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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 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