Let’s Start with Understanding
Substances and their Use
• Neuro-physiology of substance use --- the “Vulnerable
Brain” versus Genetics
• Cultural meanings and experiences over time
– As a culture, we are ambivalent and confused
• Not all use ends in addiction --- all misuse WILL impact
the overall functioning of the Brain
– We know (and our kids know) many who use and do not
develop difficult --- problem-full lives
• Personal experiences of adults --- often make it difficult
to take a stand on these issues
• Drugs Work!!! And then they Don’t!!!! Sometimes!!!!
Understanding Addiction
ASAM New Definition (8/11)
• Addiction is a primary, chronic disease of brain
reward, motivation, memory and related
circuitry. Dysfunction in these circuits leads to
characteristic biological, psychological, social,
and spiritual manifestations. This is reflected
in an individual pathologically pursuing reward
and/or relief by substance use and other
behaviors.
• Addiction is characterized by:
–
–
–
–
Inability to consistently abstain;
Impairment in behavioral control;
Craving;
Diminished recognition of significant problems with
one’s behaviors and interpersonal relationships; and
– A dysfunctional emotional response.
• Like other chronic diseases, addiction often
involves cycles of relapse and remission.
• Without treatment or engagement in recovery
activities, addiction is progressive and can result
in disability or premature death.
ABC’s of Addiction
– Inability to consistently Abstain;
– Impairment in Behavioral control;
– Craving, or increased ‘hunger’ for drugs or
rewarding experiences;
– Diminished recognition of significant problems
with one’s behaviors and interpersonal
relationships; and
– A dysfunctional Emotional response.
4 C’s of Addiction
1. Compulsive engagement in addictive
behavior --- preoccupation with it;
2. Impaired Control over the behavior --- even
when desired to have control;
3. Continue to engage in addictive behavior
despite significant negative consequences;
4. Cravings --- experience dissatisfaction,
irritability, or intense craving when the object
of the addiction is not available.
4 “Neuro-Networks” Involved in
Addiction
• Opioid Apparatus (Brain’s natural narcotics --- pain
manager/soother/not take it away, dull the conscious
experience of it --- endorphins)
• Dopamine System (performs incentive-motivation activities
(reinforcements for behaviors) as well as reward --- intense
emotional experiences of elation/desire)(the Limbic System
or Emotion Center of the Brain)---creates “mental
cues/cravings/triggers for use
• Self-Regulation System (OFC --- Orbitofrontal Cortex)
Executive functioning, social behavior, regulation of
emotions, impulse control, decision-making.
• Stress-Response Mechanisms of the Brain (excessive
amounts of the hormone cortisol and/or adrenaline) --becomes reliant on substances for self-soothing and
managing stress. Sets stress thresholds…
Change
and the
Addictive Process
The Stages of Change Model
Contemplation
Preparation
Action
Maintenance
Relapse
Progress
Precontemplation
Stages of Change Model
Precontemplation
Increase Awareness
Contemplation
Motivate & increase
self-efficacy
Relapse
Assist in coping
Preparation
Negotiate plan
Maintenance
Reaffirm commitment
Active problem solving
Action
Implement Plan
F/U
Termination
PreContemplation
• Substance using persons are not considering
change and do not intend to change behaviors in
the foreseeable future.
• They are most likely unaware that a problem
even exists, that changes need to be made
• They may be unwilling or too discouraged to
consider change.
• Most, at this point, have not experienced adverse
consequences or crises because of their use and
often are not convinced that what they do is
problematic or risky.
Contemplation
• Awareness is increasing and the individual begins
to perceive that there may be cause for concern
and reasons to change.
• Typically, there is much ambivalence at this stage,
simultaneously seeing good reasons to change
AND good reasons to not change.
• People here are still using, but may be
considering cutting back or stopping in the future
• It is not uncommon for people to remain at this
stage for long periods of time --- held in the grips
of ambivalence and fear.
Preparation
• Here, an individual becomes aware that the advantages of change
outweigh the advantages of maintaining the status quo.
• Commitment to change is strengthened as the person engages in
thinking about the very real possibility of change and altering
addictive behavior.
• The person actually begins to consider what steps they may need to
take in order to accomplish change.
• One does an analysis of capabilities, willingness, and desire for
change.
• They may already be attempting to alter addictive behavior and/or
may decide to ask for help.
• They begin to consider and choose specific goals and make
commitments to themselves to stop using.
• Telling others about these developments may be important.
Action
• A change strategy had been developed and the person is ready and
able to engage in the plan.
• People are engaged in actively modifying their behaviors, thoughts
and relationships with the addictive behavior.
• Person is engaged in treatment, or is actively exploring and
increasing their sense of personal agency.
• People recognize areas of strength as well as areas needed for
growth…may participate in skill building groups and/or recovery
support groups.
• One-to-one therapy may also be a choice for some.
• The person is actively not only ;earning about themselves as a
sober person, but developing their own skill set and self-efficacy.
• It would be important for relevant staff at school to know whether
or not an individual is in active treatment…so that a support plan
can be negotiated between the student, family, treatment provider
and key school staff.
Maintenance
• Efforts are being made to sustain the gains achieved during
the action stage.
• People here work to maintain sobriety and prevent
recurrence.
• Individuals learn to recognize and react to people, places or
things that may “trigger” cravings or relapse.
• People may choose to participate in some form of recovery
support (e.g. AA or therapy) as a way of scaffolding new
personal developments.
• Relapse is viewed as part of the learning process and not
seen as defeat…people re-group and make an effort to
move forward.
• Important to think about child/student returning to
community after a round of treatment --- building
adequate supports and strategies are vital both in the
home and at school.
Relapse
• Most people DO relapse at some point, this is not to
say we should expect it and support it.
• For many, this requires a return to a previous change,
for re-evaluation of self and the importance of change.
• Relapse also provides valuable information that one
can use in order to return to and further sustain
change.
• Providing support and re-assurance is important,
relapse is often experienced as a failure and may
contribute to the erosion of belief and self-efficacy.
Stages of Change – Parent/Teacher Tasks
Stage
Tasks
Precontemplation
Raise doubt – Increase awareness of
risks of current behavior
Contemplation
Tip the decisional balance – Evoke
reasons for change; risks of status quo;
strengthen self-efficacy
Preparation
Assist in developing a change plan
Action
Help person implement the plan; use
problem solving and support selfefficacy
Maintenance
Develop relapse prevention strategies;
resolve associated problems
Relapse
Recycle through earlier stages; alter
action plan; avoid demoralization
As the degree of mismatch increases between yourself and the person in
readiness for change, the likelihood of resistance increases proportionately.
Your
Viewpoint
Other
person
Differing viewpoints on readiness for change.
10 Processes of Change
 Coping activities or strategies used by people in
their attempts to change
 Each change process is a broad category of coping
activities which encompasses multiple techniques,
methods and interventions
Two Main Types of Change
Processes
Cognitive change processes
Involve changes in the way people think and feel
about their use of substances
Behavioral change processes
Involve people making changes to their using
behavior
5 Cognitive
Processes
Consciousness Raising
Increasing information about yourself and substance
use/abuse
e.g. - thinking about health effects of substance use
- a teacher/parent asking whether you use
alcohol or drugs
- thinking about physical, social, academic,
familial consequences of use
- learning more about addiction and the process
of addiction (health class, from recovering
friends, other trusted resources)
Dramatic Relief
Experiencing strong emotional reactions to events
associated with substance use/misuse
e.g. - seeing the effect of substance abuse on the life of a
close friend or relative
- experiencing a profound consequence either
yourself or via a close friend, that really moves you
(e.g. a drug overdose, police arrest, death)
Environmental Re-evaluation
Becoming aware of the impact of the problem behaviour
on others
e.g. - thinking about the effects of substance
use/abuse on your family and friends
- recognizing negative consequences and/or
symptoms of abuse in other people
- increase awareness of how use and the
consequences of use --- having been limiting
possibilities for life
Self-Re-evaluation
Affective and cognitive re-experiencing of one’s self and
problems
e.g. - thinking that you’re no longer happy
being a drug/alcohol user...just not worth it
any longer
- imagining yourself as a non-drug user
- the pro’s of not using outweigh the pro’s of using
AND the con’s of using outweigh the con’s of
not using
Social Liberation
Noticing and using social conditions that support personal
changes
e.g. - participation in sober activities
- connection with more and more sober friends
- active participation in recovery support
programs, like AA
- new-found ability to stand your ground and
pursue life goals without being hindered by
substance use issues
5 Behavioural
Processes
Self-Liberation
Belief in your ability to change and commitment to act
on that belief
e.g. - telling yourself that you can using substances
- setting a quit day
- telling others you’re quitting
Helping Relationships
Trusting others and accepting their support in
quitting
e.g. - asking a friend who used to use for
help
- working with a substance abuse counselor or
getting an AA sponsor
- participating in school-based support groups
Counter Conditioning
Replacing drug/alcohol using with more positive
behaviours and experiences
e.g. - “Do something else”
- develop a wide range of activities that
promote physical, emotional and social
health
- develop a range of coping skills for
stress, anger, depression, anxiety,
excitement, controlling impulses, etc.
- develop a repertoire for solving- problems and
making healthy decisions
Reinforcement Management
Rewards for maintaining sobriety
e.g.
- the family/friends showering you with praise
- buying yourself something you want
- telling yourself how wonderful you are --acknowledging and celebrating your
achievement
Stimulus Control
Avoiding or countering stimuli that elicit the problem
behaviour
e.g. - recognizing behavioural, situational, certain
people --- that “trigger” addictive behaviour
and having a plan for dealing with them
Relationship between Processes and
Stages of Change
Cognitive change processes help people to move
through the early stages of change
(e.g. from not thinking about quitting to
deciding to quit)
Behavioural change processes help people to
move through the later stages of change
(e.g. from making a quit attempt to staying
quit)
MOTIVATION
AND
CHANGE
• Let’s look at your own experiences.
– What has motivated YOU to do the things you
have done?
– What has Un-Motivated you?
– What has motivated you to make changes in your
life --- changes that you did not necessarily want
to make, changes that you did not necessarily
believe you could make, changes that you initially
had no intention on making?
Major Components of Motivation
• Motivation can be either extrinsic or intrinsic.
1. Activation --- making the decision to initiate
certain desired behaviors or setting specific
goals.
2. Persistence --- continued effort toward achieving
the goal or target behavior, even though
obstacles exist.
3. Intensity --- concentration, commitment and
energy that is dedicated towards engaging in the
objectives and activities that will lead to goal
accomplishment.
• Inherent challenge in motivating substance
users to look at their use and consider making
changes:
– Motivation is unique and entirely a personal
dynamic --- what motivates one person most likely
will not work for another --- what is important to
the individual?
– Motivation for this kind of change, ideally, comes
from within --- intrinsic --- in order for the process
to be successful.
– Inherent in creating motivation is RESISTANCE and
AMBIVALENCE --- how we react to or position
ourselves in relation to resistance and
ambivalence WILL make all the difference.
From One Parent to Another
“ People only listen to one person --- themselves.
And, as a result, they’re only influenced by one
person --- again, themselves. So, as
frustrating as this may be for a parent who
would like to sternly say, ‘You have to stop’,
and to have that be enough, the real trick to
motivating someone is to get them to convince
themselves to make a change for their own
good reasons.”
What Does Not Work
• Telling your child/student about your feelings and how their
use is making you feel (shame/blame = defense)
• Express out and out anger at the person.
• Confront with admonitions to stop --- taking one side of the
ambivalence --- may force the other
• Humiliation in front of others – being “called out”
• Tell them YOUR reasons for why THEY have to stop
• Resistance Theory --- the more you push one way, the more
they go the other (Paradoxical Impact)
• Tough Love --- has been seen in some families to only
create a hostile adversarial context --- not very conducive
for change…shifts motives for use (possibly intensifying
them)
What Does Work
• Sharing your concern, while reminding them that you know
ultimately it is their choice.
• Exploring with them reasons they might want to stop, as well as
reason why they may not want to stop (Decisional Balance)
• Simple statements of love and concern
• Establishing clear and reasonable boundaries
• Consistently enforcing boundaries with both positive rewards and
negative consequences.
• Affirming and validating the person’s efforts regardless of use
• Exploring the person’s wants, desires, hopes and dreams, intentions
and preferred ways of being in the world --- what is most important
to you and why.
• Affirming the person’s hopes and dreams and collaborating on
making them come to fruition --- creating partnerships – may not
even be talking about use at this point.
And Then…
• Given that the Brain and many of it’s key
operations for making decisions, regulating
emotions, knowing emotions, memory,
impulse control, reward circuits, pain
management (emotional as well as physical) -- are rendered dysfunctional by substance use
and addictive behavior --• You may need to act!!!!
• May be able to wait for motivation
• Fair but firm boundaries and consequences are
more effective than harsh discipline or
inconsistent discipline --- in motivating people.
• Know where you truly stand on the issues of
substance use --- hopefully informed by current
research and not influenced by your own history -- attitude check --- mixed messages from parent
as well as from teachers.
• Be able to communicate clearly your rationale for
wanting your child/student substance free (if you
are stuck…go to the Brain research --- 15 years
old versus 19)
MOTIVATIONAL
INTERVIEWING
• Motivational Interviewing is a directive, personcentered counseling style that enhances
motivation for change by helping people clarify
and resolve ambivalence about behavior change.
• The goal of motivational interviewing is to create
and amplify the discrepancy between present
behavior and broader goals.
Create Cognitive Dissonance Between
Where one is now
Where one wants to be
MI Philosophy
1. Person’s resistance typically is a behavior evoked by
environmental conditions.
2. The relationship should be as collaborative and
friendly as feasible given the intensity of the situation.
3. Motivational Interviewing gives priority to resolving
ambivalence.
4. The teacher/parent does not prescribe specific
methods or techniques…kids are free to choose
strategies they feel might be most useful. (“what can
you do?”)
5. People are responsible for their own progress
6. MI focuses on the person’s sense of self-efficacy.
The SPIRIT of Motivational Interviewing
1. Motivation to change is elicited from the person and not
imposed .
2. It is the kid’s task, not the teacher’s or parent’s, to articulate and
resolve ambivalence.
3. Direct persuasion is not an effective method for resolving
ambivalence and increasing motivation to change.
4. The conversational style is generally a quiet and eliciting one.
5. The tescher/parent is directive in helping the client examine and
resolve ambivalence.
6. Readiness to change is not an individual’s trait, but a fluctuating
product of interpersonal interaction.
7. The therapeutic relationship is more like a partnership or
companionship than expert/recipient roles.
3 Fundamental Aspects of the Spirit of
Motivational Interviewing
~ACE~
Autonomy --- this is the kid’s
life/treatment…they make key decisions.
Collaboration --- Partnership
Evocation --- the counselor’s/teacher’s/parent’s
job is to evoke and elicit motivation for
change!
The Spirit of Motivational Interviewing
Confrontation
Collaboration
Evocation
Autonomy
VS.
Education
Authority
Motivational Interviewing Assumptions
1. Motivation is a state of readiness to change,
which may fluctuate from one time or situation
to another…which can be influenced.
2. Motivation for change does not reside solely
within the user.
3. Each person has powerful potential for change.
The task of the teacher/parent is to release that
potential and facilitate the natural change
process that is already inherent in the individual.
4. The way we approach the person is a
powerful determinant of resistance and
change. An empathic style is more likely to
bring about self-motivational responses and
less resistance from the person.
5. People struggling with behavioral problems
often have fluctuating and conflicting
motivations for change, also known as
ambivalence.
6. Ambivalence is a normal part of considering
and making change and is NOT pathological.
5 General Principles in
Motivational Interviewing
DEARS
Develop Discrepancy
Express Empathy
Amplify Ambivalence
Roll with Resistance
Support Self-Efficacy
Develop Discrepancy
 Awareness of consequences is important.
 The kid rather than the parent/teacher, should
present the arguments for change.
 Exploring and Highlighting the discrepancy
between behaviors and goals, motivates change.
 Change occurs when people perceive a discrepancy
between where they are and where they want to be.
 Examination of the discrepancy between current
behavior and future goals/preferences/desires.
 Ultimately, you want to have the kid themselves present
reasons for change.
 Avoid pushing or arguing with the person in an attempt
to convince them of discrepancies in their thinking.
Develop Discrepancy
• The counselor/parent/teacher seeks to create
and amplify, from the kid’s perspective, a
discrepancy between present behavior and his
or her broader goals and values until it
overrides the inertia of the status quo.
Develop Discrepancy
Explore goals and values with which substance
use may conflict:
Long term recovery goals
Values
Dreams
Past preferred activities
Admired people
Develop Discrepancy
• Person’s verbalization of negative
consequences amplifies discrepancy.
– Payoff matrix/decisional balance exercise
Using Substances Not Using Substances
Advantages
Disadvantages
Decisional Balance
• Decisional balance is the importance a person
gives to the perceived advantages (pros) and
disadvantages (cons) of smoking, and of
quitting
• An individual’s motivation to change is
affected by his/her decisional balance
Expressing Empathy
Convey a your appreciation that person’s behaviors make sense
given their context and the their current way of thinking about
them.
•
•
•
•
•
•
•
•
Acceptance facilitates change
Ambivalence is NORMAL
Skillful reflective listening is fundamental.
Warmth
Openness
Personal Value
Understanding
Which means managing our own feelings, reactions, wants and
desires for the student/child
Express Empathy
Tips…
Good eye contact
Responsive facial expression
Body orientation
Verbal and non-verbal “encouragers”
Reflective listening/asking clarifying questions
Avoid expressing doubt/passing judgment
Amplify Ambivalence
 Ambivalence is Normal.
 Exploring ambivalence helps remove obstacles.
 Resolving ambivalence moves towards behavior
change.
 “Ambivalence cannot be forced into resolution --It must be amplified and explored so that its
fruits can be used to feed the process of change”.
(Miller)
Roll with Resistance
Use momentum to your advantage.
We do not want to fight the resistance.
Resistance is not directly opposed.
Avoid arguing for change and/or direct
opposition.
 New perspectives are invited but not
imposed.
 The student/child is a primary resource in
finding answers and solutions.
 Resistance is a signal to respond differently.




Support Self ~ Efficacy
 Believing that change is possible is an important
motivator.
 Research shows that the our belief in the other’s
ability to change --- can be a significant
determinant of treatment outcome, “a selffulfilling prophecy”.
 Refers to a person’s belief in his or her ability to
carry out or succeed with a specific task.
Six Key Elements in the Process FRAMES
•
Feedback: Provide useful feedback based on what you see and what you notice in terms of
consequences. People are motivated to change when they get feedback on their personal
situation.
•
Responsibility: Rather than telling the child what she can and can't do, emphasize personal
responsibility and freedom to choose.
•
Advice: Give specific recommendations about how using patterns can be changed.
•
Menu: Provide the person with options, such as reducing drinking or abstaining. This allows
the person to be involved in the decision-making process and thus more willing to change.
•
Empathy: Being warm, supportive, sympathetic, and attentive will be more motivational than
being confrontational and aggressive. Show an understanding of the person's goals and the
role of alcohol/drugs in her life. This will help you identify ways to help her make changes.
•
Self-Efficacy: The person must believe that she can change. Convey the message, "You can
change." Encourage optimism.
What to Do for Educators
1.
2.
3.
4.
5.
6.
7.
8.
9.
Approach your students with empathy and concern.
State your intentions from the onset.
Be prepared to point out specific situations and specific behaviors
that have shaped your concern for the student.
Do not confront or blame/shame --- rather share your thoughts.
Ask open-ended questions, attempting to gain a better
understanding as to what may be going on in the student’s life.
Listen --- hold your advise for now --- Listen
Attempt to ascertain student’s biggest worries or concerns about
current situation.
Ask for advise from the student --- “what would they think might
be a good next step in order to address these issues?”
Advocate and connect student with appropriate helping staff
within the school.
What to Do’s for Parents
1.
2.
3.
4.
5.
6.
7.
First and foremost, develop a clear and consistent position on
substance use in your household. Your position should be based
on your values and one that you and your partner can and will
stand by.
Develop skills and rituals for communication long before the
crisis…it is very difficult to have positive communication once the
crisis sets in and there is no history for interacting these ways.
LISTEN before you act --- take time to digest before you react.
Avoid power struggles – tends to strengthen resistance against
change.
State your concerns and evidence calmly, caringly, attempting to
avoid anger, blaming, interrogation, etc.
Seek help for yourselves prior confronting your child --- often
having a third party help you wrap your mind around all this, could
be useful in developing a plan of action versus a plan of attack.
Ultimately, you may have to be prepared to act.
The Pro’s and Con’s of Forced
Intervention/Treatment
• Pro’s
– Need to act to disrupt addictive cycle
– Once in treatment, child could become motivated as a
result of being engaged by staff and other participants
– Child recognizes parents/teachers as authorities that
will act in order to ensure safety
– Motivation as a dynamic process --- starts with
creating an incentive or reasons for change --- being in
treatment may provide either positive or negative
reinforcement for motivation
• Con’s
– Mismatch between where the child is in terms of
stage of change and the action being taken
– Strengthens ambivalent position against change,
thus strengthening resistance for change
– Intervention on your part is viewed as and
experienced as a betrayal
– Adolescent learns how to negotiate the treatment
process and continues to use regardless of efforts
to intervene
The people in this room are some of the
greatest motivators around….
You are teachers, coaches, parents,
collaborators on many projects with many
others….
How do you inspire? Create Incentives?
Let’s Brainstorm
What’s Worked for You?