Preparing Your Health Center for SBIRT Implementation

Christina Boyd, LSCSW, LCAC

Closer Look at Brief Interventions

Week #2

Agenda

• Check In

• Review Learning Activity-Discuss Video and review scoring of AUDIT and DAST

Welcome

• Motivating People to Change

• Using Brief Intervention Skills

• Brief Negotiated InterviewPresentation

• Preview of next week

• Assign Learning Activity- Videos and Proficiency checklist

• Questions

Summary

You Watched the Video…

➢What did you think?

How did the scoring go?Let’s Talk about your

Learning Activity!

Why are we looking at all of this??

• SAMHA SBIRT• https://www.samhsa.g

ov/sbirt

• IRETA Online Training and Toolkit and Webinars

• https://ireta.org/resources/sbirt-101/

• https://ireta.org/resources/sbirt-toolkit/

• https://ireta.org/?sfid=243&_sft_resource_type=webinar

• On-line Training and other Resources

• http://www.sbirt.care/Resources

Full Screening Tools-Targeted for those positive on Brief Screen

AUDIT: Alcohol Use Disorder Identification Test

DAST: Drug Abuse Screening Test

ASSIST: Alcohol, Smoking, and Substance Abuse Involvement Screening Test

GAIN or GAIN-SS: Global Appraisal of Individual Needs

5Ps Plus: For pregnant and post-partum women

CRAFFT: Car, Relax, Alone, Forget, Family or Friends, Trouble (adolescents)

AUDIT: Alcohol

NWATTC SBIRT Slides, 2014

Risk Levels

Severe

Harmful

Risky

IV

III

II

I

Low Risk or Abstain

Score Risk Level

14+Zone 4: Severe Use, Probable SubstanceUse Disorder

10-13 Zone 3: Harmful Use

4-9 Zone 2: Risky Use

0-3 Zone 1: Low Risk Use

What do the AUDIT Scores Mean?

Severe

Harmful

Risky

IV

III

II

I

Low Risk or Abstain

Risk Levels

• Positive health message –describe low-risk levels

• Low risk is not necessarily NO risk

Recommended Intervention

• Patient NOT at risk for health or social complications based on alcohol use

Zone 1 defined: 0-3

NWATTC SBIRT Slides, 2014

What do the AUDIT Zones Mean?

NWATTC SBIRT Slides, 2014

Severe

Harmful

Risky

IV

III

II

I

Low Risk or Abstain

Risk Levels

• Brief Intervention (BI) with goal of reducing alcohol use

Recommended Intervention

• Alcohol use likely leads to new health problems or makes existing ones worse

• An individual can fall into this zone based on amount of alcohol use alone (no negative consequences)

Zone 2 defined: 4-9

What do the AUDIT Zones Mean?

NWATTC SBIRT Slides, 2014

Severe

Harmful

Risky

IV

III

II

I

Low Risk or Abstain

Risk Levels

• Brief Intervention to reduce or abstain (Brief Treatment if available) and specific follow-up appointment

Recommended Intervention

• Patient has experienced repeated negative consequences

• Patient continues to use despite persistent problems

Zone 3 defined: 10-13

What do the AUDIT Zones Mean?

NWATTC SBIRT Slides, 2014

Severe

Harmful

Risky

IV

III

II

I

Low Risk or Abstain

Risk Levels

• Brief Intervention to accept referral to specialist treatment for diagnostic evaluation

Recommended Intervention

• Multiple signs of substance use disorder, such as:– Negative consequences; tolerance;

withdrawal; uncontrolled use

• Is not a diagnosis in and of itself

Zone 4 defined: 14+

What do the AUDIT Zones Mean?

DAST: Drugs

DAST-10 ScoringScore Degree of Problems r/t Drug

Abuse

Suggested Action

0 No Problem Reported None at this time

1-2 Low Level Monitor, Reassess at a Later Date

3-5 Moderate Level Further Investigation

6-8 Substantial Level Intensive Assessment

CRAFFT: Adolescents

12-18

• Standardized tools to quickly assess risk level

• Pre-screen - universal

• Full Screen - targetedScreening

• Help patients understand their substance use and health impact; motivate behavior change.

Brief Intervention

• Help patients showing signs of a substance use disorder to access specialty care.

Referral to Treatment

SBIRT: Brief

Intervention

Helping someone to find

Motivation

to make a Change

that is

Really,

really, really

Hard

The Spirit of Motivational Interviewing

Motivational interviewing is a counseling style based on the following assumptions:

• Ambivalence about continued substance use and change is normal.

• Ambivalence can be resolved by working with your patient's intrinsic motivations and values.

• The alliance between you and your patient is a collaborative partnership to which you each bring important expertise.

TIP #35 SAMHSA

Sustain Talk

Change Talk

Ambivalence

Exploring Ambivalence….

Think about a change you are trying to

make…

SBIRT Provider Card

READINESS RULER

• Standardized tools to quickly assess risk level

• Pre-screen - universal

• Full Screen - targetedScreening

• Help patients understand their substance use and health impact; motivate behavior change.

Brief Intervention

• Help patients showing signs of a substance use disorder to access specialty care.

Referral to Treatment

SBIRT: Screening

Forrest = • Spirit of Motivational Interviewing• Motivate the patient to consider

changing behavior

Trees = • Brief Intervention

Steps

Brief Intervention –See the Forrest, Not Just the Trees

Rollnick, Miller, Butler, 2008

FollowingGuidingDirecting

Which Communication Styles Do You Use with Patients, and When?

Oregon SBIRT Primary Care – Curriculum Module II

Directive Communication Guiding Communication

• Explain why • Respect for autonomy, goals, values

• Tell how • Readiness to change

• Emphasize importance • Ambivalence

• Persuading • Empathy, non-judgment, respect

• Clinician is the expert • Patient is the expert

Communication Styles

What Makes Brief Intervention Different?

MI Spirit = Essential for effective BI

Partnership

Evocation

Compassion

Acceptance

Sustain Talk

Change Talk

Ambivalence

Exploring Ambivalence: What is it?

Sailing through Sustain Talk

• “I just have a couple of drinks to help me relax.”

• “I’m not paying you to talk to me about drinking! Geez, I’m just here for a cold.”

• “Everyone smokes a little weed.”

• “Sure once in a while I drink more than I should, but it doesn’t cause any major problems in my life.”

• “My dad was an alcoholic. I don’t drink like him.”

Sailing through Sustain Talk:Pause and Reflect

“You are the only one who can decide what the best thing for you is relative to your use of alcohol.”

“I’m not here to tell you what to do. I’m just interested in finding out what some of your thoughts are and sharing some information with you.”

“It’s totally up to you whether you make a change.”

“You may, or may not, decide to make a change based on our conversation today.”

Sailing through Sustain Talk: Support Patient Choice

• A few good reasons to make the change

• How they could change

• How important it is to change

• Persuade

• If you meet resistance, REPEAT!

(This is NOT using the spirit of motivational interviewing)

Dyad Practice

• How would you make this change?

• What are the 3 best reasonsto do it?

• On a scale from O to 10, how important would you say it is for you to make this change?

• Why are you not a zero?

• Give a short summary

• So what do you think you’ll do?

. . . and just listen.Dyad Practice - With a Twist

“People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the mind of others.”

—Blaise Pascal

Quote

SAMHSA SBIRT, 2013

•Open-ended questions

•Reflections

•Summaries

3 Core MI Skills Used in BIs

SAMHSA SBIRT, 2013

• What are open-ended questions?• Gather broad descriptive information

• Require more of a response than a simple yes/no or fill in the blank

• Often start with words such as—• “How…”

• “What…”

• “Tell me about…”

• Usually go from general to specific

Open-Ended Questions

39

✓Ask for examples & elaboration

✓ Anticipate response

✓Try: How…What…Tell me…

• Not yes/no or brief answer

• Not fact-finding

• Rather than: Why?

Open-ended inquiry

• What does your drug use do for you?

• How many drinks do you have on a typical day?

• What are the pros and cons of your drinking?

• Did you know your drinking could be causing your acid reflux symptoms?

• What do you think about that?

• Where are you from?

Closed- or Open-Ended Questions

2. Reflective Listening

• Reflective listening is one of the hardest skills to learn.

• Without reflections it isn’t MI

• “Reflective listening is a way of checking rather than assuming that you know what is meant.”

(Miller and Rollnick, 2002)

42

• Statements. Not questions• What you hear, what you observe• Not problem solving or advice• Selective & intentional• Simple to complex

Reflections

SAMHSA SBIRT, 2013

• Demonstrates you have heard and understood the patient

• Strengthens the empathic relationship

Why Reflective Listening?

44

Alcohol doesn’t pose any problems

for you and if it did you would do

something about it.

Hanging out with your friends is an

opportunity to relax.

Drinking is not a problem.

“I like to chill with my friends. I’m not going to quit drinking because it’s not a problem.”

Summaries

• Examples

• “So, let me see if I’ve got this right…”

• “So, let me summarize what we’ve talked about”

• “Make sure I’m understanding exactly what you’ve been trying to tell me…”

• Double sided reflections are often highly effective as summaries to illustrate ambivalence.

• “On the one hand, you like a, b, c about your drug use, AND on the other hand, you don’t like x, y, and z.”

When patients feel understood they are more likely to strengthen self-esteem, become intrinsically motivated, be more willing to trust and talk about making changes. (SAMHSA SBIRT, 2013)

Why Summarize?

The Yale Brief Negotiated Interview, Manual D’Onofrio, et al. 2005

* Miller and Tonnigan, 1996; Prochaska and DiClemente, 1992

• Developed for use in emergency rooms –D’Onofrio et al., 2005

• Adapts spirit and skills from Motivational Interviewing*

❑ Patient-centered, collaborative approach

❑ Goal-directed conversation method used to enhance patient’s own motivation to change

❑ Recognizes patient’s conflicting feelings about a particular behavior change

Brief Negotiated Interview (BNI)

Negotiate plan

Enhance motivation

Provide feedback

Raise the subject

The Yale Brief Negotiated Interview Manual, D’Onofrio, et al. 2005

STEP 4STEP 3STEP 2STEP 1

Brief Negotiated Interview Steps

3

21 Use Your Tools

Making a Referral to

Treatment and Warm

Handoffs

Sneak Peek at next week ….

Watch Videos and Consider Questions

-

Complete Proficiency Checklist

Learning Activity-Week #2

QUESTIONS?