I think we can get started. Welcome, everyone. My name is Dr. Amy Neal. On behalf of the American Psychiatric Association, I'm excited to welcome you to today's webinar, Challenges in Implementing Manualized Treatment for Adolescent Substance Use Disorders. Today's activity is presented on behalf of the SAMHSA-funded Provider Clinical Support System, which is a program operated collaboratively by 19 medical specialty organizations, including the APA. Please note that following today's presentation, you will receive a follow-up email within one hour of the webinar. The email will contain instructions to claim credit for attending, and one seeming credit is available for today's presentation. Next slide. Slides from the presentation today are available in the chat area of the attendee control panel, which is at the bottom of your screen. Please click the message bubble icon to open the chat function, then select the link to download the PDF version of the slides. Slides will also be included in the follow-up email. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area, which is found on the attendee control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Next slide. Now I would like to introduce you and welcome back the faculty for today's webinar, Dr. Ifrah Kaminir. Dr. Kaminir is a child and adolescent psychiatrist and a professor emeritus of psychiatry and pediatrics at the University of Connecticut Medical School. Dr. Kaminir's main clinical interests and research lie in the spectrum of adolescent high-risk behaviors, in particular, the assessment and treatment of substance use disorders, psychiatric comorbidity, and suicidal behavior. We welcome you to today's session, Dr. Kaminir, and thank you for leading the webinar. Thank you. Happy Tuesday, everyone. This is my disclosure. I would also like to thank the chief medical examiner of State of Connecticut, Dr. Gill, and also Dr. Jane Angemach for sharing some of the slides and data with me. So this is a target audience that hopefully applies to all of you. And these are the educational objectives. There's no earth-breaking news in this specific presentation. However, it definitely will pose a challenge in planning treatment for adolescents taking into consideration adolescents' strength and weaknesses in terms of cognitive ability, emotional stability, impulsivity, sensation-seeking, and of course, attitude towards adults. So although the second half of the presentation will be relatively highly structured, the first half will address some of the challenges that we all as clinicians should be aware of and ready when we approach adolescents and enlist them and engage them in treatment. So the topics that I would like to cover, they're quite extensive, but I'll try to be effective and succinct about it, is in order to address challenges and opportunity in treatment of young people, we definitely need to address nosology and typology of the problems, specs, less disorders. We need to take into consideration patient characteristics. We need to understand how to make progress in chasing the elusive matching treatment with patient characteristics. Address some issues regarding treatment specificity versus some kind of ubiquitous support approach and understand the meaning of integrative treatment outcome. Continuity of care is a very important issue, whether you call it a one-stop shop, whether you call it aftercare, although some people don't like the term, they'd like to look at the continuity and call it continued care. Also address briefly what is adaptive treatment, which is in one line, an algorithm or decision tree that you may have to use when the adolescent is difficult to treat or the outcome is not as effective as you would like to do. And the question is, what's next? So when you look at substance use treatment, some question need to be asked, where are we going with this? We should look at the pre-treatment patient status and ask ourselves, where do we go with it in terms of present and post-treatment? Evidently, we'd like to improve the pre-treatment patient status because we need some kind of a measure or a starting point as a baseline. Treatment as compared to no treatment at all, which can be waiting list, some kind of self-help groups, meaning some help that you can get outside of the realm of the specific clinical work. What about comparison for treatment for similar disorders? For example, we have monodiagnosis such as substance abuse or substance use disorder, the way it's being termed right now of different chemical agents. But what about, for example, the majority of patients that also manifest co-occurring psychiatric disorders such as depression, anxiety, PTSD? These are the internalizing disorders and the conduct disorder, ADHD is externalizing disorder. How about comparisons between different types of treatments? Individual therapy, family therapy, group therapy, and so forth. What about the type and amount of services which include terms such as dosage and frequency? And also what are the cost factors in applying treatment in different settings? So all these factors need to be taken into consideration when you design a treatment program in general and specifically for individual patients. Now, there are some very basic questions that go back many, many years ago, and I will be citing Dr. Thomas McLaren from Penn University, one of the pioneers of treatment in the United States who developed the Addiction Severity Index. Do patients really improve after substance use treatment, as I mentioned, as compared to no treatment at all or some kind of other interventions? Are improvements specific to the target functions or the target symptoms? What exactly are we trying to improve? And to what extent are improvements due to the effects of treatment? Of course, we can ask them other questions. How well can we preserve or maintain a positive treatment outcome before relapse? And what about relapse prevention, which is part of the continuity of care? So there are a lot of questions that we will try to answer, based on what we know right now. So is one treatment or a combinational treatment superior to others? You know, it's like beauty is in the house of the beholder, and I'll get to it in a minute. Is more treatment better than less treatment? Or how much treatment do we really need until we get to the point that there is diminished return when you keep on applying more and more treatment, but you get very little for it because the patient is not gonna get any better from where he or she is right now. So it's important to compare research to practice because I believe that most of you are clinicians. Some of you hopefully have experience in some research and some of us are clinical researchers. So in terms of research, you need to make things kind of very simple. And usually the research focus on a single substance, levels of use, including peak of use. For example, in alcohol, we usually discuss days of alcohol use during the last month, but we also take into consideration heavy use of alcohol, which applies to five drinks or more for male, four drinks or more for female. In terms of adolescence, we usually reduce it by one drink, four or more drinks for adolescent male, three or more drinks for adolescent females. We would like to assess motivation for treatment. Usually we have been using manuals with fixed length of stay, usually around the 12 weeks manuals. And most of the time is single modality. In practice, we are a little bit more innovative and have more flexibility and people are using different approaches. It's almost like a buffet to some degree, a lot of cut and paste. And it's actually more challenging because research per se does not provide all the answers for the treatment we provide in practice, although it's very important to focus on the evidence-based practice, which gives us an idea what is or is not working and to what degree. Otherwise it's just an improvisation and people take the liberty of doing whatever they feel is right. And it's not always the best approach for each and every patient. So what is patient-patient matching, this elusive term? And we're looking for the identification of variables that predict the differential response, which is treatment outcome to various interventions. One of the examples, if you're interested in the mid-90s, there was a very big project called Project Match, a multi-center study that was focused at the University of Connecticut, where I'm from, but also there were participants from Yale and from other facilities. And it was really the benchmark for treatment of motivational interviewing and CBT for adults with alcohol use disorders. Patients' unidimensional factors are very important. Age, for example, difference between early adolescence, late adolescence, and adults. Gender, ethnicity, the severity of the substance use disorder, as well as co-occurring psychopathology. People measure motivation. This shows us some of the important factors that are being taken into consideration versus a multidimensional approach. So in a nutshell, no single treatment approach so far for adolescents has yet showed clear superiority at large or differentially. Some of the literature show that family therapy has been effective to some degree in some studies more than individualized therapy, but bear in mind that not every adolescent you work with has a family support system to work with. So it's a little bit more selective to conduct family therapy than to produce, to provide the motivational interviewing and CBT, which by the way, are also easier to train and are definitely less costly. It's about one third of the price of providing family therapy. Now, let's keep in mind that we have a high heterogeneity of population of patients. One size does not fit all because the picture is not similar. This is an example from a study that shows you different trajectories of response. And one of the issues, particularly working with adolescents from a developmental perspective, which could be very frustrating, adolescents are the most difficult and complex patients to work with. The main reason is that they are still in a developmental phase, that particularly the prefrontal cortex is developing in the prefrontal cortex in the area that responses to the pressure from the reward system. And when it's well developed, usually by the mid twenties, inhibition to stressors for immediate reward and pleasure from the limbic system are much better in terms of preventing or delaying negative consequences oriented behavior. When the prefrontal cortex is also responsible for abstract thinking and some kind of pragmatic approaches to deal with harm reduction. And since it's not well developed from a physiological perspective, and this is normative, we see a lot of casualties of high risk behaviors, particularly among adolescents. Another issue, and there's gonna be several slides on it, but let me just sum it now, impulsivity and sensation seeking are very high among adolescents, and particularly those who are prone to high risk behavior. And impulsivity and sensation seeking reach their peak between age 15 and 16. And when you treat substance use disordered adolescents, particularly those who will have poor, slow or no response, one of the reasons here is that they're still on a trajectory for more severe substance use oriented behavior. So it's very difficult for you to prevent this acceleration before it will plateau. And probably the relapser and the non-responder that you see on the top of the slide represents those who are still keep on developing the process of pathological behavior. So we have seen in recent research that those who are rapid responders have better prognosis as compared to later or no responders. And they kind of represent the different trajectories. And it's important, it's part of studies of biological markers to find out ahead of time, hopefully very early in treatment, who would be the adolescents who would respond faster and better to treatment. So as you can see, also our substance use treatment system is quite problematic. There's not enough resources. Not enough experts actually in the field. There's a very large and vast turnover in this field. A lot of people come and go and come and go. I do a lot of training in other places and it's always interesting. And to some degree sad to see there's always new people in the same place because people do not stay there due to a variety of reasons. From salaries to training to burnout. So a lot of our kids don't actually have the option to be referred to a place that A, is opening slots and B, is close enough geographically and C, that as the gamut of services that we would urge agencies to develop in an optimal fashion. So what are the strategies in terms of treatment? As you can see, the references look relatively old but it just shows you when things started in all earns to be taken seriously, including in research. And that was actually in the late 1980s, 1990s and early 2000. So behavioral therapy, cognitive behavioral therapy, contingency management, 12 step. some people call it the Minnesota model, motivational interviewing, that is also been terms to some degree, certain version of it, called motivational enhancement therapy, because there's a very specific manual for it. And I will address it soon when I will talk about the cannabis use treatment study that we were involved in, where some of these manuals have been developed and they're actually available to the public. Several kinds of family therapies and combination therapies, which include integrative psychosocial interventions and perhaps some medications, although medication treatment for adolescent substance use has not been highly developed and definitely not have been highly successful. So the research limitations, to go back to research, again, it does not mean we shouldn't conduct research or rely on it, but we just need to understand the rigor of research, especially when it's peer reviewed and it's difficult to get funding and it's difficult to get approval of your peers to conduct high quality research and collaboration between several centers to develop a multi-center study is usually the best possible way, because then you can have a large enough number of subjects which will provide you with enough power for data analysis. You probably also aware of all kinds of publication about meta-analysis for the same reason, to increase the power of the findings. Nevertheless, in meta-analysis, because you cluster together different studies that come from different sources and where various methodologies has been employed, sometimes you compare apple to oranges and this is definitely an approximation. So the University of Connecticut and several other universities sites here were involved in the largest study so far for adolescents with cannabis use disorders. It's called the Cannabis Use Treatment Study. The number of subjects was 600 divided by four sites and you can see Connecticut in the upper left corner. That's where we are. And we compared five different treatment approaches. And by the way, these manuals are available from SAMHSA and they are kind of very useful today, even after so many years, because they include the essence of each and every intervention. So it included a metabolism enhancement treatment in CBT of five sessions, 12 sessions, family support network, combined with MET-CBT, ACRA, which is Adolescent Community Reinforcement Approach and MDFT, which is a multidimensional family therapy, target population ages 12 to 18. So first of all, kind of to make it short, I mean, there've been a lot of publications, none of the intervention was found to be superior to other. Actually, all of them have been useful. Take into consideration that if MET-CBT five was as effective as the other interventions from cost perspective, this is definitely a very good approach. And by the way, usually when we provide CBT, most recent study shows that more than 90% of subject who would respond favorably to CBT, meaning reduce oil or stop the drug use, would get there between five to six weeks. So this is a very good news because why provide another five or six weeks of treatment to those who already responded favorably, otherwise you get a curve of diminished return. Those who have not responded well, definitely we should continue to treat them and provide some adaptive treatment or different algorithm, which may include adding dosage, changing treatment, adding another combination of psychosocial intervention or medication. But here are some of the questions that people ask. And I showed some of them in previous slides. Is more treatment or time in treatment better? Not necessarily. And I gave you the example of MET-CBT. Does the type of treatment matter? Again, not completely because what we have found and other studies have been found as well. There is definitely a specificity element to treatment, which includes what kind of manually using like MET or CBT, or in terms of individual or group therapy or family intervention or ACRA, Adolescent Community Response Approach. But also there's a very large weight given to the non-specific aspects of treatment. So it's definitely a combination of aspects. Does treatment affect the co-occurring problems? Well, based on what we did, it wasn't completely clear, but there has been improvement. And those of you who attended my presentation last month about dual diagnosis presented research that we have just finished that showed that rapid responders who have co-occurring depression, close to a third of them would respond to treatment of substance use disorder only, also by improvement of the depressive symptomatology and severity, even though there's no specific treatment for depression at that stage of the study. We show that there are several elements in cognitive behavioral therapy that address multitude of issues. And one of them is mood. Those who have not responded well needed additional treatment that were more specifically directed at the depression per se. If you're interested in these findings, you can check online some of the publication that I'm associated with, PubMed and so forth. So talking about dual diagnosis, those of you would like to look at things more from a visual perspective. As you can see, there's a lot of overlaps between mental disorders, comorbidity, alcohol disorder, other drug disorders, and comorbidity is pretty high, it's more than 70%. So you can say definitely that psychiatric comorbidity is the rule rather than the exception in terms of substance use disorder in adolescents as well as adults, by the way. And this is something that need to be addressed. Now, what do we measure when we admit an adolescent for assessment? Whether it's outpatient, inpatient, any way you look at it. We are trying to look at several characteristics that address issues pertaining to the adolescent substance use disorders, psychiatric, psychological issues, and also other domains of life. There are different ratings that can be used. One of them is a teen addiction severity index that has been translated to more than a dozen languages, which allows us to compare between different cultures and languages. So substance use, family, academic or employment, psychiatric symptomatology, peer recreational and legal status are kind of the essence of the domains that we should address. We cannot just address substance use disorder only. And I've never seen an adolescent whose only problem is substance use disorder per se. There's always one or more other issues that need to be addressed in terms of treatment management. Mentioned before, most commonly internalizing disorders that are more common among females, externalizing disorders more common among males. A small percentage, but yes, a very powerful percentage is those who have psychotic disorder spectrum, such as bipolar and schizophrenia, when the auto ratio for the use of drugs is much higher and definitely need to be taken into consideration in terms of treatment. Other behaviors to note, because we are dealing with adolescents that are not developmentally, you know, they're like work in progress under construction in terms of the brain and the prefrontal cortex. So we need to take all these factors into consideration. And I sometimes say that working with adolescents in almost like going to the shop with your car and trying to fix the engine while it's working. And that's exactly part of the difficulty of working with adolescents. It's work in progress. It's a person in progress. There's a lot of dynamic, a lot of attitude issues, and it's quite challenging to work with adolescents individually, as well as in group. There are several manuals that address these matters as well. There's some references towards the end. So one of the questions we'd like to ask once patient is in intake, and there are some structured interview that you may or may not use, but definitely the focus is on types of substances used. What was the quality, meaning the percentage? For example, THC now in cannabis is not like in the single digits. Cannabis confiscated in the street, the THC, tetrahydrocannabinol, the active ingredient that causes the high. And by the way, you measure it by weight is close to 20%. The frequency, I often use it. How you use it? It's not like with alcohol, you use it just to drink it. Now we need to deal with different ports of entry. The smoking, vaping, which is more common than smoking now. What do you smoke and what do you vape? You can vape and smoke shatter or skin emulsions that the THC concentrates in 80 to 90%. It's almost like a mind bomb. So there are different ways of using or abusing these drugs. And it's important to understand what your client is using, what is the context of use, because it gives you some idea in terms of intervention, when and where do they use, either been any kind of control of use, or it's just free floating, runaway train kind of use. Attitude and expectations from the drug, as well as from involvement in treatment, what have been so far the consequences of use and what kind of interventions have been utilized or addressed. So let's get more specifically into the interventions, particularly the most common and the most pragmatic and the least and the most cost effective one, which is multiversal interviewing or multiversal therapy plus CBT. So first of all, we usually provide one or two sessions of multiversal interviewing before we get to the CBT manual. Well, it's a CBT manual of five, six, eight, or even 12 sessions. It usually lasts not more than 45 minutes. We explore the teens drinking and motivation and drug use, of course. We provide personalized feedback of assessments during the process, especially on the second session and later on during treatment, because it's good to work with the patient, not just indicate to the patient what to do, measure where we are and discuss how and what we would like to do in order to make progress. Sometimes we have to repeat what we've been doing, but getting the feedback from the adolescent definitely improves engagement. We elicit goals for change. Some kids say, I don't wanna stop using. If you're gonna confront them, it's not gonna work. So try to elicit some goals. What would you like to do? Even if they say, well, I'd like to use less, or I'd like to switch from this drug to that drug, you sometimes need to go with the flow before you redirect them. But again, in a very constructive and patient-oriented approach. Ask them to envision future with and without the change. Identify barriers to enrollment, engagement, and treatment. Discuss different options. If you would like to choose one that would be more appealing to your client. And summarize. It's very important to summarize because adolescent's attention is very short. They may not remember things. So taking notes on both sides is kind of nice, providing them with a pen and a pad. And summarizing also in terms of language, and I'll get to it in a minute. Let me kind of remind you kind of the old Prochazka and DiClemente status of change. That in the past, we used to talk about client, therapist, and intervention. Now, since we have adopted this approach, we also need to look at the change process. That means that treatment is a moving target, and we need to go with the flow and measure the changes and make adaptations and adjustment accordingly. So this is the old classic from pre-contemplation to contemplation. And you try to bring the adolescent from pre-contemplation when the door is closed, compared to you knock on the door and they open it a little bit, and you try to put just your foot in the door and make them listen, or at least negotiate with you, where do we go from here? And I have a bunch of examples for that. And we also have a manual that one for adolescent, one for adults, that is in your reference list that can take you through some cases and show you examples of how to do it, but also how not to do it in terms of the confrontational style. One of the important issues, if you try to put yourself in the place of the adolescent is why do I need to do it? Why should I do it? I mean, do I need to get somebody off my back, such as my mom, my teacher, my probation officer, my judge, in order to get some progress in engagement, we need to be involved in an honest discussion of pros and cons, which is very much CBT like, cognitive behavioral therapy. What are the pros in terms of utility to self? Utility to others is also very important because adolescent may say, I don't care, I don't want to stop, but they will say, well, my mom or my boyfriend or my girlfriend, or I don't know, my mentor, it's really both of them that I'm doing it, that I'm using drugs and dealing with these consequences, which are negative. So what are the utility to others? Who else would also benefit or feel more comfortable if the drug use patterns gonna change? So it involves also a self-approval process and others approval process. So when you take it into consideration, you show some compassion, you show empathy, and you manifest that you try to understand, have a glimpse into the adolescent world as compared to being in a contradicting, controversial mano a mano intervention, which adolescents that will never work. If you get into a confrontation with adolescents, you're always gonna lose, why? I had a teacher once said that the raison d'etre, the essence of being an adolescent is to contradict you because you're an adult, and there's an imbalance in the power play here, and they don't like it. And if you really wanna test it, you can switch positions with the adolescent on a certain subject, and they would still continue to argue with you. So it's not necessarily the content, it's more of the style and the power imbalance. Excuse me. So what is motivational interviewing at MIT? It's based on principles of motivational psychology and it's patient-centered, and it's definitely a very useful approach in order to enroll and engage the adolescent, at least in conversation with you, because you don't want to have an adolescent sitting in your office arms closed, no eye contact, and they send you the message, I don't really want to be here. As soon as you let me go, I'm out of here. I want to do nothing. I have nothing to do with you. So as I said, no confrontational strategies, basically this is not going to work. So what you are not supposed to do, and by the way, we all can fall into this trap, either with patients or even if you have adolescents at home because sometimes they're really getting on your case. They're very good at stimulating you, irritating you, getting on your nerves quite badly. So you don't argue with them. You don't impose a diagnostic label on them. Don't tell them what they must do or else. Don't seek to break down denial by direct confrontation like the old-fashioned way, if you remember the revolving chair. Don't imply that they are powerless and express your powerlessness and your frustration by projecting it on them. This is not going to work. Many of the clients you work with have seen other therapies before. They just expect some aggression, some hostility from you in order to shut down completely. So be aware of it. On the other hand, don't try to be too sweet and too understanding because they won't believe you. They have very good senses. So try to be realistic about it and you can sometimes imply, listen, I know it's not very easy for you to be here. It's not very easy for me to start this process, but let's see what we can do together because at the end of the day, I'm here to help you help yourself. Try to convey that you're a human being, that you are caring, you're fair and square, and you're not trying to be too sweet about it, but you are really curious and interested in how to make progress. So what do you do in a motivational interview? You express empathy. It's said that I need to show you a slide saying please express empathy. But the idea is you need to look interested. You need also to show that you're listening. So sometimes you repeat what the adolescent said, or you can rephrase it a little bit positively. For example, if it said, I don't want any treatment. I don't want to be here. So you don't say, oh, I agree. I shouldn't be here. You can say, well, I hear you. And I guess it's not very pleasant to be here. Definitely not the first time with the person you've never met before. But let's see where we're going with it. I can definitely say, and please tell me if I'm accurate, that presently or at this point, you're not ready. When you say that, what does it mean? It means that you're telling me, yeah, I hear you, that you're not interested to do it. But I'm saying, well, maybe you're not ready right now, meaning I put a temporary expiration date on it and say, well, let's see what will be in the future. You don't necessarily have to say it, but you phrase it that way. You also develop discrepancy, which means as the patient, where are you now? Where would you like to be a year from now, three years from now, five years from now? For example, if patients say, I don't have any problems. And I said, OK, so tell me how things are in school. Oh, things are not so great. How are your relationships with your mom? Oh, I don't think she likes where I am right now in terms of substance use. What about the legal issues? Oh, my probation officer, excuse my language, suck. So then you break it down into domains. These are some of the domains that we use in the assessment of the teen addiction severity index and say, how about working on one of these issues one at a time? See where it takes us. So you develop discrepancy that things are not hanky dory. And even though the adolescent doesn't want to work with you, he or she recognizes there are some matters to be resolved and you offer to work with them. I would argue that these are just examples. The other information is present, what elaborated on in the manuals. Avoid argumentation. Roll with resistance. If somebody said, yeah, I'm not ready. And you say, yeah, I hear you. You know, let's see where we're going with this. Oh, we're going to take our time. I don't expect you right now to tell me what I want to hear. Actually, you can even joke that if you tell me that you're ready to quit, I will say, hey, wait a minute, man, what has changed so quickly? You know, we need to do this pro and cons kind of list. And support self-efficacy. If somebody says, well, I would like to use less or I would like not to inhale or sniff or inject certain agents and just, I don't know, smoke weed or drink alcohol. It doesn't mean that you condone alcohol or weed use by saying, cool. But you say, that sounds like a progress. That sounds like a move in the right direction. And, you know, these kids are really, they are thirsty for genuine compliments and support because they usually get negativity and hostility most of the time. So by being compassionate and empathic, yet in a measured way, don't try to be like, you know, a sweet auntie approach or grandma, how wonderful you are, how much I love you. You need to do it with a grain of salt. And that's probably a good way to work with most young people. In terms of the technical aspects, you use open-ended questions. You don't ask questions that the answer is yes or no. Like a good open-ended question is, tell me about your substance use. Active empathic listening, as I mentioned before, ask questions, repeat, make some changes, revise your responses in a way that is open-ended. Help them describe the discrepancy, elicit self-motivation statements, support self-efficacy, and offer feedback and summarize at the end of every session. It's very helpful. Same way in future sessions when you start a session with a summary of the previous session, because even if you provide them with home assignments, I don't like the term homework, they don't always do it, so you may have to help them do it when they come for the next session. After two sessions of motivation to build MET that you can find in the manuals, a couple of slides toward the end that mention them, cognitive behavioral therapy, you know, that is based on the principle of social learning theory, take into consideration behavioral aspects and cognitive aspects. And the idea is to compensate for skill deficits or for skill deviancy and or on top of the motivation, because a lot of time it's not that they don't have the skill, they're not motivated, that's why when you provide multiversal interviewing, you prime the adolescent for treatment, because if they're not motivated, what's the point of just spending time with cognitive behavioral therapy when they are totally deaf to your approach? So you need to have an opening, so this process would work. And one of the classic contribution by Ellen Marlatt in the early 80s, talking about addressing intrapersonal states and interpersonal states that can elicit craving and need to use drugs or wants to use drugs. And now we cover each and every one of them and there's a long list of situations, conditions and encounters that you can focus on from anger management to social interactions and see how to address this antecedent behavior consequences or the other ABC, which is the cognitive triangle, which talks about affect behavior and cognition, which is a triangle that each one of the elements in the triangle can affect the others. It's a bidirectional approach. The affect can impact the behavior, the behavior can impact the cognition, the cognition can affect the affect, and you need to find out where you are in this process while you are navigating with the adolescent. So this is the process that brings about positive outcomes. We are enhancing the patient's sense of self-efficacy. We decrease anticipated positive consequences of substance use. And we improve all kind of, you can call it backwards engineering, if you will, of improving cognitive and behavioral coping skills so they can avoid substance use situations. And if they do or can't avoid it, at least they can interact. Avoidance is good only for a short while, but this is the real world and you need to get ready for the encounter with high-risk situations. So in the Cannabis Use Treatment Study, these were the elements of each and every session in the manual. There was a rationale section, skill guidelines section, modeling section. And modeling is very important in treatment because if we don't model in a safe environment, which is treatment environment, the adolescents probably will never get it. So they need to try to model and do some role-playing and get feedback in a lab environment, which is like in treatment, as compared to in real life in a party when it's very difficult. Remember yourself, difficulties to say no when somebody offers you a drink or a cookie or anything else when you're on a diet or you have some dietary restrictions. So we take some exercises. In the rationale section, we want to make clear that the adolescent understand what is the rationale for this specific intervention because it will motivate them to cope with the skills that are associated. Skill guidelines are very specific, whether you do anger management or whether you do social networking. These are some examples of dealing with negative moods. So we do specific guidelines. We use posters that we put in the group room. And so they're always in sight of the adolescents. In these days, people don't want to use posters. They want to use, you know, some kind of a screen or a computer. It still includes the same elements of a very brief and precise poster that show the take-home message. There's the modeling one, which usually what we like to do is, first of all, do it the wrong way. Kind of, so to speak, that the therapist present what he or she will do and then do it in a way that will make him fail and then say, oh, that's not the way to do it. But it's very common. This is how it ends up. Now, let's see what is the right way to do it. For example, say no to drugs. We like to do rehearsal role plays. I like to work in group sessions. So you have six to eight adolescents. We pair them up and they each one of them come with a scenario and they perform in front of the group and get feedback. And it's a very productive process. And also, it can be fun. Reminder list. Some people need to have reminder list and kind of some things written when people keep on doing it and doing it and repeating it at home and coming back with it. If they don't do it at home again, no reason to lose control or get too upset. Just say, OK, since you haven't done it, let's do it. Although I allow those who did the homework to present it first, because that's a way to, if you will, reward them and make other people realize that this is something that we, the therapists, appreciate. And maybe they would like to do it next time in order to improve approval. The PFR is also very important because it's good to take a break after several sessions and sit with the adolescents and say, OK, let's see where we are. It's not enough that you think that you know where the adolescent is in terms of change. It's important to know what the adolescents think. By the way, we also do drug analysis. It's very important. So it's good to sit down and understand why there is progress, why there is no progress. Maybe there's motivation, but not good use of social skills. Maybe there's poor motivation. So we still need to work with the motivation. And again, you can find it in the manuals and also in the references that we have developed for adolescents and for adults. Session summary is very important because, again, you want to make sure the adolescents remember what happened and also summarize the previous session on the second session of the MET. MET session, as I said, it's probably, you know, anywhere from 45 to 55 minutes. Keep, you know, your eyes on the clock so you make sure that you're not moving too slow or too fast until you feel comfortable. And a couple of comments about group before we kind of end up the presentation today is, I wish I had more time to talk about group per se, but group is a very cost effective approach. If you have six to eight adolescents, two therapists are optimal. Remember, there are kind of three elements in the group in 3D is your relationship with the therapist, with the group, with each and every kid in the group, and the relationship between the different participants of the group. So all kind of dynamics can happen there. Before kids join a group, ask them if there's any reason to be anxious, whether they're going to meet somebody they know, or maybe they have some kind of a social anxiety, and also discuss expectations. Group can be a revolving admission or can be a fixed group that is close to newcomers, there are pros and cons to each approach. One last thing, what you shouldn't do in a group. Again, try to be consistent in terms of negativity, even though you can be critical and you can reflect reality, but try not to overstate it and be kind of in control of what should be the boundaries in terms of your comments in the group to individuals because you're going to have different levels of motivation to engage. You're going to be the kids who are doing well, like to engage, kids who are not sure, kind of it's patchy in terms of participation, and kids who are negative. And the question is, how do we engage them in the process without alienating other kids, because that's definitely a very sensitive issue. And I personally find group therapy very challenging, but also very rewarding. So here are a couple of the references that, you know, those of you who want to dive deeper into them, they can look at some of these publications. And some other references as well. Some of them are older, but they are like the basic references for those who really want to understand where we have come from in terms of the last, if you will, 30 years plus of developing psychotherapy for adolescent substance use. Thank you, and I will ask Dr. Yule to continue. Yes, so thank you, Dr. Kimminger, for that very informative presentation. I personally really appreciated all the concrete tips you had in terms of how to effectively engage adolescents in treatment. And I know, you know, one thing you mentioned is that group therapy with adolescents can be really rewarding and also kind of talk during the talk about some of the challenges of working with adolescents. Wanted to also hear from you kind of what you enjoy about working with adolescents with substance use disorders or some of the opportunities. I don't know if I'm frozen, but Dr. Kim, did you hear the question? Oh, I'm sorry. I didn't hear the question. Yeah, go ahead. Sorry. Yeah, no. So again, thank you for your presentation. I know you mentioned at the very end that group therapy can be really a rewarding kind of type of modality of treatment with adolescents. And then you also talked in the presentation about some of the challenges associated with working with adolescents. And so I was hoping to also hear from you about what you enjoy about working with adolescents and some of the opportunities. Yeah, well, it's probably gonna take another hour. First of all, my choice has been to work with adolescents. I think they are the most challenging and most interesting human beings in terms of the life cycle. Some people wouldn't touch an adolescent with 10 feet pole and like to work with adults and say, why don't you guys get it? And I sometimes say, and I know it may sound not totally professional, but allow me to use the term counter-transference. Sometimes you want to hug an adolescent and smack the adolescent at the same time. Like, don't you see what you're doing to yourself? But you can behave like a parent or a teacher. You need to behave like a therapist. So you need to find a smarter way to do it because there's a certain process going on in the brain of adolescents. And if you take into consideration impulsivity, sensation seeking, peer pressure, and all those things, you need to come up with a relatively safe formula to engage them in treatment. Because remember, being an adult in the eyes of an adolescent is a handicap. The best thing you can do is be a decent adult. I mean, cause you don't really get it. Cause you heard from your own kids and your patients, part of the developmental gap is that they need to understand that we don't get them. It gives them a certain power in the process encounter with us. So we don't need to tell them that we understand how they think. We just need to go with the flow and intervene in the right places. And I find it very challenging. And I don't know, I have a certain, if you will, a tender space in my heart for adolescents. This has been the population I always like to work with. Yeah. And I mean, you see tremendous change and I think it can be really rewarding to see them developmentally get back on track. And one attendee also mentioned, the best posture is to remain curious, which I think is, you're also emphasizing kind of being really curious with adolescents and as a engagement strategy. So. So those of you who like funnies, if you still look at the weekend funnies in the newspaper, I recommend Zits, because this is about the adolescent and his parents. And it's cracks me up all the time. The people who write it are so much on target, what it is to deal with adolescents. Got it. Well, next slide. But I really want to thank everyone for participating in today's session. Please visit PCSSnow.org and see the variety of helpful resources that are offered, including the free PCSS Mentor Program, which offers general information to clinicians about evidence-based clinical practices and prescribing medications for opioid use disorders. Next slide. PCS mentors also have expertise in medications for substance use treatment and clinical education. You can also find the PCSS discussion forum, which is a simple and direct way to receive an answer related to medication for substance use treatment. Next slide. And today's activity was presented on behalf of the SAMHSA-funded Provider Clinical Support System, which is a program operated collaboratively by 19 medical specialty organizations, including the APA. Next slide. And again, thank you for joining us today. Thank you, Dr. Kaminer for your informative presentation. And we hope to see you soon at our next webinar.

webinar

Challenges in Implementing Manualized Treatment

adolescent substance use disorders

engaging and treating

developmental factors

individualized treatment approaches

psychiatric comorbidity

motivational interviewing

cognitive behavioral therapy