Reading D

Substance use outcomes of patients served by a large US implementation of Screening, Brief Intervention and Referral to Treatment (SBIRT), (2017). Addiction, 112, 43-53.

Introduction

There are six elements critical to a brief intervention to change substance abuse behavior (Miller and Sanchez, 1994). The acronym FRAMES was coined to summarize these active ingredients, which are shown below. The FRAMES components have been combined in different ways and tested in diverse settings and cultural contexts.

A brief intervention consists of five basic steps that incorporate FRAMES and remain consistent regardless of the number of sessions or the length of the intervention:

1. Introducing the issue in the context of the client’s health
2. Screening, evaluating, and assessing
3. Providing feedback
4. Talking about change and setting goals
5. Summarizing and reaching closure

Providers may not have to use all five of these components in every session. It is more important to use the components that reflect the needs of the client and her personal style. Before eliminating steps in the brief intervention process, however, there should be a well-defined reason for doing so. Moreover, a vital part of the intervention process is monitoring to determine how the patient is progressing after the initial intervention has been completed. Monitoring allows the clinician and client to determine gains and challenges and to redirect the longer-term plan when necessary.

Table 1: Scripts for Brief Interventions

The below are descriptions of the five basic steps. Sample scenarios are provided where brief interventions might be initiated, with practical information about that particular step. For each step, the table below presents scripts for brief interventions that clinicians can use in substance abuse treatment units or other settings where interventions might occur.

Scripts for Brief Intervention
Component	Script in the emergency department, primary care officer, or other setting where consultations will be performed	Script in the substance abuse treatment unit
Introducing the Issue	“I’m from the substance abuse disorder unit. Your doctor asked me to stop by to tell you about what we do on that unit. Would you be willing to talk to me briefly about it? Whatever we talk about will remain confidential.” Or “This must be tough for you. Would it be OK with you if we take a few minutes to talk about your drinking?”	“Would it be OK with you if we discuss some of the difficulties you’ve had in getting homework done for the group meetings and how we can work together to help you take advantage of the treatment process?”
Screening, Evaluating, and Assessing	“In reviewing the information you’ve given me, using a scale of ‘not ready,’ ‘unsure,’ and ‘ready,’ how prepared do you feel you are to stop drinking?” Client says “unsure.” “One of the factors that might tie together your accident and your problems with your wife is your drinking.” “I think it would be worth talking more to some of the people at the substance abuse disorder unit so that your problems don’t get worse,” or, “I think a 2-week trial when you don’t drink alcohol at all would be helpful in determining whether or not drinking makes things worse and if stopping use works for you. What do you think?”	Given what you see as the additional stress in your family and your desire to make the treatment work for you this time, on a scale of 1 to 10, how ready do you feel to find a way to put time into your homework?” Client says, “6.” “I am pleased that you are willing to consider trying this, even though it won’t be easy. Let’s come up with some strategies that we can write down to help you accomplish this goal.”
Providing Feedback	“Have you had any problems with your health, family or personal life, or work in the last 3 months? Were you drinking in the 6 hours before your accident took place?”	“Have there been other parts of treatment that have been hard to follow?”
Talking about change and setting goals	“It looks as if you have been having about 30-35 drinks a week and have been doing some binge drinking on weekends. You’ve said that your accident took place after you’d had some alcohol, and you said you’ve been under a lot of stress with your family and at work. You also indicated that you don’t really think alcohol is making things worse, but you’re willing to think about that. Is that an accurate assessment of how you see it?”	“You’ve said that you completely forgot to do the homework because of arguments with your wife and daughter and that this surprised you because you had really intended to get it done. Is that about, right?”
Summarising and reaching closure	“Even though you’re not ready to stop drinking at this time, I’m glad you agree to write down the pros and cons of not drinking. How about if we meet tomorrow for a follow up?”	“You just did a good piece of work. I think you made some progress. I’m glad you’re trying something new. How about if we meet again in a week to see how things went for you?”

Screening for Brief Interventions for Alcoholism

Screen

At each visit, ask about alcohol use.

• How many drinks per week?
• Maximum drinks per occasion in past month?

Use CAGE questions to probe for alcohol problems

• Have you ever tried to Cut down on your drinking?
• Do you get Annoyed when people talk about your drinking?
• Do you feel Guilty about your drinking?
• Have you ever had an Eye-opener? (i.e. a drink first thing in the morning)

Screen is positive if

• Consumption is greater than 14 drinks per week or greater than 4 drinks per occasion (men).
• Consumption is greater than 7 drinks per week or greater than 3 drinks per occasion (women).
• CAGE score is greater than 1

Then assess for

• Medical problems: blackouts, depression, hypertension, trauma, abdominal pain, liver dysfunction, sexual problems, sleep disorders.
• Laboratory: elevated gamma-glutamyl transpeptidase or other liver function tests; elevated mean corpuscular volume; positive blood alcohol concentrations.
• Behavioral problems: work, family, school, accidents.
• Alcohol dependence: a score of 3 or higher on CAGE or one or more of the following: compulsion to drink, impaired control, withdrawal symptoms, increased tolerance, relief drinking.

Source: ASAM, 1994; reprinted with permission.

Essential Knowledge and Skills for Brief Interventions

Providing effective brief interventions requires knowledge, skills, and abilities. Studies have shown that applying the clinician’s skills listed below produces good outcomes, including getting clients to enter treatment, work harder in treatment, stay longer in treatment, and have better outcomes after treatment such as higher participation in aftercare and better sobriety rates.

• Overall attitude of understanding and acceptance
• Counselling skills such as active listening and helping clients explore and resolve ambivalence
• A focus on intermediate goals
• Working knowledge of the stages-of-change model

Attitude of Understanding and Acceptance

Clinicians must assure their clients that they will listen carefully and make every effort to understand the client’s point of view during a brief intervention. Brief interventions are by definition time limited, which increases the difficulty of adopting such an attitude. However, when clients experience this nonjudgmental, respectful interest and understanding from the clinician, they feel safe to openly discuss their ambivalence about change—rather than resist pressure from the clinician to change before they are ready to do so. The sooner they address their ambivalence, the sooner they progress toward lasting change.

When clients feel they are being pushed toward change—even if the clinician is not pushing, they are likely to resist. Clients must summon all of their attention and strength to resolve their ambivalence, and resisting the clinician may cause them to lose track and argue against change. If the client and clinician begin arguing or debating, the clinician should immediately shift to a new strategy, otherwise the brief intervention will fail. In other words, resistance is a signal for the clinician to change strategies and defuse the resistance.

Counselling Skills

Active listening

One of the most important skills for brief interventionists is “active listening”. Active listening is the ability to accurately restate the content, feeling, and meaning of the client’s statements. This is also called “reflective listening,” “reflecting,” or sometimes “paraphrasing.” Active listening is one of the most direct ways to rapidly form a therapeutic alliance. When done well, it is a powerful technique for understanding and facilitating change in clients. Active listening goes beyond nonverbal listening skills or responses such as, “Hmmm,” “Uh-huh,” “I see,” “I hear you,” or “I understand where you’re coming from.” None of these short statements demonstrates that the clinician understands. Counselors should also ask open-ended questions to which the client must respond with a statement, rather than a simple yes or no. Instead of summarizing a situation and then asking, “Is this correct?” ask the client, “What do you think? How do you feel about the situation?” Open-ended questions are invitations to share and provide a means to probe for important information that emerges in the interview.

Exploring and resolving ambivalence

Another important skill is the ability to help clients explore and resolve ambivalence. Ambivalence is the hallmark of a person in the contemplation stage of readiness. It is one of the most prevalent clinical challenges encountered in brief interventions. Whether it takes 1 minute or 40 minutes, the goal is to help clients become more aware of their position and the discomfort that accompanies their ambivalence. Increasing awareness of this discomfort within an understanding and supporting relationship can inspire the client to progress to a stage of preparation or action. For example, a client might be willing to go to counselling but not an AA meeting; in that case, the clinician should work with the client’s motivation and focus on the positive step the client is willing to make. One way to help a client recognize his ambivalence is to ask him to identify the benefits and costs of the targeted behavior (e.g., using alcohol) and the benefits and costs of changing the behavior. The clinician listens and summarizes these benefits and costs, then asks the client if any of them is more important than the others. This helps identify values that are important to the client and can therefore increase or decrease the chance of changing.

Clinicians might also ask if any of the pros and cons is more or less accurate than others. This provides an opportunity for irrational thoughts to be refuted, which can help remove barriers to change (see example in the text box below). Another approach to raising awareness of ambivalence is to explore the client’s experience of feeling caught between opposing desires. For more specific techniques for resolving ambivalence.