BNI-ART InstituteBU School of Public Health & Boston Medical Center

Brief Intervention

Brief Negotiated Interview (BNI)

& Motivational Interviewing

How To Do…

SBIRT Toolbox Outline

• Motivational Interviewing principles

and skills practice

• Brief Negotiated Interview algorithm

• Live demonstration

• Practice SBIRT with case studies

WHY DO SBIRT?• 200 Homeless patients with alcohol dependence

MGH ED in 1962

Chafetz et al. Establishing treatment relations with alcoholics.. J Nerv Ment Dis 1962; 134: 390-410.

65%

40%

5%0%

0%

10%

20%

30%

40%

50%

60%

70%

showed fortreatment

kept 5 appts

BI GroupControls

Two Approachesto talking to patients about alcohol or drugs

Doctor A Doctor B

Blaise Pascal: Pensées

“People are generally better persuaded by the

reasons which they have themselves discovered than by those

which have come in to the mind of others.”

Motivational Motivational Interviewing (MI)Interviewing (MI)

• Patient-centered

• Goal-directed (behavior change)

• Helps resolve ambivalence

A-C-E• affirms client’s Autonomy

• Collaboration between pt & practitioner

• Elicits patient’s intrinsic motivation & reasons for change

Motivational

InterviewingStandard of Care

Brief Negotiated Interview:

A collaborative conversation about health

promotion (shared agenda)

• patients as expert in their lives

• listening not telling

– silence

– OARS

• open-ended questions, affirmations,

reflective listening, summaries

Patient Voice and Choice

OARS: Closed v.s. Open Questions

OPEN

• What worries you

most about your

current situation?

• What changes have

you noticed?

• How so?

CLOSED

• Are you worried about

your current situation?

• Have you noticed

changes?

• Do you care

about your health?

OARS: Affirmations Statements and gestures that recognize

strengths and acknowledge behaviors that lead in the direction of positive change

– I am really impressed with the way you….

– That’s great how you’ve reached your goal of cutting back on your drug use.

– Using protection shows that you have real respect for yourself and your partners.

Communication ModelFrom Thomas Gorden

The Words the Listener Hears

What the Listener Thinksthe Speaker Means

The Words theSpeaker Says

What the Speaker Really Means

1 3

4

2

OARS: Reflective Listening3 Levels

• Repeat - restate using the same words• Rephrase - use synonyms • Paraphrase - infer meaning behind the words or

emphasize emotional aspects

Client: “I got jumped outside the bar. They probably saw me as an easy mark because I was stumbling a little bit. It really sets me off.”

Practitioner: “You don’t like being unable to defend yourself.”

OARS: Summaries• Transition or ending statements• Collect “change talk” statements• Present bouquet of patient’s own

reasons for change

Summary Intros:

“Here is what I’ve heard so far…..What did I miss?

“We’ve gone over quite a bit. Let me make sure I am understanding you…”

Brief Negotiated Interview:

• Guiding not directing– avoid the “righting reflex”

• Client as decision maker

Patient Voice and Choice

OARS Tally

In His Own WordsDr. Miller explains MI

http://vimeo.com/20901845

The BNI Algorithm

Would you mind taking a few minutes to talk about your [X] use? Before we go further, I’d like to learn a little more about you.What is a typical day like for you?Where does your [X] use fit in?

1. Build rapport

BNI ALGORITHM

Help me understand through your eyes the good things about using [X]? What are some of the not so good things about using [X]?

2. Ask about Pros & Cons

So on the one hand you said <PROS>, and on the other hand <CONS>. Summarize

Ask permission

Give information

Elicit reaction

BNI ALGORITHM

I have some information on low-risk guidelines for drinking, would you mind if I shared them with you?

We know that drinking • 4 or more (F)/ 5 or more (M) in 2hrs • more than 7(F)/14(M) in a week • use of illicit drugs can put you at risk for illness and injury. It can also cause health problems like [insert medical information].

What are your thoughts on that?

3. Feedback

4. Readiness to Change

BNI ALGORITHM

This Readiness Ruler is like the Pain Scale we use in the hospital. On a scale from 1-10, with one being not ready at all and 10 being completely ready, how ready are you to change your [X] use? You marked ___. That’s great. That means you’re ___% ready to make a change.

Why did you choose that number and not a lower one like a 1 or 2?

Readiness ruler

Reinforce positives

1 2 3 4 5 6 7 8 9 10

Create action plan

BNI ALGORITHM

What are some options/steps that will work for you? What do you think you can do to stay healthy and safe? What will help you to reduce the things you don’t like about using [X]?

Tell me about a time when you overcame challenges in the past. What kinds of resources did you call upon then? Which of those are available to you now?

Identify strengths & supports

BNI ALGORITHM

Those are great ideas! Is it okay for me to write down your plan, your own prescription for change, to keep with you as a reminder?

Will you summarize the steps you will take to change your [X] use?

I’ve written down your plan, a prescription for change, to keep with you as a reminder.

5. Prescription for Change

Write down action plan

BNI ALGORITHM

Give referrals if appropriate:-Outpatient counseling-Suboxone, methodone clinic-Needle exchange-NA/AA-Primary Care-Mental Health-Shelter-Handouts/Information

Thank you for sharing with me today.

Seal the deal

Thank the patient

The BNI in practiceHaving a conversation with a heroin user