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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. - PowerPoint PPT Presentation
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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