Connection before Direction: Helping Youth with Alcohol / Drug Use in Primary

Care

51st Annual Scientific Assembly, Hilton Toronto, Toronto, ON

Thurs, Nov 28, Nov 2013, 1530-1700 hrs

Dr. Michael Cheng, Children’s Hospital of Eastern Ontario

Mentor, Collaborative Mental Health Care Network, Ontario College of Family Physicians

Faculty/Presenter Disclosure

• Faculty: Michael Cheng• Program: 51st Annual Scientific Assembly

• Relationships with commercial interests:– NONE

Disclosure of Commercial Support• This program has received NO financial support • This program has received NO in-kind support

• Potential for conflict(s) of interest:– NONE

Mitigating Potential Bias• N/A

Objectives

• This presentation will review:1. How to screen for youth with alcohol/drug

problems

2. How to help youth in the office using motivational interviewing and interpersonal strategies, with a focus on…

3. How empathy, validation and unconditional acceptance is perhaps the most powerful way to reconnect youth to parents and vice-versa

Faculty/Presenter Disclosure

• Faculty• Michael Cheng

• Program• 51st Annual Scientific Assembly

• Relationships with commercial interests• None

• Conflict of Interest• None

• Disclosure of Commercial Support • None

• Mitigating Potential Bias• None

Case

“So what? Its going to be legal anyways…”

• Britney is a 15-yo in your primary care practice• You have known since she was a young age as

a sweet, but always active and spirited child• However, as she has gotten older, she has

become more moody, strong willed and defiant…

• You look at your schedule, and see that Britney is booked to see you later today for MARIJUANA PROBLEMS

Britney’s mother

“Why is she doing marijuana? When she was younger, she was cheerful, happy, and a good, well behaved kid.

Etiology of Substance Use

An Attachment Perspective

Q. Ever notice that it’s the older children like teens that turn to drugs?

Q. Ever notice that young children seem happier than older children?

Q. Why are young children so happier?

Q. Why are young children so happier?

• A. Because they are closely attached to parents.

Q. When a young child needs something from you, do they let you know?

Q. When a young child needs something from you, do they let you know?

• A. Young children are very good about letting you know they need something! (Unlike teens who may just as likely say everything is “fine” and storm off to their room…)

Q. When a young child cries, what do you do?

A. When a young child cries, what do you do?

Pick up child and provide physical comfort and reassurance

FoodDiaper change

Its not a very long list of things!

1. Young children express their needs…

2. Caregivers meet the needs (which are a smaller list and easier to meet than with older kids)

Young children are well attached to caregivers because:

CaregiverChild

3. Attachment forms with caregiver (or whoever meets their need)

Q. What happens when you consistently meet a child’s needs?

A. Secure attachment between child and parent

Ainsworth; Bowlby

Child’s working model / schema

View of world: “The world is a safe place… I can trust others…”

View of self: “I feel better thus I am competent…”

Attachment and Resiliency

• Resiliency: The ability to overcome adversity• Not everyone exposed to stresses develops problems;

many in fact, will thrive despite stress• Q. What is the single most important resiliency factor?

Attachment and Resiliency

• Resiliency: The ability to overcome adversity• Not everyone exposed to stresses develops problems;

many in fact, will thrive despite stress• Q. What is the single most important resiliency factor?

– Secure attachments to caregivers and nurturing adults

• Studies of high school student mental health show that – Parent-child relationships are the key to mental health – Strength of peer relations is not the key

Bowlby, 1940; Ainsworth, 1979; Schore, 2001; Neufeld, 2004

Attachment Theory

Why is attachment so important for us?

Many species have young that can survive on their own…

Q. What does a human baby/child have to do in order to survive?

Child

A. To survive, a human child must attach to parents (or caregivers)…

Child Parents

Attachment is essential for…

• Survival• Human young, unlike young of other species (e.g. reptiles,

fish), cannot survive on their own• Attachment to a nurturing caregiver is hardwired for survival• Continuation of the species…

• Normal development• Motor, sensory, self-regulation, including emotional

regulation, left/right hemisphere integration, etc. • Mental health, including happiness, contentment...

– Secure attachments to caregivers and nurturing adults as the number one resiliency factor

Bowlby, 1940; Ainsworth, 1979; Schore, 2001; Neufeld, 2004

Attachment: Nature’s antidepressant

We will even make attachments if we don't have them…

We will even make attachments if we don't have them…

We will even make attachments if we don't have them…

* Our survival as a species depends on this drive!

If all goes well, then young children are well attached to parents...

Unfortunately, as children grow up, things change…

Q. What often happens to child-parent attachments as children grow older?

?Child Parents

Q. What happens to parent-child attachments as children get older?

A. They often weaken….

ParentChild

Q. If a child turns away from parents, who do they often turn to instead of

parents?

ParentChild

A. Peers

Child Parent(s)

Peers

A. Peers, drugs, technology, etc…

Dalai Lama, 1998; Neufeld, 2005

Negative behaviours

Technology / Consumerism

Child Parent(s)

Peers

Turning to peers is bad because…

• Peers can never meet a child’s emotional/ attachment needs as well as only healthy parents can

• Only parents can reliably provide emotional support, validation and unconditional acceptance

• Peers – Friendships come and go– Peers are still maturing– Your BFF one day can be your worst enemy the

next…

Peer orientation vs. Caregiver orientation

Peer connections

(Healthy)Parent

connections

Britney’s mother

“What’s so bad about friends? When I was her age, I preferred to be with my peers too!”

Peers/Friends are okay as SECONDARY attachments

Child Parent(s)

Peers

Turning to peers as a primary source of emotional support is like putting all your

attachment eggs in one basket

Child Parent(s)

Peers

Peers/Friends are okay if…

• If you truly have mature peers (which usually doesn't happen until adulthood), then peers may indeed provide the stable support that perhaps parents cannot provide…

Turning to drugs is bad because…

• Drugs can never meet a child’s emotional/ attachment needs as well as only healthy parents can

• Only parents can reliably provide emotional support, validation and unconditional acceptance

• Drugs may help one feel temporarily better, but it is not a long-term solution…

Why do today's young people turn away from parents as they get older?

Q. Back in the old days, what did kids learn about parents from these shows?

VIDEO CLIP: MODERN TELEVISION SHOW

Q. What is the message about parents?

Media helps push our kids away...

• Today’s kids (either your kids or your kids’ peers) spend several hours a day on average in front of a TV, or other screens

• Media messages are that• Parents are lame• The secret to

happiness and success is having friends, and turning to your peers

Q. A child is playing ball with a parent. Who is going to be more competent at it?

A. The parent and thus the child learns that parents are competent and to look up to parents…

In traditional societies, the young learn from and thus respect their elders… (But not so in modern ones!)

Margaret Mead, 1956

VIDEO CLIP: MODERN TELEVISION SHOW

Q. In today’s technology obsessed world, who is better with modern technology, our 1) children or 2) parents?

A. Our children know more about the technology than we do, which makes them think they are superior…

Boy, my dad is

terrible!

Boy, I hate these video

games!

Economic Factors: Housing costs 2-3X more than in the 1970s – 40% of Canadian couples divorce… thus both parents work outside the home..

Q. So who are the kids hanging out with when both parents are working outside the home?

Kershaw, 2012

From an early age, our children spend more time with peers in daycare and school than they do with adults.

How modern technology weakens relationships, even the peer-peer relationships

2010 Kaiser Family Foundation Survey• U.S. children/teens

• 7 hr/day • ”Entertainment screens"

• Television, cell phones, hand-held games, iPads, Internet games, Facebook and video games

• 2-hrs/day• Violent video games

Q. What’s the big deal about video games?

VIDEO CLIP: MODERN VIDEO GAME

Screenshot from Call of Duty

Violence negatively affects children’s brains

• Violent video games are harmful – Research confirms numerous harmful effects of video games on

behaviour, mood, relationships, physical health, sleep

• Violence in media in general– Children/youth are exposed to violence in movies, televisions,

popular culture– All of this desensitizes us to violence and cruelty

American Academy of Paediatrics, Media Policy Statement

Dangers of modern communication and social media

• Potential for addiction• Superficiality is not true

intimacy• “I have 500 Facebook

friends, but I can’t really talk to anyone”

• Promotes jealousy and insecurity

• Cyberbullying

Dr. Gwenn O'Keeffe, 2011; Dr. Sherry Turkle, MIT and TEDS Talk

Texting

Destroying genuine human interaction two thumbs at a time

Screening

Screening

• American Medical Association's Guidelines for Adolescent Preventive Services recommends:– Adolescents be asked annually about their

use of alcohol– Those who report any use during the past

year should be assessed further

Screening with CRAAFT

• In the past year, have you:– Drank any alcohol?– Smoked any marijuana or hashish?– Used anything to get “high”?

• If YES to any of the above, then ask the patient the CRAAFT…

Screening with CRAFFT

C)ar Ever ridden in a CAR driven by someone (which includes yourself) who had been using alcohol or drugs at the time?

R)elax Ever use alcohol or drugs to RELAX?

A)lone Ever use alcohol / drugs while you are ALONE?

F)orget Ever FORGET things you did while on alcohol or drugs?

F)riends/Family

Do your FAMILY/FRIENDS ever tell you that you should cut down on alcohol or drugs?

T)roubles Ever gotten into TROUBLE while using alcohol or drugs?

Screening for Comorbid Conditions

• Mood problems– “Any problems with your mood?”– “Any problems with (sleep, interests, energy, concentration, appetite,

thoughts that life isn’t worth living)?”

• Anxiety problems– “Any problems with anxiety?”

• Psychosis – “Do you ever see things that others can’t see?” “Do you ever hear things

that others can’t hear?” “Is there anyone out to harm you?”

• ADHD– “Any troubles focusing or paying attention at school?” “Any troubles

sitting still in class?”

• Behavioural, legal or other problems – “Any legal problems?”

Diagnosis

Diagnosing Alcohol Abuse/Dependence

• Abuse– Alcohol use that causes problems

• Dependence– Alcohol use that causes problems plus signs

of physiologic dependence (such as tolerance, withdrawal)

Diagnosing Substance Abuse/Dependence

• Abuse– Alcohol use that causes problems

• Dependence– Alcohol use that causes problems plus signs

of physiologic dependence (such as tolerance, withdrawal)

Interventions

Therapeutic Alliance

The relationship, connection (i.e. attachment) between the patient

and physician

Therapeutic Alliance

• We all know its important, but exactly what is it?

• Q. What is the most important component of the therapeutic alliance?

77

Video Clip from Good Will Hunting: Trust…

78

Case Example: World War II

VERSUS

ALLIES

AXIS

Stalin (Russia) Truman (USA) Churchill (UK)

VERSUS

Hitler (Germany) Mussolini (Italy)

Q. What was this alliance based on?

Stalin (Russia) Truman (USA) Churchill (UK)

Therapeutic Alliance

• We all know its important, but exactly what is it?

• Q. What is the most important component of the therapeutic alliance?

• A. It depends…

83

Conclusion?

• Trust isn’t everything• Sometimes more important is…

– Agreement on (common) goals– Agreement on tasks

• Situations where there is not (yet) a good bond include:– You’ve just met the patient / client – Your patient values their Autonomy /

Independence over wanting to please you (i.e. most teenagers!)

84

Bordin’s Alliance Concept

• Agreement on Goals– Goals comprise the desired outcome

• Agreement on Tasks– Tasks comprise the specific therapy activities that will lead to

the desired outcome

• Bond– Attachment between the Therapist-Patient (e.g. Warmth,

Empathy, Genuineness)(Bordin, 1973)

What if my patient gives me an unhealthy goal?

• Underneath every unhealthy goal is ultimately a healthy one…

• Patient: So what if I cut?• Healthy goal: To feel better• Patient: I’ve had thoughts of killing myself, I can’t take it

anymore. • Clinician: What makes you want to kill yourself?• Patient: I’m depressed all the time, and I just want to stop

feeling like this. And my parents just fight all the time. • Clinician: What if we could find a way to help your mood?

And perhaps help your parents not fight all the time?

What if my patient gives me an unhealthy goal?

• Underneath every unhealthy goal is ultimately a healthy one…

• Keep asking “What makes you (cut yourself, do drugs, play video games, etc.)?” until you find a healthy goal

• If patient says “I don’t know”, ask about universal, default goals– Feeling better– Feeling connected (to peers, parents, or others)– Dealing with a stress

What if my patient gives me an unhealthy goal? Self-cutting

• Self-cutting– Patient: So what if I cut? Lots of kids cut.

• Q. What do you say?– A. Clinician: I agree, you should keep cutting.– B. Clinician: What makes you want to cut?

What if my patient gives me an unhealthy goal? Self-cutting

• Self-cutting– Patient: So what if I cut? Lots of kids cut.

• Q. What do you say?– A. Clinician: I agree, you should keep cutting.– B. Clinician: What makes you want to cut?– Patient: It takes away the pain, and I feel less

anxious after. – Clinician: I agree, we need to find a way to help

you to take away the pain, and help you feel less anxious.

What if my patient gives me an unhealthy goal? Suicidality

• Suicidal ideation – Patient: I’ve had thoughts of killing myself, I

can’t take it anymore. – Clinician: What makes you want to kill yourself?– Patient: I’m depressed all the time, and I just

want to stop feeling like this. And my parents just fight all the time.

– Clinician: I agree, we need to find a way to help your mood. And we need to find a way to help stop your parents from fighting all the time.

Suicidal ideation: What’s the healthy goal

• Suicidal ideation – Patient: I’ve had thoughts of killing myself, I

can’t take it anymore.

• Q. What do you say?– A. I agree, you should kill yourself. – B. Clinician: What makes you want to kill

yourself?

What if my patient gives me an unhealthy goal? Suicidality

• Suicidal ideation – Patient: I’ve had thoughts of killing myself, I can’t take it

anymore.

• Q. What do you say?– A. I agree, you should kill yourself. – B. Clinician: What makes you want to kill yourself?– Patient: I’m depressed all the time, and I just want to stop

feeling like this. And my parents just fight all the time. – Clinician: I agree, we need to find a way to help your

mood. And we need to find a way to help stop your parents from fighting all the time.

Interventions in the Primary Care Office

Is there really much that I can do in a 15-minute

appointment?

Brief interventions can make a difference

• Evidence suggests that brief interventions result in greater reductions in alcohol consumption and heavy drinking days compared with usual care (Jones, 2012)

• Primary goal is to prevent or reduce alcohol use

Brief Interventions

• Duration: 5-15 min.• Number of sessions: 1-4; the more the

better.• Clinicians: Primary care physicians• Target population: Those who score

positive on CRAFFT

Jones, 2012

Brief Interventions

• Express concern– Be empathic, and explain your concerns about

alcohol use

• Provide feedback linking drinking to health– Describe how drinking might affect health and

safety• E.g. Mixing alcohol and drugs is dangerous• E.g. Unwanted sex (or sexual abuse) is more likely

to happen after drinking alcohol or using drugs, or being around those who are drinking or using drugs

Brief Interventions

• (Tentatively) offer advice, as opposed to giving it – Do not drink and drive– Do not ride in a car driven by someone who

has been drinking or using drugs – Help the youth with what to say and do if

• Offered alcohol or drugs • Offered a ride driven by someone who has been

drinking/using drugs

Brief Interventions

• Elicit response, assess readiness to change, and support goal setting, if ready– Support patient in selecting a goal– Goals depend on their stage of change

• Pre-contemplative and Contemplative– Monitoring, such as filling out drinking diary– Identifying triggers

• Action– Decreasing/stopping drinking

Brief Interventions

• Offer to refer to an addictions or mental health professional

Core principles in working with youth with addictions (or any negative behaviours)

Case

“So what? Everyone does weed. After all, Justin Trudeau does it.”

Clinician Role Play

• A busy family physician is seeing a youth brought in for negative behaviours (i.e. substance use)

Debrief

• Q. How successful was this clinician in having the youth do what the clinician wanted?

• Q. Why was this?

Strengthening attachments: For resiliency and treatment

Detaching youth from substance use, and reattaching to healthy adults, using common sense principles from Neufeld,

Hughes, Segal

Britney’s mother

“I know attachment is important, but isn’t it the most important when your kids are young? Now that she’s a teen, isn’t it too late?

Classic view

• Attachment as a fixed foundation for the future… all built in a child’s early years

Good news…

• Attachment is more like bathing – you have to keep up with it…

Britney’s mother

“I heard family dinner is important. I always try to eat dinner with my daughter.”

How Family Dinners Really Help

• Eating dinner is correlated with good attachment, but it is not eating dinner per se

• Ask yourself: – Does the child turn to parents for needs? (i.e. as

opposed to primarily relying on peers/drugs)?– Does the child turn to parents for emotional

needs? (e.g. expressing feelings, allowing parents to soothe difficult feelings, as opposed to relying on peers/drugs)

Neufeld’s Six Stages of Attachment: A way of seeing how close a relationship is (i.e.

how well attached)

Britney’s mother

“But I am close to my daughter. We eat dinner together every night. I still don’t understand why she doesn’t listen.”

Britney’s Story

Yes, I do spend a lot of time with my mom, but I can’t talk to her… She worries too much… She nags me and lectures me… Nothing is ever good enough for her.

How connected are you to your child?

• Do you and your child 1. Spend 1:1 time together?2. Have things in common?3. Prioritize each other’s relationship over other

competing distractions and relationships?4. Enjoy doing things and being helpful for each

other?5. Express affection to each other?6. Does your child openly come to you to share

feelings, and do you validate/support your child unconditionally?

Neufeld’s Six Stages of Attachment, 2005

Deep relationships are better than shallow

Deep relationship• E.g. “I spend time with my dad,

we have lots in common, he puts me first, he always tells me he love me, and I can tell

him anything.”

Shallow relationship• E.g. “I spend time with my dad, but

can’t talk about anything with him”

The Most Powerful Strategy to Connect: Empathy and

Validation

Empathy and Validation

• Every one has the core need to feel loved and accepted no matter what• No matter how they are feeling• No matter how successful/unsuccessful• No matter how good/bad• No matter how smart/dumb, etc…..

• Parents can and need to be able to meet this need better than a child/youth’s peers

Even your spouses can’t meet this as well as only parents can…

For the men in the room…

• Your girlfriend/wife/female friend tells you a problem she is having with a co-worker at work…

• Q. Most of the time, what does she want? 1) Your brilliant advice2) Your listening, validation and support

Listen for feelings, accept and validate (Connection before Direction)

SOOTHE “We’ll get through this…” “How can I support you?” “Do you want me to listen?” “Or do you want some advice?”

EMPATHIZE “I can see that you’re feeling really sad about this…” (giving supportive hug)

VALIDATE/ACCEPT “That’s okay if you’re feeling sad…”

Avoid advice, minimizing, invalidating

“You’re feeling sad about that? Come on, there’s a lot worse things than that… Don’t worry about it…Don’t cry…There’s a lot of fish in the sea…”“You need to just get over this…”

Crying is good because parents can then provide comfort

• When your child is upset, explore your child’s feelings so that your child can ‘grieve’ about whatever the stress is

• Crying with a parent is therapeutic:

1) It helps your child’s brain process the sadness

2) It helps your child see that s/he can turn to you for support

Empathy and validation: Connection before direction

• Its Tuesday after a long weekend, and you need a favor from a co-worker; your co-worker could say no

• Q. What do you say?

A. “I need you to do this for me right now!”

B. “Good morning!” “How’s it going?” “How was your weekend?” “How are the kids doing?”

Other ways to connecting based on Neufeld’s Stages of

Attachment

Spend 1:1 time with your child

▪ Invite your child to spend 1:1 time with you

▪ Have “dates”▪ 1:1 time encourages deeper

communication and connection

▪ Example▪ Car rides together (good) ▪ Going for a hot chocolate

together (better!)▪ Warning sign is a youth that

doesn’t want 1:1 with a parent

Connect through things in common

• We feel closer someone when we are similar or have things in common

• Find things in common with your child, such as

– Interests and activities…

– Shared memories– Warning sign is a youth that

wants nothing in common with parents

Prioritize your child

• When you are with your child, show your child that you value your attachment to your child over your cell phone, email, texting and other distractions…

• Warning sign is a youth that does not prioritize parent, or vice versa

Cats in the Cradle, Cat Stevens

Be helpful and useful to your child

• Counter the tendency in Western society to encourage kids to be overly independent and not need us anymore

• You WANT your child to be dependent on YOU

• You do not want your child to be overly dependent on others, or turning elsewhere…

Be helpful and useful to your child

• Surprise your child every once in awhile by doing things that your child should be able to do on their own– Driving them– Helping when they are short on time– Picking up stuff they need, etc.

• Warning sign is a youth that refuses help or being dependent on parents

Express love and affection

• Harlow’s monkey experiments showed that monkeys required physical affection for development

• Children and youth need affection, both physical and emotional

• Warning sign is a youth that refuses affection from parents

Attachment Strategy:Bridge Separations by Talking about the

Reunion

Q. You’re just had a great date with someone, and you want to see the other person again… What do you say?

1) “I had a wonderful time. Bye!”, or

2) “I had a wonderful time. Want to get together on the weekend?”

Whenever there is a separation, talk about the next reunion

• If you as an adult would feel insecure about a lack of bridging, then think how insecure a child would feel...!

• Children naturally feel more insecure because they are still forming their primary attachments with caregivers…

ChildAdult

Neufeld, 2005

Whenever there is a physical separation, talk about the next reunion

• Before your child leaves for school– Parent: “See you after school” “Can’t wait until we go for our

walk later after school” – Text your child during the school day – Give your child transition objects, e.g. notes in your child’s

lunch box; special jewelry or possessions

• Before parent leaves for an errand– Parent: “See you in an hour”

• Before bedtime:– “See you in the morning” “What do you want for breakfast?”

Neufeld, 2005

Whenever there is an emotional separation, talk about the next reunion

• Parent: – “I really can’t let you talk to me that way. It is unacceptable. You

need to go to your room and cool down.” (or, if that isn’t going to happen, “I need to go to my room and cool down.”

• Bridge the separation – “Let’s get back together in 20 minutes if we’re both calmer

then”– “I love you; we’ll talk about this later and work it out.”

Neufeld, 2005

When there is a reunion, ensure there is a greeting

• When the child wakes up in the morning– “Good morning!”

• When child comes home after school– “Hello!” “Good to see you!” – “I was thinking about you doing your presentation when I was

at work today”

• When parent sees child after a longer than usual absence– “I missed you so much” “I was thinking about you” “It wasn’t the

same with you gone”

Neufeld, 2005

Management and Intervention

Motivational Interviewing and Stages of Change

Recognizing Readiness to Change and Matching Tasks to Goals

What is motivational interviewing?

• Powerful way of interviewing patients used originally for substance use and addictions

• Can actually be used for any negative behaviours (where patients don’t think they have a problem with their behaviour)

• E.g. – Self-Cutting – Eating disorders– Unhealthy behaviours in chronic conditions (e.g.

diabetes, asthma, cardiovascular, etc)

How does change occur?

• Most change does not happen as a result of an expert physician giving brilliant advice

• Most people who change their addictive behaviors do so on their own, with no formal treatment

• Those who change go through the same sequence of change stages, whether or not they received help

• “Resistance” / “non-compliance” arises from strategies that are inappropriate to the client’s stage of change

Stages of Change

Contemplation

Relapse

Precontemplation

Maintenance

Action

“Connection before Correction”

• Perhaps the most important is keeping the relationship between the patient and the physician

• If you can’t change ‘em, then book a follow-up!• Q. What keeps patients coming back?

– A. Feeling judged and criticized– B. Feeling accepted and validated

“Connection before Correction”

• Perhaps the most important is keeping the relationship between the patient and the physician

• If you can’t change ‘em, then book a follow-up!• Q. What keeps patients coming back?

– A. Feeling judged and criticized– B. Feeling accepted and validated

Precontemplation

Contemplation (towards agreement on goals and tasks)

Relapse

Precontemplation (no agreement on goals

and tasks)

Maintenance

Action (agreement on goals, and possibly goals)

Precontemplation

• Patient is not considering change, and does not recognize the need for change

• The youth does not agree with clinician (or parents’) goals for change

• Example– Patient: “Yes, I smoke pot. I don’t have a

problem. I feel better and focus better on it.”

Precontemplation

• Q. Does this teen look ready to stop smoking pot?

• Q. What is this teen’s likely response when the clinician says… “You should stop…”

Talking with the Precontemplative Teen

• Goal: – Get the patient to think about change– Be non-judgmental and accepting (i.e. forming a

relationship/attachment with the patient), so the patient comes back

• Clinician– “What do like about smoking?” “What don’t you like?”– “What warning signs would tell you the pot is a

problem?”– “Have you tried to change in the past?” “Why?”– “So it sounds like pot is one of the few ways you have

to cope with all the stresses right now” – “The door is always open if you want to talk about this

later”

Principles of working with Precontemplation

• As physicians, we are used to people following our brilliant advice

• In addictions work, we have to hold back, and resist the urge to be the all-knowing physician

Contemplation

Contemplation (towards agreement on goals and tasks)

Relapse

Precontemplation (no agreement on goals

and tasks)

Maintenance

Action (agreement on goals, and possibly goals)

Contemplation

• Patient is considering change, but the person is not ready to commit to change

• There is not yet agreement on goals (and hence not tasks)

• Example– Patient: “Yeah, I’d probably save a lot of

money if I didn’t waste it on weed. But right now, things are too stressful, and I’m not ready to cut back.”

Talking with the Contemplative Teen

• Help the patient examine benefits and barriers to change

• Examples:– “In what way do you want things to change?”– “Why do you want to change at this time?”– “What is your goal?”– ”What would be some of the good things

about making a change?” “What would you miss if you made this change?”

– “What would keep you from changing at this time?”

– “What might help you with that aspect?”

Talking with the Contemplative Teen (cont’d)

• “It sounds like things can’t stay the way that they are now, what are you going to do?”

• “How would you like for things to turn out for you, ideally?”

• “What are your options?”• “What things have helped in the past to

change?”• “what change could you make before your next

visit?”

Contemplation (towards agreement on goals and tasks)

Relapse

Precontemplation (no agreement on goals

and tasks)

Maintenance

Action (agreement on goals, and possibly goals)

Action

• Person is actively wanting to change, they are ready, willing, and able

• There is agreement on the goal of change, and (possibly) agreement on tasks

• Example– Patient: “I really need to stop using. Can you

help me with this?”

Approach to Action Stage

• “What supports do you have in place for this change?”

• “Have you set a quit date?”• “How do you see things in 1 month, 3

months?”• “Where will you be going for counselling?”• “How about I see you in two weeks so that

you can tell me how the program is going?”

Approach to Action Stage

• There is agreement on the goal of change, but remember to collaborate on coming up with the tasks

• Examples– Clinician: “Its great that you want to stop using

marijuana. How would you like to go about doing that?”– Clinician: “Its great that you want to find some other

ways to cope. What other ways have you thought about?”

– Clinician: “How can I be helpful and support you in this?”

Contemplation (towards agreement on goals and tasks)

Relapse

Precontemplation (no agreement on goals

and tasks)

Maintenance

Action (agreement on goals, and possibly goals)

Maintenance

• Person is adjusting to change, and acquiring and practising new skills and behaviors that support the change

• Example– Patient: “I’m off weed right now. Its not easy,

but I’m trying my best. I don’t want to disappoint my parents or my girlfriend.”

A core therapeutic factor in Motivational Interviewing is thus Empathy, Validation,

and Acceptance

Empathy, Validation and Acceptance is the core of Healthy Attachment, which

is the strongest resiliency factor for

Addictions and Mental Health in

General…

Q. Coincidence?

A. Of course not!

Its all about ATTACHMENT

Attachment Call to Action for Parents

Spend 1:1 with your childConnection before connection (by listening,

accepting, validating, and ideally avoid giving advice or judgment)

Give hope by bridging all separations▪ Every time a parent leaves a child, whether

physically or emotionally, talk about the next reunion with the child

Unplug and limit negative media messages

Neufeld, 2005; Hughes, 2009

Attachment Call to Action for Society

Family friendly media– Culture/media that promotes parents as

more important than peersFamily friendly workplace policies

– On-site daycare, flex time, job sharing, temporary/permanent part-time, telecommuting, mandatory parental leave, family medical leave, family health benefits

Family friendly government policies

Review of Objectives

• This presentation will review:1. How to screen for youth with alcohol/drug

problems

2. How to help youth in the office using motivational interviewing and interpersonal strategies, with a focus on…

3. How to empathy, validation and unconditional acceptance is perhaps the most powerful way to reconnect youth to parents and vice-versa

References and More Information

References and More Information

eMentalHealth.ca: for information about mental health and help…

Questions?