The process of brief intervention is based on gathering the most accurate information. It ensures that those in need are not missed by the screening process so they have the opportunity to make change. Many will not feel they are ready for change, though some will be in the right mental space for the change. This is why brief interventions are based largely on finding an opportune moment for the intervention.
By the end of this topic, you will understand:
- How to identify strengths, issues, and concerns
- Supporting change
- Health and wellbeing: asserting awareness
As discussed in the previous topic, identifying a person’s strengths can lead the way to hope and growth. The professional aims to create and promote their humility to gather strengths-based information. This approach establishes the person as the expert in their own life. It builds an acceptance that enables them to work together with the professional, following their lead towards change.
Identifying strengths may include:
- Identifying goals
- Identifying interests
- Understanding the person's history and experiences
- Identifying skills, capabilities, and personal strengths
- Exploring networks and supports that already exist in their lives
- Exploring their culture
- Listening to their stories and the impact these have on them
- Building a rapport with the person, ensuring a positive and effective relationship
Although strengths-based questions and implementation are core to the person-centred practice, it is important to not ignore why the person has been screened for requiring brief interventions.
Providing the person with relevant resources, such as reputable and current information on the impacts of drug use and clinically sound (EBP) questionnaires around the established concerns, may help to provide a barrier between ‘opinion’ and ‘reality’. At times, patients may feel that they do not need support, and it may be the ‘opinion’ of a professional that they do.
A collaborative approach means that the person is working together to agree to a decision about what will occur. This gives them autonomy and power over their own decisions and life choices, including change. It is important to remember this is a collaborative approach that also involves negotiation and ongoing education and support. Gathering information helps to develop a solid understanding of the person's experiences, strengths, and challenges and also in order to prioritize goals.
It can help to gather information from the person around:
Their home life and environments | Understanding the reality and lifestyle of the family, home life, or culture can support the professional to know where the reasoning and actions of the person may have stemmed from. This can also highlight supportive factors that may assist in sobriety or positive behaviours (change). |
Their education and employment history | This information helps to understand the goals and educational and professional challenges the person may face. And how these may impact their lifestyle, employability, and self-esteem. This can also support an understanding of their behaviours and their potential effect on their work environment. |
Relationships and sexuality |
This information helps the professional to understand the support that may be available. Also, social challenges they may be facing regarding their sexuality and relationships with others, currently and in the past. |
Preferred activities (in addition to the interests named above in strengths-based questions) |
These help the professional to support the person from a strengths and interests-based approach. Positives and opportunities in their lives are recognized and utilized as life highlights and goals. It also helps to understand the individual culture of the person. |
Previous/current diagnosis (conduct or risk-taking difficulties, psychosis, depression, ADHD, anxiety, etc). |
Many challenges and diagnoses often become paired with dependencies. Understanding the underlying factors can help the professional and the person positively work through these. |
General health and nutrition | The professional will better understand their lifestyle choices and challenges when identifying any health challenges and how they impact their emotional and physical capabilities. |
Current drug use and method of ingestion, frequency, duration and age of first use. | This information is vital in understanding the support required. Some people with longer histories of drug abuse require more intensive support. |
There are a variety of tools that can be used to complete questionnaires around health concerns, especially drugs, alcohol, and smoking, such as:
- AUDIT-C questionnaire for engaging patients about their alcohol use
- Severity of Dependence Scale (SDS)
- Alcohol, Smoking and Substance Involvement Screening Test (ASSIST-Lite)
- AUDIT, Alcohol Use Disorder Identification Test
- CRAFFT (for 12-21-year-olds)
Each state will have variations and preferences in the tools they use, as will different organizations, but typically at least one of the above will be used in most organizations in Australia for screening and assessment.
According to the Australian College of General Practitioners (2016), there are some key factors that may help people to accept alcohol or other drug assessments:
- Establishing a clear reasoning for the discussion around drug or alcohol use, e.g., specific information and data on how it may be affecting them
- Utilization of a health framework such as SNAP
- Using a person-centered and positive collaborative style. Avoiding over-interrogating when the person is not ready or comfortable
- Being comforting and aware of potential sensitivities within the discussion
- Negotiating the agenda and purpose of the meeting around a scope of comfort. E.g., this may begin with a discussion of the person's discomfort around any perceived concerns
- Avoiding moral language-use data-oriented information e.g., highlight health risks rather than use labels such as 'sensible' drinker
Explore
Follow the links below to view various examples of assessment tools and guidelines used in different states and organizations:
The transtheoretical model for understanding behaviour change focuses on the change process as a series of stages through which the person moves until they are ‘ready’ and motivated to change their behaviour. These stages are:
These people are often referred to as ‘happy users’. They usually consider the positives they receive from the behaviors over the contrary information provided by others, which is often ignored or discounted.
This is the stage where the person may be ‘sitting on the fence’ about their behavior. They are still enjoying it and find it desirable but can also see the adverse effects of it in their lives and within their health and wellbeing. The adverse effects they may be beginning to observe and acknowledge may be medical, personal, psychological, legal, or causing social or family problems.
The determination or preparation stage is one of the most challenging, as many do not progress past this point. This is the point where they know the behavior is problematic and that change needs to occur. They see change as imminent, but it is getting over this line and into ‘action’ that is the most difficult for them.
The action stage is when a person commits to change and the process required to make it occur; this is where their journey begins.
Maintenance is where a person has successfully halted their behaviour and sustained the ongoing behaviour required. At this point, the behaviour has been abandoned for long enough that they can state they have stopped the behaviour and made the change, usually occurring after around 6 months of change.
Relapse can occur during the stages of action and maintenance, and it’s important to note that people may move between stages within the process. Many of those who make changes will return to the behaviour by changing their minds or reverting to old patterns of behaviour. Once a relapse occurs, they will revert to one of the previous stages. Some may ‘lapse’, which is short-term or a one-off change, or some may relapse, which is for a longer period.
This theory is helpful in developing support strategies to assist a person in changing negative health behaviours, such as alcohol and/or drug use, because it recognises that, unless the person is ready and motivated to change, interventions are not likely to succeed.
In some domains, four stages of change are considered:
READING
Read this article to understand the transtheoretical model:The Transtheoretical Model (Stages of Change)
Watch
Watch this video to learn about the stages of behavioural change.
The context is encouraging healthy exercise, but the same principles apply within an AOD context.
Important
You will have noticed the term ‘lapse’ used in this document. As mentioned, it is considered a short, or one-off, return to the use of drugs or alcohol. You might find that in your line of work, or in your experience, this term is not used frequently, or you may have been advised not to use it. Some institutions or groups tend not to use the term as it can minimize or justify the behavior; after all, a drink is a drink and taking drugs is taking drugs. To someone who has a problem or addiction, one drink or ten makes little difference. Always be mindful of the use of terminology in your place of work, and if in doubt, ask a colleague or supervisor.
Assessments for change used in Australia include:
- The University of Rhode Island Change Assessment (URICA) scale
- The Readiness to Change Questionnaire (RTCQ)
Barriers to Change
It is important for the professional to always remember that ‘change is hard’ and to empathize. Changing behaviour requires a process such as the stages of change mentioned above. Those who don’t follow a process are found to be less likely to successfully change.
Barriers to change can occur for many reasons, both situational and environmental, that are individual to the person, such as:
Situational factors
Difficulty passing the contemplation stage. The person may be content with the problematic behaviour (problem recognition).
- The person may need to be further informed on the deficits of the behaviour e.g., they often require something more concrete such as information or facts to move on.
- The person may see it as a necessary method for minimizing either physical or emotional pain.
- They may not be ready for change or have no desire for help.
Environment and family
The behaviour is one of an environmental culture from which, were they to change, they would feel or be excluded. It is an everyday behaviour that is seen as ‘the norm’.
- Some may need to see the adverse effects firsthand within themselves or in others around them at a dangerous level to prompt change.
- A person may have limited positive supports to encourage the change process and be a part of their network for change.
- Many may see themselves as functioning in areas of life which demonstrate no need for change; they may have employment, a relationship and no obvious physical or mental health problems.
- Intergenerational drug and alcohol abuse can bring a denial of side effects and a natural inclination to take up the drug use. This can be a common cause for the ongoing abuse of alcohol and drugs within families, communities and environments. The Australian government have put a lot of time and advertising into ‘breaking the cycle’ within these families and communities.
Co-dependency
Many of those with addictions have also been found to have relationship co-dependencies as well. This means that the relationship appears to ‘work’ through the ‘need for support’ of the addicted person and the ‘carer’ role of their (usually) non-addicted partner. The relationship is co-dependant because while the addicted person has a need for support, the carer also tends to need to be needed to feel secure. This can lead to a self-perpetuating cycle of both addictive and enabling behaviours.
Recovering addicts often find that a major challenge for them is their co-dependency. As a result, they can experience strong feelings of guilt and shame. Guilt and shame are both emotions that can fuel addictive behaviours and ongoing co-dependent cycles. Guilt is a judgment to whether you have done something right or wrong and shame is how you feel about yourself, which can include ‘self-talk’ e.g., self-loathing, inadequacy, inferiority. When addicts feel this within themselves, they need the co-dependent to enable them and tell them otherwise, so they don’t feel unlovable, defective or undeserving of happiness for using. People with co-dependency and addiction problems both run on a cycle of shame, bouncing their inadequacy back and forth to each other. The co-dependent can feel guilt and shame for enabling the person to continue to be needed, as the carer, themselves.
Culture and Drug Use Barriers
Category | Description |
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Culture |
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Drug Use Barriers |
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Organisation Barriers |
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Effects of Treatment Barriers |
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Privacy and Confidentiality Barriers |
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Case Study
Bonnie’s ConcernBonnie, we met in previously, where she is provided with a brief intervention due to her weekend drug use.
At the end of the session, she pulls Cath aside and asks her, “where will this information be kept? Will anyone see it?” She further informs Cath that she is applying to study social work and wonders if this will have an impact on her ability to get into the course and get a job once she has finished.
Cath informs Bonnie that the database of information is kept on a secure site that only professionals with permissions can access. The law states that she cannot verbally or in any other way inform others of their work together on her change process. Unless otherwise authorized, the information must be kept confidential.
Cath provides her with the organization ‘Confidentiality Statement’ and information on the ‘Client Charter’, which outlines the rights and responsibilities of those using drug and alcohol services.
Read more about confidentiality and healthcare.
Incentives for Change
Many studies show that the major incentives for change include:
- Social dysfunction due to the behaviour or use
- Pressure to seek help from others
- Inability to function well and solve own problems
- Workplace related pressures and inducement to seek help
Loss of control is a key factor for many and often ‘hitting rock bottom’ is informed about when discussing why choice for change occurred. Many people experience family, friend, and financial difficulties due to the behaviour and also physical ailments that are alcohol or drug induced.
When providing intervention, it is important to identify what a person’s incentives may be, asking things like:
- What is important to them?
- What can they not lose?
- What makes them who they are?
- Who or what matters the most in their lives?
The aim of the questioning is to understand what their barriers to change may be, but also, what could become an incentive.
Reading
Read the following to learn more about the impact of culture on drug use and treatment approaches: Cutlure and Substance Abuse: Impact of Culture Affects Approach to Treatment.
Read the following to learn more about the effect that shame can have on addiction and co-dependency:Shame: The Core of Addiction and Codependency.
A large part of the change process is having reason or motivation (incentive) for change. It is typically more successful to focus on the benefits of change than to place moral ideals onto others, such as ‘drink responsibly’, or stating that one is not being a ‘responsible drinker’. Often a person who is not contemplating change will be motivated by further information about the effects that drugs and/or alcohol may be having on their health and life, now and in the future.
Information to Bring About Awareness
Providing valuable and meaningful information is imperative for incentivising the change process. Professionals provide current, accurate and relevant self-help materials from reputable sources. These are combined with verbal affirmations on why change will bring about a more positive and healthier lifestyle for the person.
This process informs the person on the deficits they face if they continue, and the benefits of making change. The result is that they can now be considered to be both informed and aware. By becoming more aware of the negative impacts, the aim is that they will find at least one reason to change.
Discovery Brings Awareness
Asserting awareness may also include supporting a person in discovering why they exhibit the behaviour and what their objective was/is for substance use. This may also include discovering why any barrier may occur to them making change and where this may stem from. The professional may need to provide proof, or documentation to hopefully ‘debunk’ the reason for the barrier. E.g., showing them their privacy and confidentiality policy if they are concerned others will find out. Or, providing data or current research that shows when and why change has occurred for others, if they are concerned about the efficacy of the intervention.
Resources
Providing information to bring about awareness and the intervention questionnaires themselves are both wonderful resources to support the person in making change. Below are various sites and resources that could be used to support a better understanding of the harmful effects of AOD, the process of change, and areas for support.
When providing resources, there is standard information that is provided to a person. However, the professional would need to consider the individual’s needs, abilities, stage of change, and accessibility when contemplating the resources they provide. For example:
- Is the person educated?
- Are they literate?
- Do they have access to the internet?
- Do they have visual impairment?
- How do they want information provided to them?
This can all be taken into account when considering what resources to provide for them to be purposeful and intentional.
Watch
Understand more about the change process by watching the following video.
5 minutes.
In the age of technology, it can be useful to have online access to information that is reputable and impacting on a person to make change. Watch the following video to understand more about the effects of alcohol on the brain.
5 minutes.
Note:
There is a list of helpful clips for many drug varieties on the ‘your room' website below, along with fact sheets.
Motivational Interviewing
Motivational interviewing is a therapeutic approach that supports a person’s willingness and motivation to change. It is often used in working with people with addictions but can also be used to encourage a person to change any harmful behaviour. It includes:
- Assessing the person’s readiness to change their behaviour
- Using collaboration rather than confrontation
- Encouraging self-direction and autonomy.
Motivational interviewing techniques address the needs and interests of the individual and are based on the belief that people make their own choices. This means you do not try to persuade or coerce the person to change. Instead, you support the person in identifying for themselves the benefits and barriers to change and working out their strategies for initiating and sustaining changes in their behaviour.
Motivational Interviewing
Resist telling the person what to do:
Avoid telling, directing or convincing the person about the right path to good health.
Understand their motivation:
Seek to understand their values, needs, abilities, motivations and potential barriers to changing behaviours.
Listen with empathy:
Seek to understand their values, needs, abilities, motivations and potential barriers to changing behaviours.
Empower them:
Work with them to set achievable goals and to identify techniques to overcome barriers.
A key aspect of motivational interviewing is to shift the person’s mindset from one in which change does not seem possible to one in which change does seem both possible and desirable. Strategies in motivational interviewing include:
- Active listening
- Avoiding confrontation and ‘rolling with’ resistance
- Developing the person’s awareness of discrepancies or inconsistencies between their negative behaviour and their values and aims
- Helping the person to move through the stages of change
- Providing feedback
- Planning and strengthening the person’s commitment to change.
Reading
- Read this article and the topics in its drop-down menu for a comprehensive discussion of motivational interviewing and its techniques. Each subtopic has a short video explaining the key points, so watch these as well. You can also print the content for each topic to keep for future reference:Motivational Interviewing.
- Read this summary to learn more about motivational interviewing:;The Effectiveness of Motivational Interviewing for Young People with Substance Use and Mental Health Disorders.
- Read this article for useful information about strategies and techniques that can be applied within an AOD service setting:Motivational interviewing techniques Facilitating behaviour change in the general practice setting.
Steps for Motivational Interviewing
Question
Questions are open-ended and encourage the person to explore the question with the professional instead of provoking a yes or no answer. This helps the professional to understand their needs, interests, and what they care about. For example: 'I understand you have some concerns about your drug use. Tell me about some of these?'
Affirm
The professional uses affirmations such as statements of understanding or compliments, helping to demonstrate empathy and build rapport. This affirms and validates the patient’s strengths and actions. For example: 'You are really proud that you made the step to come to see me today. You seem almost excited about change. It sounds like you have so much you want to achieve in life.'
Reflect
Reflections occur when the professional rephrases statements and information to capture the feelings or meanings that the person is expressing. This encourages an understanding of the motivations involved in reinforcing the desire for change. For example: 'You are worried about the effects this behavior is having on your work life and employability. In fact, you were recently approached about the behavior by your workplace. This is making you doubt the sustainability of the behaviour and recognize the need for change.'
Summarize
This is where the professional meaningfully pulls together and links key information provided and reiterates, to ensure a clear understanding. For example: 'So, if I understand correctly, some areas of discussion so far have been… … is that correct?'
Case Study
Read the ‘Case study - using the spirit of motivational interviewing’ and ‘Table 2: The spirit of motivational interviewing vs an authoritative or paternalistic therapeutic style’ following the link below:
Consider the key differences between the two approaches.
Watch
The following video shows a good example of motivational interviewing in action. 10minutes