths that can help you achieve your goals. I’m sure you’ll be able to work through any challenges that you face. But remember that you can ask for help if you need it. We came up with your list of supports, but I’m also here if there’s something you need to talk about. Is there any information I can give you now that’ll help you face some of these challenges more confidently?”
|
Some young people may be disinterested in or resistant to making changes to their use of alcohol and other drugs. They may be partly or even completely unaware a problem exists, that they should make changes, and that they may need help to get there. They may have never considered the potentially harmful consequences of their drug use. Or they may see themselves using drugs in the same way as everyone around them and not feel particularly concerned about the risks.
It can be challenging to convince youth in this situation that their drug use can be harmful because they may not have experienced any negative consequences yet and therefore won’t believe you. The first step in helping them is to figure out why they’re not open to change.
Typically, there are four types of resistance:
- Reluctance results from a lack of sufficient knowledge about the dimensions of the problem—or the personal impact it can have—to think change is necessary. Reluctant youth are most likely to respond to sensitive feedback about how their drug use is affecting their lives.
- Rebellion often results from a fear of losing control over one's lives and having a large investment in the drug(s) of choice. Your challenge is to help young people in this situation shift this energy into making more positive choices rather than rebelling against what they perceive as coercion. Emphasizing their personal control can work well with this type of youth.
- Resignation comes with a feeling of hopelessness about change and being overwhelmed by the energy it may require. Youth in this situation have probably been in treatment before or have tried repeatedly to change on their own but haven’t been successful. These youth need to regain hope and optimism about their capacity for change. This can sometimes be accomplished by exploring specific barriers that impede new beginnings.
- Rationalization involves having all the answers. These youth may understand drug use is a problem for others but not for themselves because the odds are against their being at risk. Reflection, rather than reason-based argument, seems to work best with youth in this situation. That is, acknowledge what they say, but remind them of issues they brought up earlier about the potential downsides of their use.
Tip: With youth who are not currently open to change, using terms such as “problem," “substance abuse” or “denial” is more likely to inflame their resistance than increase their motivation to overcome it. Instead, focus on language that builds rapport and encourages them to question their own beliefs about the harmlessness of their drug use patterns.
|
To increase motivation, you can do one or more of the following:
Often youth feel they have little control in the justice process. And they expect to hear nothing but criticism from adults. You can change their perception by giving them credit for making it to your meeting. Praising them for demonstrating responsibility will increase their confidence that change is possible. It also sends the message that they’re capable of making good choices that are in their own best interest.
You can also change their perception by accepting without judgment their current level of readiness to change. Here’s an example of how the conversation might go:
YPO: I’m impressed with your knowledge about drugs, and I understand that you don’t want to make any changes right now. But a condition of your order is that you stop using drugs. It’s your choice, but I want to help you complete this order successfully. So what can we do about that?
Youth: I don’t know. I don’t have a drug problem and I don’t think I should be punished for wanting to have fun with my friends once in a while.
YPO: You feel like this condition is unfair, and having fun with your friends is something that is important to you. Perhaps if we put our heads together and talk about this some more, we can come up with a solution.
Your goal in asking them to talk about the benefits and harms of their drug use is to get them to raise their own doubts and concerns. You can start by getting them to fill out a Weekly Substance Use Diary and discussing anything that surprised or concerned them. Here are some other ways to stimulate them to consider the idea of change:
- Explore the meaning of the events that brought them into the justice system, noting how drug use may have played a role.
- Explore the good and not-so-good aspects of their drug use. If they can’t recognize any of the not-so-good things about using drugs, chances are they’re not ready to consider changing and may need more information. By showing that you understand why they value alcohol or other drugs, you set the stage for further dialogue. You can start by saying, “Help me understand what you like about your drinking. What do you enjoy about it?" and then move on to ask, "What do you dislike about drinking?" Or you can use a tool such as Continue versus Change or Good and Not-So-Good.
- Ask them to consider all the ways in which drug use is affecting their life experiences. You could ask, "How’s your drug use affecting your studies and family life?”
- Give them feedback on the risks associated with their use of a particular substance, and how their pattern of use compares to others of the same age, gender or culture. Use data from a recent survey such as the BC Adolescent Health Survey.
- Offer basic evidence-based information about drugs and drug use, especially if they’ve never been exposed to drug education or seem particularly interested in learning about it. Be sure to ask them what they already know about the benefits or risks of drug use before giving them more information. And stay general—talk about what can happen to any user rather than focus on what can happen to them—and explain that you’re saying what experts have found to be true rather than what you personally think happens. While providing information, ask, “What do you make of all this?” and offer self-help resources where needed.
When you’re done, summarize the conversation using their language so they can clearly hear any ambivalence that is developing. You can say something like:
“So, using ___ helps you relax, you enjoy using it with friends, and it helps when you’re really angry. On the other hand, you say you sometimes resent all the money you’re spending on it, and it’s hard for you to get to school on Mondays."
Even if they’re not ready to make changes right now, ask them to consider what might make them want to change in the future. You could even move the conversation away from talking about drug use and focus on anything that they might like to change. Here are some examples:
“Right now it seems like you’re not that concerned about your substance use. You feel that there are more good things about it than bad things. But there were some concerns you had. What do you think would make you want to change your substance use pattern? How will you know when you should think about changing?”
“Thanks for talking about your drug use with me. I know you’re not happy about being here and you’ve made it clear to me that you don’t want to discuss changing your substance use. Maybe we can move away from substance use for a moment. Is there anything in your life right now that you’d like to change? Maybe we can work on something you’re interested in.”
Express your confidence in their ability to achieve any goals they set, including changing their drug use habits. Emphasize your support for them and provide them with self-help resources that may help them explore change. You could also offer them harm reduction information to help keep them safe in the meantime. Here are two examples of what you might say:
“Thank you for taking the time to talk with me about this. I think we both have a better understanding of this issue, and I hope you’ll come to me if you decide you want to make a change. In the meantime, I hope you’ll think about what we talked about today and try to find some ways to keep safe. Here’s some information that might help you...”
“I really appreciate all the concerns you brought up today. I understand that you’re not interested in changing because substances help you relax and you like drinking alcohol with your friends. But if you don’t make some effort here to change, it will get in the way of your completing your supervision successfully. Maybe you can take some time to think about how you can complete this order, but not lose the benefits that you feel drugs give you. I’d be happy to help you brainstorm some ideas when you’re ready. Does that sound okay?”
Note: You’ll probably need more than one session to get these messages through to youth who are currently not interested in change. And you’ll likely run into road blocks and resistance. Don’t worry about it. Let it go for now. But raise the issue again later on and work with them to come up with something that’ll work for both of you.
|
When we talk about youth who are receptive to changing their drug use behaviour, we’re talking about two distinct types: (1) youth who are ambivalent about change, or who are committed to change but aren’t sure how to, and (2) youth who may be somewhat ambivalent but who know change is necessary and are already actively trying to change.
When working with youth contemplating change, your aim is to help them see that change is worthwhile and that they’re capable of doing it. When working with youth actively engaged in trying to change, your aim is to provide encouragement and support to help them stick with their decision.
Brief intervention for youth in either of these situations should include
- cementing their decision to change,
- enhancing their confidence in their ability to change, and
- helping them plan realistic change.
|
In facilitating change, you can:
It’s important to support them at their current stage of change, but also challenge them to move forward. Start by providing them with some positive feedback. Thank them for being so honest and willing to talk about difficult issues, or reflect on something they told you earlier. Starting with something positive keeps the focus on supporting self-efficacy and increases their confidence to change.
Next, reflect on and clarify what they said they may want to change, and try to get them to use change talk. Here’s an example of what you could say:
“Thank you for having this discussion with me. It’s really helped me get to know you better and understand where you’re coming from. It’s clear that you’re quite independent and have a lot of ambition. From what you’ve said today, it seems that you might be ready to make some changes to your drug use habits so that we can make sure you complete your order successfully. Is that right?”
Since they’ve already agreed that they’d like to make some changes, summarize some of the issues you talked about earlier and ask them to choose one or two items to work on (e.g., a risky or harmful behaviour, or something that’s not directly related to their substance use such as wanting to try out for the school basketball team).
Note: Remember that the choice should be theirs, not yours. Trying to influence a behaviour that they don’t care about is unlikely to be successful. That said, if they’re engaging in behaviour that’s particularly harmful or strictly against their court order, use motivational interviewing strategies to try to redirect the youth in addressing this concern. Be sure to help the young person choose something that is achievable and can be measured.
Asking action questions—"Where do we go from here?” or “What do you want to do about it?”—can help move the young person toward a commitment to change. If they want your help with this, it’s okay to offer advice. Here’s an example of how the conversation might go:
YPO: We’ve talked about a lot of things recently but it seems that you’re most concerned about _______. What do you want to do about that?
Youth: I don’t know.
YPO: Would it be okay if I offered you some suggestions?
Youth: I guess.
YPO: This may or may not work for you but one thing you might think about is….
Tip: If the young person says they want to make changes to their drug use but are unclear about what they need to change, they may find it helpful to keep a Weekly Substance Use Diary and have you go over it with them during your next appointment.
Working together to come up with “a menu of harm reduction options” can make the young person’s problems seem less overwhelming and help them gain a sense of control. To facilitate the change process, it may be useful to offer some self-help resources.
Ask them to decide on the change strategy that suits them best. Discuss the pros and cons of this strategy, and explore factors that may impact their chances of being successful. Help them plan ahead in the event that they run into problems. Talk about how to identify and deal with high-risk situations, and how they’ll know when they’ve been successful in navigating the situation. Remind them they can draw on their strengths and support network in times of need.
Tip: You can use My Change Plan as a guide to helping the young person clarify what they want to change, identify potential obstacles, and both decide on and commit to a change strategy of their choice.
In order to change their drug use habits, they need to believe they can change. Self-efficacy and optimism are crucial for success. They may also need support to make the change.
You can assess their confidence by asking them to rank it from 1 to 10 (or by using the Change Scales tool). If they say “1 out of 10”, you might respond with, “Pretty low. What would it take to raise that estimate a little bit? Tell me about a change you made in the past. How did you go about it? Who might help you to...?"
If they say 4, you could say, “So, about in the middle. But why a 4 and not a 1? What else? What would it take to raise your confidence to, say, an 8? How would you go about it? How can I help you to make that happen?”
If they say “10", you could say, “Very confident. How would you go about it? What would it look like? What else? How can I help you make that happen? Who could support you in doing this?”
Tip: If they can’t come up with examples of people who can offer support, give them some ideas. Remind them that you’ll always be there for them to talk to, but that there may also be others—coaches, teachers and community centre staff—who can listen without being too judgmental. Extended family members and friends can be supportive too. If none of these ideas resonates with the youth, suggest other ways of getting support, such as exploring different faiths or talking to people who have found strength, courage and a feeling of groundedness in their religion.
Express your confidence in their ability to achieve their goal and overcome any challenges they’re likely to face. Tell them that if it doesn’t work, it’s not a reflection on them as a person but a reflection of the strategy they chose or of an unexpected barrier. Emphasize your support for them and offer resources that may help them be successful. You might want to say something like:
“So, you’ve decided that you’re ___ and that you’re going to try to do this by ____. I know this isn’t going to be easy for you, but we talked about what you can do if you run into problems. I think you will be able to overcome any challenges you face. But if the strategy we chose today doesn’t work, give me a call...”
Note: You’ve done a great job in helping the young person get on track. But don’t stop there. They’ll likely run into challenges and need your help again, or they may be successful and need your help to tackle a more difficult challenge. In other words, this might be their first step in the process of reducing or quitting their use of alcohol or other drugs. Be sure to keep checking in with them to see how’re they’re doing and, if necessary, repeat the steps that brought you to this point.
|
Relapse prevention involves helping a young person develop skills to continue their health-promoting behaviours while avoiding their old patterns of harmful behaviour related to using alcohol or other drugs.
Note: Behaviour change isn’t linear. Moving back and forth between various levels of motivation should be seen as a normal part of the change process. In other words, it’s normal for the young people you work with to have lapses in motivation and behaviour change.
Relapse prevention should be seen as a part of the change process and a normative and essential component of brief intervention. Following any intervention, you should check in with the youth to monitor their progress since the last session, and to try to help them
- identify any barriers to their progress,
- reinforce self-efficacy and skills, and
- strategize about where to go from there.
It’s important to keep in mind that you may need to repeat the steps of your brief intervention several times before seeing significant progress in the youth’s behaviour. It may also be helpful to reuse some of the worksheets and techniques you’ve been using to support their positive behaviour, such as My Change Plan, Strength Meter and Identifying and Dealing with High-Risk Situations.
Tip: You may want to go outside the traditional helper role and suggest some faith-based ways for them to tunnel through the “stuff” in the outside world that’s getting in their way of success. For some youth, simply understanding that they are loved by something bigger than themselves (and bigger than anyone they know) may give them the comfort and confidence they need to get back on track.
|
To help prevent a relapse, you can:
Look for successes and reinforce or support their positive behaviours.
Emphasize learning from their experience and look for strategies that may be more effective in helping them reach their goal. Discuss ways to maintain positive behaviour change. You could ask, “What can we learn from this?” or “What could you do differently next time?”
Praise them for the changes they’ve made and help them create new goals using My Change Plan. Continue to support self-efficacy to change. You could say, “Congratulations on reaching your goal! What can we do to make sure that you can keep up the good work?” or “It seems like you’ve reached your goal. Where would you like to go from here?” or “Is there anything else you’d like to work on?”
They may want to set a new goal or try a new strategy. They may feel hopeless and need encouragement to try something new. Or you may need to continue to work on increasing or reinforcing their motivation to change.
Here are some examples of how the relapse prevention process starts:
YPO: What’s been happening since our last visit? Did you try out that strategy we were talking about?
Youth: Yeah, but it didn’t work. I couldn’t do it.
YPO: Sounds like you gave it a try. Good for you. Tell me what happened.
Youth: I don’t know.
YPO: It sounds like maybe this wasn’t the right strategy for you. There were some barriers we didn’t expect. That happens sometimes. Maybe we could come up with a new strategy that would work better for you. What do you think?
YPO: I want to support you in completing this order successfully. What do you think about what we last discussed?”
Youth: I’m not sure I can make that change.
YPO: I think this is something we could work out together. Let’s brainstorm about what you think you could do or would like to do. Earlier you mentioned…
|
|