Screening
It is the first step of the SBIRT process and determines the severity and risk level of the patient’s substance use. Screening for risky alcohol or drug use includes asking questions of all patients to identify those who may misuse alcohol or drugs, or are at risk for developing a problem. The result of a screen allows the provider to determine if a brief intervention or referral to treatment is a necessary next step for the patient, and it is a significant step toward effective intervention.
The Difference Between Screening and Assessment
Universal Screening means to screen everyone who walks in the door annually for substance use and mental health disorders.
Screening is a brief process that occurs soon after the individual seeks services and indicates whether the individual is likely to have a substance use disorder and/or mental health disorder. Individuals who screen positive for co-occurring disorders should receive an in-depth assessment.
Assessment occurs after screening and consists of gathering key information to collaboratively conceptualize the problem and develop a treatment plan. Mental health and substance use disorders are assessed in the context of each other. The goals are to:
- Establish (or rule out) the presence or absence of a co-occurring disorder
- Determine the individual’s readiness for change
- Identify the individual’s strengths or problem areas that may affect the processes of treatment and recovery
- Begin the development of an appropriate treatment relationship
Why Providers Should Screen Universally
- To detect current health problems related to at-risk alcohol and substance use at an early age, before they result in more serious disease or other health problems.
- To detect alcohol and substance use patterns that can increase future injury or illness risks.
- To intervene and educate about at-risk alcohol and other substance use.
Resources
- Center for Adolescent Substance Abuse Research “Self-Administered CRAFFT”
- SBIRT Vermont “CRAFFT Adolescent Screener”
- The Center for Adolescent Substance Abuse Research “CRAFFT 2.0 Clinician Interview”
- National Institute on Alcohol Abuse and Alcoholism “Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide”
- Screening and Brief Counseling for Alcohol and Other Drugs
Brief Intervention
Builds motivation through a collaborative conversation. Brief Intervention is a short conversation between patient and health care provider about the patient’s screening results, information on safe use, and next steps. Brief Interventions are motivation-enhancing discussions focused on increasing insight and awareness of substance use disorders, and decreasing or discontinuing unhealthy alcohol and substance use. The ultimate goal of a brief intervention is to negotiate a plan based on motivational interviewing to change behavior and assist the patient in accessing treatment if needed. About 15 percent of those screened require a brief intervention; those interventions typically take 5 to 15 minutes.
Four Steps to Brief Intervention
- Build rapport; raise the subject
- Provide feedback
- Build readiness to change
- Negotiate a plan for change
Resources
- SBIRT Vermont Downloadable Clinical Tools
- Adolescent Brief Intervention – Jacob (alcohol)
- Brief Intervention – Tom (methamphetamine)
- Brief Intervention – Steve (alcohol)
- Brief Intervention – Jill (alcohol)
- SBIRT Colorado: Demonstration of Brief Intervention for Alcohol
- Anti-SBIRT BNI
- Using SBIRT Effectively
- SBIRT for Drug Use
- SBIRT for Alcohol Use (College Student)
- SBIRT for Alcohol Use (Older Man)
- SBIRT for Alcohol Use (Family)
Motivational Interviewing
Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. “Motivating” often means resolving conflicting and ambivalent feelings and thoughts.
Motivational Interviewing Tasks
- Engage: through having sensitive conversations with patients
- Focus: on what’s important to the patient regarding behavior, health, and welfare
- Evoke: the patient’s personal motivation to change
- Negotiate plans
Principals of Motivational Interviewing
- Express empathy
- Develop discrepancy
- Roll with resistance
- Support self-efficacy
- Resist the “righting” reflex
- Understand your patient’s motivations
- Listen to your patient
- Empower your patient
Core Motivational Interviewing (OARS)
Open-ended questions
When therapists use open-ended questions it allows for a richer, deeper conversation that flows and builds empathy with clients. In contrast, too many back-to-back closed- or dead-ended questions can feel like an interrogation (e. g., “How often do you use cocaine?” “How many years have you had an alcohol problem?” “How many times have you been arrested?”). Open-ended questions encourage clients to do most of the talking, while the therapist listens and responds with a reflection or summary statement. The goal is to promote further dialogue that can be reflected back to the client by the therapist. Open-ended questions allow clients to tell their stories.
Affirmations
Affirmations are statements made by therapists in response to what clients have said, and are used to recognize clients’ strengths, successes, and efforts to change. Affirmative responses or supportive statements by therapists verify and acknowledge clients’ behavior changes and attempts to change. When providing an affirmation, therapists should avoid statements that sound overly ingratiating (e.g., “Wow, that’s incredible!” or “That’s great, I knew you could do it!”). While affirmations help to increase clients’ confidence in their ability to change, they also need to sound genuine.
Reflections
Reflective listening is the primary way of responding to clients and of building empathy. Reflective listening involves listening carefully to clients and then making a reasonable guess about what they are saying; in other words, it is like forming a hypothesis. The therapist then paraphrases the clients’ comments back to them (e.g., “It sounds like you are not ready to quit smoking cigarettes.”).
Another goal in using reflective listening is to get clients to state the arguments for change (i.e., have them give voice to the change process), rather than the therapist trying to persuade or lecture them that they need to change (e.g., “So, you are saying that you want to leave your husband, and on the other hand, you worry about hurting his feelings by ending the relationship. That must be difficult for you. How do you imagine the two of you would feel in 5 years if things remain the same?”). Reflections also validate what clients are feeling and doing so communicates that the therapist understands what the client has said (i.e., “It sounds like you are feeling upset at not getting the job.”). When therapists’ reflections are correct, clients usually respond affirmatively. If the guess is wrong (e.g., “It sounds like you don’t want to quit smoking at this time.”), clients usually quickly disconfirm the hypothesis (e. g. “No, I do want to quit, but I am very dependent and am concerned about major withdrawals and weight gain.”)
Summaries
Summaries are used judiciously to relate or link what clients have already expressed, especially in terms of reflecting ambivalence, and to move them on to another topic or have them expand the current discussion further. Summaries require that therapists listen very carefully to what clients have said throughout the session. Summaries are also a good way to either end a session (i.e., offer a summary of the entire session), or to transition a talkative client to the next topic.
Resources
- Addiction Technology Transfer Center Network “Online Course Registration”
- National Institute on Drug Abuse “Blending Initiative Motivational Interviewing CME/CE Patient Simulation”
- Introduction to Motivational Interviewing
- Increasing Importance in Motivational Interviewing
- Advanced Motivational Interviewing: Smoking Cessation
- Motivational Interviewing: A Bad Example
- Motivational Interviewing: A Good Example
- 5 Steps of Motivational Interviewing
- Motivational Interviewing Reminder Card
- Motivational Interviewing Techniques
- Sample MI Questions and Statements
- Motivational Interviewing Observation Form
Referral to Treatment
Directly links patient with appropriate, requested services. Referral to Treatment is provided for patients who have moderate- to high-risk alcohol or drug misuse and who wish to receive further assessment and/or treatment — on average, about 5 percent of those screened. There are a range of different treatments that are appropriate for different uses and should be matched to specific behaviors and health issues.
Treatment
Treatment may include
- Counseling and other psychosocial rehab services
- Medications
- Involvement with self-help (ex., AA, NA)
- Complementary wellness (diet, exercise, meditation, etc.)
- Combinations of the above
Resources
- SAMHSA “Behavioral Health Treatment Services Locator”
- SAMHSA-HRSA Center for Integrated Health Solutions “SBIRT Referral to Treatment”
- National Institute on Alcohol Abuse and Alcoholism “Treatment for Alcohol Problems: Finding and Getting Help”
- National Institute on Drug Abuse “Treatment Approaches for Drug Addiction”