In this 1 hour introductory lecture you will learn about brief intervention At the end of this session you should be able to: Understand what is meant by “brief intervention” Recognise the Stages of Change and how they relate to brief interventions Describe the FRAMES approach to Motivational Interviewing Translate examples of BI in the alcohol field to the wider substance misuse arena

2. How to do a brief intervention
Advanced Clinical management of Addiction
Dr Bob Patton
Addictions Department

3. In this 1 hour introductory
lecture you will learn about brief
intervention
At the end of this session you should be
able to:
Understand what is meant by “brief
intervention”
Recognise the Stages of Change and how
they relate to brief interventions
Describe the FRAMES approach to
Motivational Interviewing
Translate examples of BI in the alcohol
field to the wider substance misuse arena

4. Introduction
In todays lecture we will cover the basics of how
to deliver a brief intervention, covering
identification & brief advice (IBA), the Stages of
Change, and FRAMES based approaches.
As my background is in alcohol research, I will be
utilising examples from work that I have been
involved with, however the principles remain
valid across all areas of substance misuse.

5. Features of Brief Interventions
A family of interventions ranging from a few minutes of
simple, but structured, advice to 20 minutes counselling
with repeat consultations.
Two basic levels of brief intervention:
• simple structured advice ~ 1-2 minutes to deliver.
• brief counselling (extended brief intervention) ~ 10-20
minutes.

6. Features of Brief Interventions
Brief interventions can be delivered by different practitioners in
community settings, e.g. GPs, practice nurses, health visitors,
dieticians and other primary health care professionals in the
normal course of their work.
They can also be delivered by more specialist workers (CPNs,
lifestyle counsellors, alcohol health workers).
Normally aimed at a goal of harm reduction(i.e., under medically
recommended levels).
But patients who prefer to become abstinent should not be
discouraged.

7. Brief Interventions
• Time-limited, structured.
• Self-help.
• Prevention strategy.
• Orientated to reduction in use rather than
abstinence.
• Not teaching specific skills.
• Not changing social environment.

8. Brief Intervention for alcohol
• Describes short information and
advice sessions where patients
are given motivational
interviewing / counselling and
may be referred on to specialist
agencies
• Assessment of alcohol
consumption
• Provision of guidance / advice
• One or more sessions
• Aims to convince recipient that
they are drinking at a level that
could be harmful to their health

9. Identification & Brief Advice
Detection with an appropriate screening tool is
followed by the delivery of an intervention.
This could be an information booklet, a few
minutes of focused dialogue or a longer in-
depth assessment and either a motivational
intervention or onward referral to specialist
services.

10. Screening (Alcohol)
Although the recording of an alcohol history should form
part of routine clinical practice, ambiguity regarding the level
of consumption regarded as problematic may lead
physicians to overlook potential alcohol problems.
We know that using a specialist screening tool detects
almost twice as many hazardous drinkers as staff relying
upon their clinical intuition alone.
AUDIT FAST
CAGE SASQ
PAT AUDIT - C

11. CAGE
• C Have you ever thought you should CUT DOWN on your
drinking?
• A Have you ever felt ANNOYED by others' criticism of your
drinking?
• G Have you ever felt GUILTY about your drinking?
• E Have you ever had a drink first thing in the morning to
steady your nerves or to get rid of a hangover (EYE-
OPENER)?
The CAGE screening test is short and easy to administer. Two or
more positive answers are correlated with alcohol misuse in
90% of cases.

12. The AUDIT was developed
by the World Health
Organization to identify
persons whose alcohol
consumption has become
hazardous or harmful to their
health.
AUDIT is a 10-item
screening questionnaire with
3 questions on the amount
and frequency of drinking, 3
questions on alcohol
dependence, and 4 on
problems caused by alcohol.
A score of 8+ is indicative of
alcohol misuse.
The AUDIT

13. AUDIT-C

14. © SIPS
The FAST
alcohol
screening
test

15. The Paddington Alcohol Test
A brief
instrument that
measures
quantity /
frequency of
consumption.
Designed for
use in busy ED
settings.

16. M-SASQ
M-SASQ comprises only question 3 from the full AUDIT and will
identify very quickly whether or not a patient's drinking is
beyond lower risk (Fig 1). It is simple enough that, with a little
practice, practitioners can usually deliver the question orally and
mentally calculate a score.

17. Which screen?
• As the variety of settings in which SBI can be delivered in is so wide,
practitioners will need a variety of tools from which to choose:
• In most situations there will be time to spend 2 or 3 minutes completing a
full AUDIT, which will give an accurate indication of the patient's level of
risk and possible dependence
• Where there is less time, AUDIT-C might be used or the three questions
asked orally
• For occasions where there is really very little time, or the patient appears
unlikely to submit to any screening, there is the modified single alcohol
screening question (M-SASQ), which uses one question to establish
simply whether the patient is drinking above lower risk levels or not. The
question can be asked orally, even conversationally, to establish whether
it would be appropriate to deliver brief advice.

18. The Teachable Moment
Interventions are best delivered at a
time of accident, illness or crisis.
This is called the teachable
moment.
To maximise attendance the delay
between identification and
intervention should be minimal,
preferably on the same day.
Patient selection of an appointment
could offer a compromise
Williams S, Touquet R & Patton R, 2005, The Half-Life
of the ‘Teachable Moment’ for Alcohol Misusing
Patients in the Emergency Department, Drug &
Alcohol Dependence, 77(2):205-208

19. Stages of change (i)
Not everyone is ready for an intervention.
Prochaska & DiClemente (1992) devised their
Stages of Change model to illustrate the
processes an individual must go through in
order to effect a change in behaviour:

21. Stages of change (ii)
Pre-contemplation ~ Not considering any change
Contemplation ~ Thinking about change
Preparation ~ Gathering info, making a plan
Action ~ Changes are being made
Maintenance ~ New behaviours are preserved
Brief interventions can be tailored to suit
whatever stage of change the patient is at,
with a goal to move them to the next level.

22. A middle-aged business woman attends her
doctor’s surgery with concerns about her
weight and insomnia. During her consultation
she mentions her alcohol consumption twice.
In relation to her alcohol use, in which stage of
the change cycle is she most likely to be?
Contemplation

23. A graduate in his first job with an active social life complains of
feelings of anxiety. Further discussion discovers that he is having
problems in his relationship and, when asked, he claims not to
drink much - about four pints a night and eight on a Saturday.
In relation to his alcohol use, which stage of the change cycle is
he most likely to be in?
Pre-contemplation

24. A man in his 60s who has a history of high blood
pressure, high blood sugar levels and who has
recently experienced chest pains, consults a
specialist. He decides to start using a drinks
diary to record the number of units he
consumes each week. Which stage of the
change cycle is he most likely to be in?
Preparation

25. Brief Interventions - Steps
1. Screening
2. Assessment
3. Advice giving
4. Assessing motivation for change
5. Establishing drinking goals
6. Conducting follow-up

26. Enhancing Motivation for Change: FRAMES
• Feedback (personalized, non-judgmental)
• Responsibility (respect for autonomy)
• Advice (clear and timely)
• Menu of options (what works for you?)
• Empathy (reflective listening)
• Self-efficacy (offer optimism and hope

27. Evidence of Effectiveness
A recent review of reviews (O’Donnell et al, 2014) found that BI was
consistently effective at reduction both consumption and harm in both
hazardous and harmful drinkers.
Most effective among Male, Middle Aged patients. The evidence on its
effectiveness on an adolescent population is less clear cut (Pilowsky & Wu,
2013)
However the design of the trials themselves can influence outcomes.
Reactivity to screening refers to the potential intervention that screening and
baseline measurement of behaviour might represent (McCambridge & Kypri,
2011)

28. Evidence of effectiveness cont…
 Estimates of number needed to treat (NNT) range from 2 to
12.
 Compares favourably with smoking cessation advice (NNT =
20).
 Some recent evidence of a reduction in mortality following
screening and brief intervention.
 Also evidence of reductions in number of alcohol-related
problems.
 Effects of intervention still present after 4 years in one US
study and after 10-16 years in a Swedish study, though an
Australian study did not find an effect after 10 years.

29. An example of brief advice
This is taken from the SIPS training programme and is
an illustration of how a health worker can help a
client work out how much they are drinking, how
risky that is, and what can be done.

30. Using the Brief Advice Tool

31. Using the Brief Advice Tool

32. Brief Advice Delivery Structure
1. Start with general information regarding drinking that increases risk of
harm.
2. Give the patient an opportunity to consider what this means to them.
3. Show the patient how their drinking compares with the general
population.
4. Go through the benefits of reducing drinking.
5. Look at strategies for reducing drinking.
6. Discuss the sensible drinking targets they should aim for.
“Your drinking places you at an increased level of risk, you can work
out where you would fit in this table by counting the units you drink…
some of the effects of drinking at this level could be..”
“ How do you feel about this?”

33. Training video – Brief Advice
• Add links to the Alcohol Learning Centre
training videos here

34. Talking to people about their alcohol consumption can be quite emotive and
helping them to recognise ways in which they could reduce their alcohol
intake requires skill.
Which of the characteristics listed below do you think would be useful?
Select one or more options ...
• A. A blaming or confrontational attitude
• B. Empathy
• C. A practitioner-centred approach
• D. Using active listening
• E. A patient-centred approach
• F. An approach which instils self-efficacy

35. Talking to people about their alcohol consumption can be quite emotive and
helping them to recognise ways in which they could reduce their alcohol
intake requires skill.
Which of the characteristics listed below do you think would be useful?
Select one or more options ...
• A. A blaming or confrontational attitude
• B. Empathy
• C. A practitioner-centred approach
• D. Using active listening
• E. A patient-centred approach
• F. An approach which instils self-efficacy

36. Which of the following statements best describes the clinical approach that a
practitioner should take during Brief Advice?
Select one option from the list below:
1. The practitioner should be firm, authoritative and determined in his or her efforts to
get the patient to cease drinking
2. The practitioner needs to be authoritative but concerned as he or she facilitates the
patient’s decision making
3. The practitioner needs to debate with the patient, the risks associated with drinking
while highlighting the patient’s weaknesses with regards to alcohol

37. Which of the following statements best describes the clinical approach that a
practitioner should take during Brief Advice?
Select one option from the list below:
1. The practitioner should be firm, authoritative and determined in his or her efforts to
get the patient to cease drinking
2. The practitioner needs to be authoritative but concerned as he or she facilitates the
patient’s decision making
3. The practitioner needs to debate with the patient, the risks associated with drinking
while highlighting the patient’s weaknesses with regards to alcohol
The practitioner providing Brief Advice should aim to be empathetic and non
judgemental while facilitating the patient’s decision making process. Deflecting denial
and being authoritative about the facts relating to alcohol consumption can help the
patient focus on the risks associated with alcohol. Patients will respond best to genuine
concern for their health and wellbeing.

38. Approaches to Brief Advice
• Each patient will be at a different stage of awareness about how their
alcohol consumption is negatively impacting on their life.
• Reducing their alcohol consumption may be one of many aspects of their
health that they should ideally address
• One of the simplest ways to assess a patient’s readiness to change their
drinking is to ask them to rate, on a scale of 1 to 10, ‘How important is it for
you to change your drinking?’
• The patient’s level of motivation to change (stage of change) indicates to the
practitioner how best to approach the Brief Advice

39. Note on your own behaviour:
If you indulge, it may be tempting to demonstrate your empathy
by taking the "We've all done it" approach. Resist this
temptation if it arises. Your role is to give the patient
information, so that they can make decisions about their own
behaviour. Your own use should not be discussed, even if the
patient asks directly.
The practitioner, whilst friendly and empathic, is acting in a
professional capacity. For some patients this may play an
important part in the effectiveness of the intervention.

40. • Ensure adequate confidentiality for the intended discussion
• Be non judgmental
• Recommended clinical approach is to be encouraging,
empathetic, authoritative and aim to facilitate the patient's
decision making
• If dealing with an angry question or response from a patient be
assertive but calm, drawing the patient's attention back to the
relationship between the screening test and their health
• Single item screening to establish whether the patient is using
above lower risk levels or not, can be used for occasions where
there is really very little time
• Addressing potential dependency is beyond the scope of the Brief
Advice session, offer referral to a specialist service
In summary

41. Split into small groups of three: Patient, Practitioner &
Observer
Take turns to engage in delivering FRAMES based BI for a
patient who is :
1. Pre-contemplative
2. Contemplative
3. In Preparation
ROLE PLAY (in your own time… )

42. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing:
Preparing people to change addictive behavior. New York:
Guilford Press
Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief
interventions for alcohol problems: A review. Addiction, 88,
315-336. doi: 10.1111/j.1360-0443.1993.tb00820.x
Dunn C, Deroo L & Rivara FP (2001) The use of brief
interventions adapted from motivational interviewing across
behavioral domains: a systematic review. Addiction
96(12):1770-2
Background reading

43. THANK YOU!