Screening & Brief Alcohol intervention:

Level 2: session 3

Extended brief intervention

Background – clinical context

Case finding

Negative screenCongratulate/check awareness

Positive ScreenPossible dependence

Assess further, refer on

Assess interest/motivation

No interest – offer PILKeep door open for future

Interest/ hazardous drinkerSimple structured advice

Interest/ harmful drinkermotivational counselling

Motivational extended brief intervention

• Accords with broad principles of patient centred practice

• Motivational approach to behaviour change counselling not Motivational interviewing

• Based on Health Behaviour Change: A Guide for Practitioners Rollnick, S., Mason, P. & Butler, C. (1999)

• Following ‘How Much is Too Much’ – Level 2

• Longer 2-3 hour skill-based training session by Dr. Malcolm Thomas on Promoting effective behaviour change

Patient centred practice- key ingredients

• Both are experts

• disease and illness

• person in a context

• finding common ground

• mutual decision making

Patient presents problem

Gathering information

Parallel search of two frameworks

Disease framework

Doctor’s agenda:Doctor’s agenda:• Symptoms• Signs• Investigations• Pathophysiology

Differential diagnosisDifferential diagnosis

Illness framework

Patient’s agenda:Patient’s agenda:• Ideas• Concerns• Expectations• Feelings

Understanding theUnderstanding thepatient’s uniquepatient’s uniqueexperience of experience of illnessillness

Integration of the two frameworks

Shared understanding & decision makingShared understanding & decision making

Patient centred practice - active listening

What I say What I hear

What I mean or feel

What I understand

patient practitioner

assumptions

• This person ought to change

• this person wants to change

• patient’s health is motivation

• no change=failure• either do or don’t

• Now is the right time• being tough is best• I know - my advice is

good• negotiation is always

best

Check out the assumptions

Identify which two are the most interesting and discuss in groups of

three or four ( 10 mins)

Motivational interviewing

• ‘client-centred , directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence’ Miller & Rollnick 2002

Principles of MI

1. Express empathy

2. Develop discrepancy

3. Avoid argumentation

4. Roll with resistance

5. Support self-efficacy

Behaviour change counselling

• ‘ways of structuring a conversation which maximises the individual’s freedom to talk and think about change in an atmosphere free of coercion and the provision of premature solutions’ Rollnick et al. 1999

Three broad stages in BCC

• Assessing readiness

• Weighing up pros and cons

• Determining action - moving patients on

Assessing Readiness

Importance + Confidence = Readiness

Importance of changing drinking

On a scale of 0 (not at all) to 10 (very important), what number would you give yourself right now?

Why are you here and not higher? Or lower?

What would need to happen for you to get to a higher point?

How can I help you get from where you are now to a higher number?

Confidence about changing drinking

On a scale of 0 (not at all) to 10 (very confident), what number would you give yourself right now?

Why are you here and not higher? Or lower?

What would need to happen for you to get to a higher point?

How can I help you get from where you are now to a higher number?

Weighing up the pros and cons of drinking

Determining action

• Identifying reasons for change

• Setting achievable goals

• Recognising difficult times/situations

• Prepare for difficult times/situations

• Finding support

• Sticking to goals

Discussion

• Trying out components

• Feedback

• What about patients who need more?

Referral (1)

• Patients should be referred to specialist services who:

• show a relatively high level of alcohol dependence or alcohol-related harm

• are harmful drinkers who have not benefited from brief counselling and wish to receive further help for their alcohol problems

Referral (2)

• can be defined as score of 20+ on the full AUDIT

• obvious signs of physical dependence (e.g. withdrawal symptoms, withdrawal relief or avoidance drinking, very high tolerance, blackouts)

• severe alcohol-related problems or risk of such problems (e.g. possible loss of job, family, etc.)

• score on recognised measure of dependence (e.g. 10-item Leeds Dependence Questionnaire)