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

Source: Mokdad AH, Marks JS, Stroup DF, Geberding JL, JAMA 2004;291:1238-1245

Actual Causes of Death, United States, 2000

Excess alcohol consumption is the third leading “actual” cause of death

Nationwide, alcohol kills more than twice as many people

as illicit drugs

Source: McGinnis JM and Foege WH. Proc Ass Am Physicians 1999;111:109-118

105,000

38,900

0

40,000

80,000

120,000

Alcohol Illicit Drugs

Death

s

Estimated prevalence of Binge Drinking

Estimated prevalence of Heavy Drinking

Drinking patterns vary by neighborhood in NYC

1 in 10 of all hospitalizations in NYC are alcohol-related

9 9.3 9.6 9.6 9.810.1 10.1 10

6.46.877776.8

6.5

1.6 1.5 1.6 1.5 1.7 2 2.2 2.4

0

2

4

6

8

10

1999 2000 2001 2002 2003 2004 2005 2006

Year

Per

cen

t

Source: NYS DOH SPARCS, 2006

Any Alcohol

Alcohol Dependence

Alcohol Abuse

Alcohol-related ED visits are increasing in NYC

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

2004 2005 2006 2007 2008 2009

Year

Pe

rce

nt

of

To

tal E

D V

isit

s

21 to 64

12 to 20

Source: NYC DOHMH Syndromic

Among underage drinkers, alcohol-related ED visits have nearly doubled

Source: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2008 (11/2009 update).

139.5

179.2

198.4

244.8

264.2

0

50

100

150

200

250

300

2004 2005 2006 2007 2008Year

Rate

per

100,0

00 P

op

ula

tio

n

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 SBIRTSource: SAMSHA/CSAT, 2005

Overall, what do we hopeSBIRT 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 non-Medicare 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 InterventionDraft 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:- resistance met with argumentation and correction

- goals and strategies for change are prescribed for the patient since patient is seen as incapable of making sound decisions

• Motivational:- resistance is met with reflection

- 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 drinkingTypical quantity

Frequency of heavy drinking

Dependence Symptoms 4 5 6

Impaired control over drinkingIncreased salience of drinking

Morning drinking

Harmful Alcohol Use 7 8 9

10

Guilt after drinkingBlackouts

Alcohol-related injuriesOthers concerned about drinking

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 High Level of Alcohol Problems and Possible Dependence

20-40 IV 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

ScoresAUDIT Score Risk Level Intervention

0-7 Zone I 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. Have you used drugs other than those required for medical reasons?

2. Do you abuse more than one drug at a time?

3. Are you unable to stop using drugs when you want to?

4. Have you ever had blackouts or flashbacks as a result of drug use?

5. Do you ever feel bad or guilty about your drug use?

DAST-10:Timeframe: last 12-months

6. 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)?

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 InterventionDraft 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 InterventionDraft 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

RELAPSE Help renew contemplation,

preparation, and action without giving up.

MAINTENANCE

Identify Strategies and support to

prevent relapse.

PRE-CONTEMPLATION

Doesn’t see behavior as a problem.

PREPARATION

“I’ve got to do something about this

problem.” “This is serious. Something has to change.” /30

days

ACTIONContinued new

behavior for more than 6 mos.

CONTEMPLATIONAmbivalence Reasons for concern vs.

justifications for concern . Begin change within

6mos.

Stages of Change

• 80% of substance mis-users are in pre-contemplation or contemplation

• Define success by the movement from one stage to the next

The Stages of ChangeStage Participant Helper

PRECONTEMPLATION

• May or may not be aware of the problem • Overwhelmed, hopeless

• Resigned, low energy, hostile

• High energy, no feeling of control

• Denial, little or no fear of consequences

• Minimizes harmful consequences.

• Build trust and rapport

• Non-judgmental

• Accept autonomy

• Empathize, Help clarify

• Look for ambivalence

• Identify participant goals

• Provide information

• Focus on safety

The Stages of ChangeStage Participant Helper

CONTEMPLATION

• Acknowledges that a problem exists

• Ambivalence is high

• Struggles to under- stand the problem and possible causes and solutions

• Considers action (may take time)

• Build trust and rapport

• Clarify ambivalence-tip the balance!

• 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 Participant Helper

PREPARATION

(Deter-mination)

• Motivation for change evolves into a plan of action

• Gathers knowledge and resources necessary for change

•patient begins to set goals with timelines

• patient could get overwhelmed or stuck

•Explore patient goals

• Change plan should be acceptable, accessible and effective

• Identify and trouble shoot barriers and triggers

• Identify supports

• Menu of options

The Stages of ChangeStage Participant Helper

ACTION

• Implement plan

• patient begins to modify behavior

• Gives greatest commitment – time and energy

• Most visible to others

• Careful listening

• Affirmation

• Review plan with patient for revisions

• Plan for relapse

• Build self-efficacy!

• Action is not change- but a step in the process of changing

The Stages of ChangeStage Participant Helper

MAINTENANCE

• Sustains behaviors

• It takes time to make actions into established behaviors

• Work with relapse triggers

• Realize that relapse is a potential part of the process not failure

• Careful listening

• Affirmation

• Identify triggers • Anticipate unexpected stressors

• Plan for potential relapsing situations

The Stages of ChangeStage Participant Helper

RELAPSE

• Fear that the habit is stronger than they are

• Takes place gradually after initial slipup

• Self-efficacy erodes

• Strong unexpected urge

• Relaxed guard

• Didn’t realize the cost of the change

• Opportunity for both to learn

• Normalize relapse

• Help patient to under- stand the cycle of change

• Tweak the plan

Use of Change Rulers in Brief Intervention

0 - - - - - - - - > 10SCALE

Readiness Confidence Importance

0

IM Low Importance Low ImportanceP Low Confidence High Confidence OR 0 10TA N High Importance High ImportanceC Low Confidence High ConfidenceE

10

C O N F I D E N C E

Screening and Brief InterventionDraft 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

EXPRESSEMPATHY

Motivational Interviewing is not a technique, but more of a style, a facilitative way of

being with people

DEVELOPDISCREPANCY

ROLLWITH

RESISTANCE

SUPPORTSELF

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 InterventionDraft 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 InterventionDraft 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