2. week-2 powerpoint-sbirt_feb-2019

1. Preparing Your Health Center for
SBIRT Implementation
Christina Boyd, LSCSW, LCAC

2. Closer Look at Brief Interventions
Week #2

3. 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 Interview
Presentation
• Preview of next week
• Assign Learning Activity- Videos and
Proficiency checklist
• Questions
Summary

4. You Watched
the Video…
➢What did
you think?
How did the
scoring go?Let’s Talk about your
Learning Activity!

5. Why are we
looking at
all of this??

6. • SAMHA SBIRT
• https://www.samhsa.g
ov/sbirt
• IRETA Online Training and
Toolkit and Webinars
• https://ireta.org/resourc
es/sbirt-101/
• https://ireta.org/resourc
es/sbirt-toolkit/
• https://ireta.org/?sfid=2
43&_sft_resource_type
=webinar
• On-line Training and other
Resources
• http://www.sbirt.care/Resources

7. 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)

8. AUDIT:
Alcohol

10. 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 Substance
Use 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?

11. 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?

12. 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?

13. 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?

14. 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?

15. DAST: Drugs

16. DAST-10 Scoring
Score 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

17. CRAFFT:
Adolescents
12-18

18. • Standardized tools to quickly assess risk level
• Pre-screen - universal
• Full Screen - targeted
Screening
• 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

19. Helping someone
to find
Motivation
to make a
Change
that is
Really,
really, really
Hard
The Spirit of
Motivational Interviewing

20. 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

21. Sustain
Talk
Change Talk
Ambivalence
Exploring Ambivalence….

22. Think about a
change you
are trying to
make…

23. SBIRT Provider Card

24. READINESS RULER

25. • Standardized tools to quickly assess risk level
• Pre-screen - universal
• Full Screen - targeted
Screening
• 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

26. 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

27. Rollnick, Miller, Butler, 2008
FollowingGuidingDirecting
Which Communication Styles Do You Use with
Patients, and When?

28. 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?

29. MI Spirit =
Essential for
effective BI
Partnership
Evocation
Compassion
Acceptance

30. Sustain
Talk
Change
Talk
Ambivalence
Exploring Ambivalence: What is it?

31. Sailing through
Sustain Talk

32. • “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

33. “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

34. • 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

35. • How would you make this
change?
• What are the 3 best reasons
to 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

36. “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

37. SAMHSA SBIRT, 2013
•Open-ended
questions
•Reflections
•Summaries
3 Core MI Skills Used in BIs

38. 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. 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

40. • 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

41. 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. 42
• Statements. Not questions
• What you hear, what you observe
• Not problem solving or advice
• Selective & intentional
• Simple to complex
Reflections

43. SAMHSA SBIRT, 2013
• Demonstrates you have heard and
understood the patient
• Strengthens the empathic relationship
Why Reflective Listening?

44. 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.”

45. 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.”

46. 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?

47. 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)

48. 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

49. 3
21 Use Your Tools

51. Making a
Referral to
Treatment and
Warm
Handoffs
Sneak Peek at next
week ….

52. Watch Videos and Consider
Questions
-
Complete Proficiency Checklist
Learning Activity-Week #2

53. QUESTIONS?