Transcript Screening and Brief Intervention E

Screening and Brief Intervention
E-Learning Module Draft
Module I: Overview
•
•
•
•
Alcohol use and health in NYC
What is SBIRT?
Core components of SBIRT testing
Reimbursement
Excess alcohol consumption is the third
leading “actual” cause of death
Actual Causes of Death, United States, 2000
Source: Mokdad AH, Marks JS, Stroup DF, Geberding JL, JAMA 2004;291:1238-1245
Nationwide, alcohol kills more than
twice as many people
as illicit drugs
120,000
105,000
Deaths
80,000
38,900
40,000
0
Alcohol
Illicit Drugs
Source: McGinnis JM and Foege WH. Proc Ass Am Physicians 1999;111:109-118
Drinking patterns vary by
neighborhood in NYC
Estimated prevalence of
Binge Drinking
Estimated prevalence of
Heavy Drinking
1 in 10 of all hospitalizations in NYC are
alcohol-related
10
9
8
Percent
6.5
9.3
9.6
9.6
6.8
7
7
9.8
7
10.1
10.1
10
Any Alcohol
7
6.8
6.4
6
Alcohol
Dependence
4
2
1.6
1999
1.5
1.6
1.5
1.7
2000
2001
2002
2003
2
2.2
2.4
Alcohol
Abuse
0
Year
2004
2005
2006
Source: NYS DOH SPARCS, 2006
Alcohol-related ED visits
are increasing in NYC
3.0%
21 to 64
12 to 20
Percent of Total ED Visits
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
2004
2005
2006
2007
2008
2009
Year
Source: NYC DOHMH Syndromic
Among underage drinkers, alcoholrelated ED visits have nearly doubled
300
Rate per 100,000 Population
264.2
244.8
250
198.4
200
150
179.2
139.5
100
50
0
2004
2005
2006
Year
2007
2008
Source: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2008 (11/2009 update).
Alcohol-related ED visits are more
common in particular neighborhoods
What is Screening Brief Intervention &
Referral to Treatment (SBIRT)?
An Evidence-based Model Program :
- Identifying persons at ALL levels of alcohol and drug use
through to dependence
- Providing brief intervention to patients who are misusing
alcohol and other drugs
- Assessing patients who may be using alcohol and/or
drugs to determine if they would be eligible for treatment
- Referring patients who are probably alcohol and/or other
drug dependent to addiction treatment.
SBIRT is a Paradigm Shift from the traditional
model of service provision to one that is more
expansive, focusing on the “at-risk” individual
for prevention and early intervention.
Substance use occurs along a
continuum SBIRT is grounded in this perspective
Core components of SBIRT
Source: SAMSHA/CSAT, 2005
Overall, what do we hope
SBIRT will do?
• Improve public health
• Increase clinical knowledge
• Decrease stigma
• Prevent alcohol-related violence and
interpersonal abuse
• Reduce high risk behaviors
• Prevent alcohol dependence
Benefits analysis
(more than just cost-effectiveness)
–SBIRT Effectiveness
Reduce unhealthy drinking
Reduce alcohol-related
consequences
»Morbidity & Mortality
»Trauma (MVCs)
»Lost wages
»QoL (pt, family, society)
»ED visits
»Cost and burden to society
Are there codes that can be used for reimbursement?
In January 2008, the AMA introduced new health care codes for substance abuse screening and brief
intervention. Healthcare professionals now have four different codes that can be used in 2008
for screening and brief intervention (SBI). Two of the codes are for privately insured patients
(99408 and 99409), and two for Medicare patients (G0396 and G0397). Fees are based on
length of activity (15 -30 minutes; more than 30 minutes).
The definitions of the Healthcare Common Procedure Coding System (HCPCS) codes focus on
"assessment" instead of "screening." These codes, again, will only be used for people age 65 and
above. The G-code definitions are "Alcohol and/or substance (other than tobacco) abuse
structured assessment (e.g., AUDIT, ASSIST, DAST) and brief intervention, 15-30 minutes" for
G0396, and "Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g.,
AUDIT, DAST) and intervention, greater than 30 minutes" for G0397. Note that Medicare calls the
15-30 minute intervention "brief," but does not use that same denomination for the longer
intervention. The G codes also are defined as "assessment" instead of "screening". Medicare will
instruct its carriers to pay for G0396 and G0397 "only when considered reasonable and
necessary."
For patients not covered by Medicare -in other words, patients under age 65 -the only codes
healthcare professionals can now use are the Healthcare Common Procedure Coding System
(CPT) codes. In some areas of New York State, private payers have already started to use these
codes. But Medicare made it much easier for them to do so by publishing the RVUs (relative value
units) for the CPT codes. These RVUs, when multiplied by the conversion factor, give the dollar
amount payable per code. Since most payers rely on the Medicare fee schedule, at least as a
jumping off point to set their own fees, the publishing of RVUs makes it much more likely that nonMedicare patients will get these services as well. Medicaid coding is in place, but requires each
individual state Medicaid authority to "turn on" the codes. New York State had done so in January
2010 for Primary Care and Emergency Department settings.
Source: http://www.oasas.state.ny.us/Admed/FYII sbirt. cfm
Screening and Brief Intervention
Draft Module II
SBIRT: The Components
1. Screening: Purpose of
2. Validated Screens:
AUDIT/DAST-10/CRAFFT
Scoring
1. Purpose of Screening
• Create a professional, helping atmosphere
• Identify both hazardous/harmful drinking or
drug use and those likely to be dependent
• Use as little patient/staff time as possible in
doing so
• Provide information to patient(s) needed for
choosing the appropriate intervention(s)
Screening Process
• IS NOT a substitute for care of clients with a
moderate to high level of abuse or
dependence.
• IS NOT a formal diagnosis of alcohol or drug
dependence, but a reliable indicator of
either the presence or absence of one.
• IS an impartial tool used to engage and
motivate clients who need specialized
treatment to accept a referral for diagnostic
evaluation and possible treatment.
What does “at-risk” mean for
alcohol users?
• National Institute on Alcohol Abuse and Alcoholism defines:
- Men who drink more than 14 standard drinks per week or
more than 4 drinks on occasion
- Women who drink more than 7 standard drinks per week or
more than 3 drinks on occasion
BUT I ONLY HAD ONE DRINK
Alcohol
• Most people ask “What’s a Standard Drink?”
1 standard drink =
1 can of ordinary beer
(e.g. 12 oz. at 5%)
- OR -
A single shot of spirits (whiskey, gin, vodka, etc.)
(e.g. 1.5 oz. at 40%)
Alcohol
(cont’d)
A glass of wine or a small glass of sherry
(e.g. 5 oz. at 12% or 3 oz. at 18%)
- OR A small glass of liqueur or aperitif
(e.g. 2.4 oz. at 25%)
*How much is Too Much?
The most important thing is the amount of pure alcohol in a
drink. These drinks, in normal measures, each contain
roughly
the same amount of pure alcohol. Think of each one as a
standard drink.
Problem & Dependent Drinkers
• Problem drinkers are persons who drink above NIAAA
limits and also have one or more alcohol-related
problems or adverse events
• Dependent drinkers are persons who are unable to
control their alcohol use, have experienced one or more
adverse consequences of alcohol use, and have
evidence of tolerance or withdrawal
Drinking Pyramid
Negative Effects of Alcohol
Effects of High-Risk Drinking
 Vitamin deficiency, Bleeding, Vomiting, Diarrhea, Malnutrition
 Trembling hands, Tingling fingers, Numbness, Painful Nerves.
 Severe inflammation of the stomach and/or Ulcers
 Inflammation of the pancreas.
 Impaired sensation leading to falls.
 Men: Impaired sexual performance
Women: Risk of giving birth to deformed, developmentally
disabled or low birth weight babies.
 Numb, Painful nerves.
 Physiological dependence.
Interviewing Styles
• Approaches to screening: Motivational vs
Confrontational
Effect of High-Risk Drinking
• Psychological & Behavioral Concerns
- Aggressive, Irrational behavior, Arguments, Violence,
Depression, Nervousness, Substance Dependence,
Memory Loss
• Physiological Concerns
- Premature aging, Drinker’s nose, Frequent colds,
Reduced resistance to infection, Increased risk of
pneumonia
- Weakness of heart muscle. Heart failure, Anemia,
Impaired blood clotting. Breast Cancer
- Liver Damage
- Dependence
Motivational vs. Confrontational
Approach
• Confrontational:
- emphasis on
acceptance of self as
having problem;
acceptance of diagnosis
essential for change
- emphasis on
personality pathology
which reduces personal
choice, judgment and
control
• Motivational:
- less emphasis on labels;
acceptance of labels
unnecessary for change
- emphasis on personal
choice and responsibility
for deciding future
behavior
Confrontational
Motivational vs. Confrontational
Approach
• Confrontational:
- present evidence of
problems to convince
patient to accept
diagnosis
- resistance is “denial” a
trait requiring
confrontation
• Motivational:
- counselor conducts
objective evaluation,
but focuses on eliciting
patient’s own concerns
- resistance is an
interpersonal behavior
pattern influenced by
counselor’s behavior
Motivational
Motivational vs. Confrontational
Approach
• Confrontational:
• Motivational:
- resistance met with
argumentation and
correction
- resistance is met
with reflection
- goals and strategies
for change are
prescribed for the
patient since patient
is seen as incapable
of making sound
decisions
- goals and strategies
for change are
negotiated between
the patient and
counselor;
collaboration is vital
2. Validated Screens
1. Alcohol Use Disorders Identification Test
(AUDIT)
2. Drug Abuse Screening Test (DAST)
3. Car, Relax, Alone, Family Friends,
Forget, Trouble (CRAFFT for
Adolescents)
Validated Screens
1. The AUDIT: Standardized, validated
instrument
• AUDIT is the acronym for Alcohol Use Disorders
Identification Test
• Developed in 1993 from a six-country World Health
Organization (WHO) collaborative project as a screen for
hazardous and harmful alcohol consumption.
• It consists of 10 brief questions that effectively
demonstrate levels of drinking behavior that become a
springboard for intervention.
Using the AUDIT
•
•
•
•
Review Questions
Tips for Administering the Questions
Scoring
Interpretation and Recommendations
NOTE: Place graphic version of
AUDIT C/10 with scoring
instructions (PDF version).
In place of the 2 following AUDIT slides
AUDIT: 10 Questions
1.
How often do you have a drink containing alcohol?
2.
How many drinks containing alcohol do you have on a typical day
when you are drinking?
3.
How often do you have 6 or more drinks on one occasion?
4.
How often during the last year have you found that you were not
able to stop drinking once you had started?
5.
How often during the last year have you failed to do what was
normally expected of you because of drinking?
AUDIT: 10 Questions (cont’d)
6. How often during the last year have you needed a first drink in the
morning to get yourself going after a heavy drinking session?
7. How often during the last year have you had a feeling of guilt of
remorse after drinking?
8. How often during the last year have you been unable to remember
what happened the night before because of your drinking?
9. Have you or someone else been injured because of your drinking?
10. Has a relative, friend, doctor, or other health care provider been
concerned about your drinking or suggested you cut down?
Key Terms and Definitions for
AUDIT
Hazardous Drinking
Pattern of alcohol consumption
that increases the risk of harmful
consequences for the user or
others.
Harmful Use
Alcohol consumption that results
in consequences to physical and
mental health.
Alcohol Dependence
A cluster of behavioral, cognitive,
and physiological phenomena that
may develop after repeated alcohol
use.
Domains and Item Content of Audit
Domain
Question
Number
Item Content
Hazardous Alcohol Use
1
2
3
Frequency of drinking
Typical quantity
Frequency of heavy drinking
Dependence Symptoms
4
5
6
Impaired control over drinking
Increased salience of drinking
Morning drinking
7
8
9
10
Guilt after drinking
Blackouts
Alcohol-related injuries
Others concerned about drinking
Harmful Alcohol Use
Interpretation of AUDIT
Score
Zone
Degree of Problems
0-7
I
No Problems at this time
8-15
II
Hazardous & Harmful Alcohol Use
16-19
III
20-40
IV
High Level of Alcohol Problems and
Possible Dependence
Possible Alcohol Dependence
Advantages of Different Approaches to
AUDIT, DAST and CRAFFT Administration
• Questionnaire
- Takes less time
- Easy to administer
- Suitable for computer
administration and scoring
- May produce more accurate
answers
• Interview
- Allows clarification of
ambiguous answers
- Can be administered to
patients with poor reading
skills
- Allows seamless feedback
to patient and initiation of
brief advice
Introducing the AUDIT
“Now I am going to ask you some questions about
your use of alcoholic beverages during the past
year. Because alcohol use can affect many areas
of health (and may interfere with certain
medications and treatment), it is important for us
to know how much you usually drink and whether
you have experienced any problems with your
drinking. Please try to be as honest and as
accurate as you can be.”
Considering the Patient
• The interviewer is friendly and non-threatening;
• The patient is not intoxicated or in need of
emergency care at the time;
• The purpose of the screening should be clearly
stated in terms of its relevance to the patient’s health
status;
Considering the Patient
• The patient must understand that for the information
shared to be of value the questions require truthful and
accurate responses; and
• Assurance is given that the patient’s responses will
remain confidential.
Match AUDIT Score with type of
response or intervention
• Types of Brief Intervention:
– Alcohol Education
– Simple Advice
– Simple Advice plus Brief Counseling and
Continued Monitoring
– Referral to Specialist for Diagnostic Evaluation
and Treatment
Matching Risk Levels and
Interventions Based on AUDIT
Scores
AUDIT Score
0-7
Risk Level
Zone I
Intervention
Alcohol Education
8-15
Zone II
Simple Advice
16-19
Zone III
Simple Advice plus Brief
Counseling and Continued
Monitoring
20-40
Zone IV
Referral to Specialist for
Diagnostic Evaluation and
Treatment
2. Validated Screens
2. Drug Abuse Screening Test (DAST)
•
•
Yudko E; Lozhkina O; Fouts A. A comprehensive review of the psychometric
properties of the Drug Abuse Screening Test. Journal of Substance Abuse
Treatment 32(2): 189-198, 2007. (24 refs.)
This article reviews the reliability and the validity of the (10-, 20-, and 28-item) Drug
Abuse Screening Test (DAST). The reliability and the validity of the adolescent
version of the DAST are also reviewed. An extensive literature review was conducted
using the Medline and Psychinfo databases from the years 1982 to 2005. All articles
that addressed the reliability and the validity of the DAST were examined.
Publications in which the DAST was used as a screening tool but had no data on its
psychometric properties were not included. Descriptive information about each
version of the test, as well as discussion of the empirical literature that has explored
measures of the reliability and the validity of the DAST, has been included. The DAST
tended to have moderate to high levels of test-retest, inter-item, and item-total
reliabilities. The DAST also tended to have moderate to high levels of validity,
sensitivity, and specificity. In general, all versions of the DAST yield
satisfactory measures of reliability and validity for use as clinical or research
tools. Furthermore, these tests are easy to administer and have been used in a
variety of populations.
NOTE: Place graphic version of
DAST 10 with scoring instructions
(PDF version).
Eliminate next two DAST slides
DAST-10: Timeframe: last 12 months
1.
2.
3.
4.
5.
Have you used drugs other than those required for
medical reasons?
Do you abuse more than one drug at a time?
Are you unable to stop using drugs when you want to?
Have you ever had blackouts or flashbacks as a result
of drug use?
Do you ever feel bad or guilty about your drug use?
DAST-10:Timeframe: last 12-months
Does your spouse (or Parents) ever complain about
your involvement with drugs?
7. Have you neglected your family because of your use
of drugs?
8. Have you engaged in illegal activities in order to
obtain drugs?
9. Have you ever experienced withdrawal symptoms
(felt sick) when you stopped taking drugs?
10. Have you had medical problems as a result of your
drug use (e.g., memory loss, hepatitis, convulsions,
bleeding)?
6.
DAST Guidelines for Determining
Intervention Strategy
Score
Degree of Problems
Related to Drug Abuse
Suggested Action
0
No Problems Reported
None At This Time
1–2
Low Level
Monitor, Reassess
At A Later Time
3–5
Moderate Level
Further Investigation
6–8
Substantial Level
Intensive Assessment
2. Validated Screening Tools
3. Car, Relax, Alone, Family Friends, Forget,
Trouble (CRAFFT for Adolescents)
The CRAFFT is intended specifically for adolescents. It draws upon adult
screening instruments, covers alcohol and other drugs, and calls upon situations
that are suited to adolescents.
The sensitivity of the CRAFFT is similar to the AUDIT and much greater than
that of the CAGE (which is not recommended for use with adolescents.)
The CRAFFT works equally as well for alcohol and drugs, for boys and girls, for
younger and older adolescents, and for youth from diverse race and ethnic
backgrounds.
The CRAFFT Screening Tool
CeASAR (Center for Adolescent Substance Abuse
Research) describes the CRAFFT as a behavioral health
screening tool for use with children under the age of 21
and recommended by the American Academy of
Pediatrics’ Committee on Substance Abuse for use with
adolescents.
It consists of a series of 6 questions developed to screen
adolescents for high risk alcohol and other drug use
disorders simultaneously. It is a short, effective
screening tool meant to assess whether a longer
conversation about the context of use, frequency, and
other risks and consequences
of alcohol and other drug use is warranted.
Screening using the CRAFFT begins by asking the
adolescent to “Please answer these questions honestly”
and then assure them that their answers will be kept
confidential.
There is a Part A and Part B to the CRAFFT screening
questionnaire or interview.
Part A has three opening questions:
During the PAST 12 MONTHS, did you:
1. Drink any alcohol (more than a few
sips)?
2. Smoke any marijuana or hashish?
3. Use anything else to get high?
(“Anything else includes illegal drugs,
over the counter and prescription drugs,
and things that you sniff or huff”.)
CRAFFT
• If the adolescent answered NO to All three
questions, only ask the first question in
Part B.
• If the adolescent answered YES to ANY
question, ask all questions in Part B.
Part B has six CRAFFT questions:
CRAFFT is a mnemonic acronym of first
letters of key words in the screening
questions.
When using the interview style of
administration of the CRAFFT, the six
questions should be asked exactly as
written:
1. C- Have you ever ridden in a CAR driven by someone
(including yourself) who was “high” or had been using
alcohol or drugs?
2. R- Do you ever use alcohol or drugs to RELAX, feel better
about yourself, or fit in?
3. A- Do you ever use alcohol or drugs while you are by yourself,
or ALONE?
4. F- Do you ever FORGET things you did while using alcohol or
drugs?
5. F- Do your Family or Friends ever tell you that you should cut
down on your drinking or drug use?
6. T- Have you ever gotten into TROUBLE while you were using
alcohol or drugs?
Scoring:
Two or more positive items indicate the
need for further assessment suggesting a significant
problem.
Privacy:
It is important that adolescents are screened
in a private place away from the parent or guardian in
order to get honest answers and maximize the
effectiveness of the CRAFFT.
Adolescents usually prefer the questionnaire self
administered or computer screening.
Safety Risk: Information that could be uncovered
during an assessment may present a safety risk
(e.g., injection drug use, illegal behaviors,
ingestion of potentially fatal amounts of alcohol)
and may warrant a referral to treatment.
Parents must be informed of safety risks and
treatment referrals for adolescents less than 18
years old. (Of course the adolescent should be told
as soon as possible whenever this is necessary and
discuss with them what information will be
disclosed.)
RECAP
Screening: With just a few questions on
a questionnaire or in an interview,
practitioners can identify patients who
have alcohol or substance use problems
and determine how severe those problems
already are.
Screening and Brief Intervention
Draft Module III: Brief Intervention
Brief Intervention: If screening results
indicate “at risk” behavior, individuals
receive brief interventions. The
intervention educates them about their
substance use, alerts them to possible
consequences, and motivates them to
change their behavior.
Brief Intervention: Objectives
• Define Brief Intervention
• Discuss some different types and models of brief
interventions
• Discuss “Stages of Change” and their implications for
provider interventions
• Discuss use of “Change Rulers” and their impact on
patient change
• Discuss motivational interviewing and its role in the brief
intervention
• Review video examples
Brief Intervention (BI): What is it?
A Brief Intervention is a short (2-10 minute)
dialogue between the service provider and
the patient that typically involves:
•
•
•
•
•
A screening or assessment process
Feedback
patient engagement
Simple advice or brief counseling
Goal setting and follow-up regarding the drug and/or
alcohol use of the patient
Brief Intervention: Tools
• The most commonly used are a combination of the following:
- Printed information
- Short advice session
- Motivational interviewing
- Brief counseling
- Questionnaires and self-assessments
- Self-help manuals
- Controlled drinking programs
- Drunk Driver programs
- Videos
BI: Reluctance of Primary Workers
•
•
•
•
Lack of time
Inadequate training
Fear of antagonizing clients
AOD not a matter to address in providing
services
• Users will not respond
The Five A’s For Brief Interventions
• Ask about use.
• Advise to reduce intake or quit.
• Assess willingness to attempt to quit.
• Assist in quit attempt.
• Arrange Follow-up.
Screening and Brief Intervention
Draft Module IV: Stages of Change
• Stages of Change Defined
• Implications for Provider in Brief
Intervention
• Readiness Rulers
Prochaska & DiClemente’s Six
Stages of Changing Behaviors
MAINTENANCE
Identify Strategies
and support to
prevent relapse.
PRECONTEMPLATION
Doesn’t see behavior
as a problem.
CONTEMPLATION
Ambivalence
Reasons for
ACTION
concern vs.
Continued new
justifications for
behavior for more
PREPARATION
concern . Begin
than 6 mos.
change within
“I’ve got to do
6mos.
something about this
problem.” “This is
serious. Something
has to change.” /30
days
RELAPSE
Help renew contemplation,
preparation, and action
without giving up.
Stages of Change
• 80% of substance mis-users are in precontemplation or contemplation
• Define success by the movement from one
stage to the next
The Stages of Change
Stage
P
R
E
C
O
N
T
E
M
P
L
A
T
I
O
N
Participant
• May or may not be aware of
the problem
Helper
• Build trust and rapport
• Non-judgmental
• Overwhelmed, hopeless
• Accept autonomy
• Resigned, low energy,
hostile
• High energy, no feeling of
control
• Denial, little or no fear of
consequences
• Empathize, Help clarify
• Look for ambivalence
• Identify participant
goals
• Provide information
• Minimizes harmful
consequences.
• Focus on safety
The Stages of Change
Stage
Participant
Helper
• Build trust and rapport
C
O
N
T
E
M
P
L
A
T
I
O
N
• Acknowledges that a
problem exists
• Clarify ambivalence-tip
the balance!
• Ambivalence is high
• Struggles to understand the problem and
possible causes and
solutions
• Considers action
(may take time)
• Assess how long they
have contemplated
change
• Give accurate personal
information
• Inquire about pros/cons
of the behavior?
•Increase self-efficacy
The Stages of Change
Stage
P
R
E
P
A
R
A
T
I
O
N
(Determination)
Participant
• Motivation for change
evolves into a plan of
action
• Gathers knowledge and
resources necessary for
change
•patient begins to set
goals with timelines
Helper
•Explore patient goals
• Change plan should be
acceptable, accessible
and effective
• Identify and trouble
shoot barriers and
triggers
• Identify supports
• patient could get
overwhelmed or stuck
• Menu of options
The Stages of Change
Stage
A
C
T
I
O
N
Participant
Helper
• Implement plan
• Careful listening
• patient begins to modify
behavior
• Affirmation
• Gives greatest commitment –
time and energy
• Review plan with
patient
for revisions
• Most visible to others
• Plan for relapse
• Build self-efficacy!
• Action is not changebut a step in the
The Stages of Change
Stage
M
A
I
N
T
E
N
A
N
C
E
Participant
Helper
• Sustains behaviors
• Careful listening
• It takes time to make actions
into established behaviors
• Affirmation
• Identify triggers
• Work with relapse triggers
• Anticipate unexpected
stressors
• Realize that relapse is a
potential part of the process
not failure
• Plan for potential
relapsing situations
The Stages of Change
Stage
R
E
L
A
P
S
E
Participant
Helper
• Fear that the habit is stronger
than they are
• Opportunity for both
to learn
• Takes place gradually after
initial slipup
• Normalize relapse
• Self-efficacy erodes
• Help patient to understand the cycle of
change
• Strong unexpected urge
• Tweak the plan
• Relaxed guard
• Didn’t realize the cost of the
change
Use of Change Rulers in Brief Intervention
0 - - - - - - - - > 10
SCALE
 Readiness
 Confidence
 Importance
0
I
M
P
O
R 0
T
A
N
C
E
Low Importance
Low Confidence
Low Importance
High Confidence
10
High Importance
Low Confidence
High Importance
High Confidence
10
CONFIDENCE
Screening and Brief Intervention
Draft Module V: Building Motivation
• Decisional balance sheet
• Assist the patient in becoming
action-oriented; making some
commitment to change and following
through
• Values clarification
Building Motivation
• Focus on steps patient plans to take
• Assist patient in identifying supports
for behavior change
• Assist patient in identifying barriers for
behavior change
• Focus on solutions
Person-Centered Counseling (OARS)
 Open-ended questions
 Affirmations
 Reflective Listening
 Summary
OARS: Open-Ended Questions
 What
 How
 Tell me
OARS: Affirmations
 Positive language
 Past successes
 Pats on the back
OARS: Reflections
 Thoughts
 Feelings
 Behavior
 Ambivalence
OARS: Summary
 Collecting
 Linking
Transitional
Motivational Interviewing Guiding Philosophy
“The strategies of Motivational Interviewing are
more persuasive than coercive, more supportive
than argumentative. The clinician seeks to
create a positive atmosphere that is conducive
to change. The overall goal is to increase the
patient’s intrinsic motivation, so that change
arises from within rather than being imposed
from without. When this approach is done
properly, it is the patient who presents the
arguments for change, rather than the clinician.”
Miller and Rollnick (1991, p. 52)
Motivational Interviewing
Influencing behavior change involves:
• Identifying the level of readiness for change
• Gathering information in a non-judgmental way
(conversational tone)
• Negotiating an action plan with the patient, using
the information the patient has provided as well as
objective information, to move the patient to the
next level of readiness to change.
The “SPIRIT” of Motivational Interviewing
EXPRESS
EMPATHY
DEVELOP
DISCREPANCY
Motivational Interviewing is not a technique,
but more of a style, a facilitative way of
being with people
ROLL
WITH
RESISTANCE
SUPPORT
SELF
EFFICACY
Motivational Interviewing (ADRES)
 Amplify Ambivalence
 Develop Discrepancy
 Roll with Resistance
 Express Empathy
 Support Self Efficacy
Amplify Ambivalence AA
• Ambivalence is normal
• Exploring ambivalence helps
remove obstacles
• Resolving ambivalence moves toward
behavior change
Develop Discrepancy DD
• The patent should present the argument for
change
• Change is motivated by perceived conflict
between present behavior and personal
goals and values
• Triggered by awareness of and discontent
with costs of one’s present behavior and
perceived advantage of change
Roll with Resistance RR
• Avoid arguing for change
• Do not directly oppose patient
• New perspectives invited but not
imposed
• A signal to change strategy and
respond differently
• Involves patient actively in the process
of problem-solving
Express Empathy EE
• Acceptance facilitates change
• The key to expressing empathy is
reflective listening.
• Listening in a supportive, reflective
manner; demonstrating you understand
their concerns and feelings without
judging, criticizing or blaming.
Support Self-Efficacy SS
• Belief in the possibility of change
• The patient, not the provider, is responsible
for choosing and carrying out change
• Provider’s belief in the patent’s ability to
change
• A reasonably good predictor of treatment
outcomes
• Enhances a patent’s confidence in his/her
capability to cope with obstacles and to
succeed in change
Patient Change Talk (DARN-C)
 Desire
 Ability
 Reason
 Need
 Commitment
DARN-C: Desire
Importance
Commitment
Confidence
DARN-C: Ability
 Knowledge
 Skill
 Confidence
DARN-C: Reasons
 Disadvantages
 Advantages
 Optimism
 Intention
 Successes
DARN-C: Need
 Physical
 Psychological
 Cognitive
 Relational
DARN-C: Commitment
 Motivation
 Confidence
Screening and Brief Intervention
Draft Module VI: Brief Treatment
• Brief Treatment: If individuals are at
moderate to high risk, the next step is brief
treatment. Similar to brief intervention, this
emphasizes motivations to change and
patient empowerment, though it consists
of a limited number of highly focused and
structured clinical sessions with the
purpose of eliminating hazardous and/or
harmful alcohol and/or substance use.
Screening and Brief Intervention
Draft Module VII: Referral to Treatment
Referral to Treatment: For those whose
screening indicates a severe problem or
dependence, the next step is referral to
substance abuse treatment.
Referral for Treatment
• When using BI for referral, having information about and
linkage to the available treatment providers is necessary
- Levels of care including detoxification, outpatient, day
treatment and residential programs
- Connections for mental health providers to address
co-occurring disorders
- Halfway houses and group homes for patients in need
of living arrangements
- Local mutual self-help groups, individual counselors
and other supportive community services