Brief Interventions& MotivationalEnhancement Therapyfor Alcohol problems

© Bob Patton 2003

Dr Bob PattonVisiting Lecturer in AddictionNational Addiction Centre

With thanks to Dr Catherine Gilvary

Learning Objectives

To understand what is meant by a brief intervention

To recognise the Stages of Change and how they relate to brief interventions

To be able to describe the FRAMES approach to Motivational Interviewing

To be able to translate examples of BI in the alcohol field to the wider substance misuse arena

What is the Rationale for Screening and BriefIntervention?

• SBI is effective for both early intervention and secondary prevention of hazardous and harmful alcohol use but also more severe abuse and dependence.

• Recent UK alcohol policy suggests that alcohol problems are not detected early enough at present in the NHS and that vital opportunities to intervene in the patient’s best interests are being lost.

• Evidence that brief interventions lead to reduced consumption, harm and consequently reduced use of health-care resources and cost-effectiveness.

What is Brief Alcohol Intervention?“… the giving of information, advice and encouragement to the

patient to consider the positives and negatives of their drinking

behaviour, plus support and help to the patient if they do decide

they want to cut down on their drinking.”

“Brief interventions are usually ‘opportunistic’ – that is, they are

administered to patients who have not attended a consultation to

discuss their drinking”

(from the Alcohol Harm Reduction Strategy for England, p.37)

Features of Brief Interventions• A family of interventions ranging from a few minutes simple, but structured, advice to 20

minutes counselling with repeat consultations.

• Two basic levels of brief intervention:

– (i) simple structured advice ~ 1-2 minutes to deliver.

– (ii) brief counselling (extended brief intervention) ~ 10-20 minutes.

• 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 low-risk drinking (i.e., under medically recommended levels).

• But patients who prefer to become abstinent should not be discouraged.

Advantages of Locating SBIin Primary Health Care

• 78% of population visit GP at least once a year.• Stigma avoided.• Intervention possible at “teachable moments”.• Intervention in context of ongoing relationship with

patient and family.• Advice from GPs, practice nurses and other primary

health care staff likely to be respected.

Don’t forget the ED!

It’s busy. Up to 40% presentations related to alcohol consumption, rising to 70% on Saturday nights.

It’s a teachable moment – highlighting the relationship between alcohol and attendance.

It’s an ideal location to access a wide cross-section of the population.

ED accounts for 27% of the NHS alcohol bill

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 et al, DAD, 2005

Who are the Targets for BriefInterventions?

• Hazardous drinkers, including regular excessive• drinkers & “binge drinkers” (behavioural rather

than physiological dependence evident).• Harmful drinkers, including regular excessive

drinkers & “binge drinkers”.• NOT people who are alcohol dependent.

Brief Interventions

1111

• 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

Brief Interventions

• Time-limited, structured.• Self-help.• Prevention strategy.• Negotiated reduction in alcohol use rather than

abstinence.• Not teaching specific skills.• Not changing social environment.

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.

Brief Interventions - Steps

1. Screening

2. Assessment

3. Advice giving

4. Assessing motivation for change

5. Establishing drinking goals

6. Conducting follow-up

Screening

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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

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.

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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

AUDIT-C

© SIPS

The FAST alcohol screening test

The Paddington Alcohol Test

A brief instrument that measures quantity / frequency of consumption.

Designed for use in busy ED settings.

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.

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.

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)

Brief Interventions: Assessment

• Perform with anyone who drinks above established cut-offs.

• Assess potential alcohol-related problems.• Assess for symptoms of dependence.• Refer to specialist practitioner if evidence of

alcohol dependence.

Brief Interventions: Advice Giving

• Express concerns about the alcohol use pattern.• Provide personalised feedback about how

alcohol affects people.• Advise about need to change the drinking

behaviour.

Stages of change

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Not everyone is ready for an intervention. Prochaska & DiClemente (1982) devised their Stages of Change model to illustrate the processes an individual must go through in order to effect a change in behaviour:

Precontemplation Contemplation Action Maintenance

Precontemplation ~ Not considering any changeContemplation ~ Thinking about changeAction ~ Changes are being madeMaintenance ~ New behaviours are preserved

Brief interventions can be tailored to suit whatever stage of change the patient is at.

Brief Interventions: EstablishingDrinking Goals

• Negotiate specific drinking amounts.• Establish specific dates.• Develop a written contract.• Offer resources, materials, information,

workbook, exercises, drinking diary.

Brief interventions: Conducting aFollow-Up• Review drinking goals.• Assess ongoing problems.• Support ongoing efforts to change.• Assess new problems that might emerge.

Evidence of EffectivenessOver 56 controlled trials of effectiveness, most in primary care.

At least 13 meta-analyses and/or systematic reviews, including 5 specifically focused on primary care - and reaching favourable conclusions.

In the best meta-analysis so far (Moyer et al., 2002), small to medium aggregate effect sizes in favour of brief interventions emerged across different follow-up points.

At follow-up of 3-6 months or more, the effect for brief interventions compared to control conditions was significantly larger when individuals showing more severe alcohol problems were excluded from the analysis.

Moyer, A., Finney, J., Swearingen, C., Vergun, P. (2002). Brief interventions for

Alcohol problems: A meta-analytic review of controlled investigations in treatment

Seeking and non-treatment seeking populations. Addiction, 97, 279-292.

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.

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.

Using the Brief Advice Tool

Using the Brief Advice Tool

Brief Advice Delivery Structure1. 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?”

Training video – Brief Advice

Brief InterventionsMethodological limitations exist:

• Most but not all interventions consisted of a single 15-20 minute session.

• Medical doctors were the primary interventionists in most trials.

• Small sample sizes.• Low follow-up rates.• Lack of “blinding” of the control participants.

REDUCE project – 2001/2003

AIM: Examine the effect of referral to an AHW on levels of alcohol consumption.

DESIGN: Single blind pragmatic RCT

METHOD: Patients screened in the ED. Hazardous drinkers allocated to experimental or control conditions. Follow-up at six and twelve months.

Experimental & Control treatments

All participants were given a copy of the HEA booklet ‘Think about drink’.

Participants in the Experimental Treatment (ET) were made an appointment with the AHW.

Control Treatment (CT) participants did not receive this appointment.

Study MeasuresAlcohol consumptionScreening using the PAT occurred at baseline for all participants. At follow-up we employed the Form 90 AQ, Steady Pattern Grid and the PAT.

Psychiatric Morbidity & Quality of LifeAn indication of psychiatric caseness was assessed at six months using the GHQ-12. At twelve months we used the EQ-5D to gauge quality of life.

ED attendanceData extracted from routine hospital records

Results – Alcohol ConsumptionSix months after randomisation participants referred to the AHW had significantly lower levels of weekly alcohol consumption (59 vs. 83 units / week) than the control group.

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55

60

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80

85

90

6 Months 12 Months

Follow-up

Mean Weekly Alcohol

Consumption

CT

ET

Results – Other Measures

ET participants were also less likely to re-attend the A&E in the one year following their initial presentation than CT (1.2 visits vs. 1.7, p<0.05, NNT=2)

However we detected no significant differences between the groups on GHQ-12 or EQ-5D.

Cost / BenefitScreening and referral to the AHW has a cost, but this should be offset against the savings gained by reducing attendance:

For every 1000 patients screened, costs are approximately £2500 (including the cost of the AHW for those referred), and savings of £4000.

Net: £1500 savings

Limitations of the study

This was a pragmatic trial – we were unable to collect comprehensive data at baseline, and so were unable to measure the change in our primary and secondary outcome measures

All study participants received as self-help booklet; a “no treatment” control group was considered unethical

Low numbers of our ET group actually attended the AHW session

Conclusions from REDUCEIBA in an ED is feasible and results in lower levels of alcohol consumption over the following 12 months.

Reduced alcohol consumption is associated with lower levels of reattendance in the department.

Reduced reattendance in the ED offsets the costs of screening and providing brief intervention.

In summary – Alcohol IBA• Ensure adequate confidentiality for the intended discussion • Be non judgmental - avoid making judgemental comments about a

patient's drinking revelations • 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

• M-SASQ, which uses one question to establish whether the patient is drinking above lower risk levels or not, can be used for occasions where there is really very little time, or the patient appears unlikely to submit to any screening

• Addressing potential alcohol dependency is beyond the scope of the Brief Advice session, offer referral to a specialist service

MotivationalEnhancementTherapy

(Motivational Interviewing)

Motivational EnhancementTherapy

• Aimed at problem and dependent drinkers.• Aimed at increasing motivation to change drinking behaviours.• Based on Motivational Enhancement Therapy (MET) principles.

Patient participation in treatment dependent on:

• Modifying unrealistic treatment expectations.• Resolving client ambivalence about drinking.• Enhancing client self-efficacy.

What is MET?• Client-centered and directive counselling style that elicits

behaviour change by helping clients explore and resolve ambivalence to change.

• Designed to produce rapid, internally motivated change.• Evokes from clients their own motivation for change and

helps client to consolidate a personal decision and plan for change. It uses motivational strategies to mobilize the client’s own change resources.

• Can be delivered as a primary intervention or as a pre-treatment intervention to increase motivation for treatment and is useful in both out-and in-patient settings.

MET features

• Little emphasis place on acceptance of a diagnostic label.• Personal choice regarding future substance use is

stressed.• Resistance behaviour is not viewed as an obstacle or

denial, instead ambivalence is seen as a normal part of change.

• Evoke from the client perceptions of problems and the need for change. Do not impose truth on client.

• Emphasizes ability to change (Self-efficacy) rather than helplessness over substances.

MET - Summary

DEFINITIONMotivational Enhancement Therapy is a treatment intervention

based on principles from humanistic psychology

It is:• Client-Centered• Directive• And seeks to increase internal motivation for change

through resolution of ambivalence and an increase in perceived self-efficacy.

Differences to Other TreatmentApproaches

Differences to Other TreatmentApproaches

Differences to Other TreatmentApproaches

Rogerian* Constructs on which MET is basedEmpathy - is the ability to put oneself in another’s situation and accurately convey an understanding of their emotional experience without making a judgment about it. Empathy is different from sympathy which connotes “feeling sorry” for another person. In comparing the two, empathy is a more egalitarian sharing of a feeling state. It encompasses a wide range of affect where sympathy is generally a reaction to another’s sadness or loss.

Warmth - Someone who is warm uses the self to convey acceptance and positive regard through their own positive affect and body language.

Rogerian* Constructs on which MET is basedGenuineness - is the ability to be oneself and feel comfortable in the context of a professional relationship with a client. It does not imply a high degree of self-disclosure, but a genuine presence in the relationship. It may involve an ability to use the skill of immediacy.

Immediacy - means that the counsellor conveys thoughts, feelings and reactions “in the moment”. An example is the counsellor’s sharing of their own feelings of sadness in response to a client story of a loss. It is different from empathy in that empathy will convey an accurate understanding of the client’s feeling of sadness.

Joining the Patient

Another tenet of client-centered counselling is to “meet the client where they are at.”

Some patients may not be interested in addressing substance abuse in the first sessions. The counsellor can engage the patient by talking with them about their interests. For example, a client referred to substance abuse treatment by his/her GP does not see her substance use as problematic but is pre-occupied with issues of getting her 13 year old son to attend school more regularly.

In this scenario the counsellor works with the patient on parenting issues and uses this area of patient concern to further explore substance abuse issues.

Directive

Motivational Enhancement Therapy is not impartial. The goal is to move the client in the direction of making a positive change.

This is one of the major differences between MET and Rogerian Counselling, which assumes that clients will ultimately move towards self-actualization. Rogers advocated no particular direction in the treatment.

Principles of MET

1. Express Empathy

2. Roll with Resistance

3. Develop Discrepancy

4. Support Self-efficacy

5. Avoid Argumentation

Principle 1: Express Empathy

• Client centred, empathetic style is a fundamental defining element of MET.

• Reflective listening/accurate empathy is a key skill:

– Communicates acceptance of clients as they are.

– Communicates respect for the client.

– Builds a working therapeutic alliance.

– Supports client’s self esteem.

– All of the above promote further behaviour change.

• Client’s freedom of choice and self-direction are respected:

– It is only the client who can decide to change and can carry out that choice.

– More listening than telling.

– Persuasion is gentle and subtle – assume change is up to the client.

Principle 2: Roll with Resistance

• Handling of client ‘resistance’ is a crucial and defining characteristic of MET

• MET does not meet resistance head-on (eg. Break through denial), but ‘rolls with the momentum’, with a goal of shifting client perceptions in the process

• Resistance is a red flag to a therapist – change behaviours or strategies – Indicator of therapist behaviour rather than client’s traits.

• Ambivalence is viewed as normal, not pathological and is explored openly – meet resistance with reflection.

Principle 3: Develop Discrepancy

Motivation for change occurs when people perceive a discrepancy between where they are, and where they want to be

MET seeks to enhance and focus clients’ attention on discrepancies regarding substance use: Flight to health

Discrepancies disrupt emotional equilibrium and result in cognitive dissonance – person may change to reduce perceived discrepancy and regain equilibrium

With pre-contemplators, one would first need to raise awareness of adverse personal consequences of drinking so that discrepancies can develop

Counsellor must help client find and voice discrepancies and need for change.

Principle 4: Support Self-efficacy

A person who is persuaded they have a problem will not change unless they believe that change is possible (hope/confidence)

Self-efficacy is the belief that one can perform a particular behaviour or accomplish a particular task

In MET, client must be persuaded that it is possible to change substance use and thereby reduce related problems

Unless self-efficacy is present, a discrepancy crisis is likely to resolve into defensive coping to reduce discomfort, without changing behaviour

Principle 5: Avoid Argument

If handled badly, ambivalence and discrepancy can result in defensive coping strategies that reduce client’s discomfort, but do not alter substance use.

Unrealistic attacks’ on substance use evoke defensiveness and opposition and suggest that the therapist does not understand.

MET explicitly avoids argument, which tends to evoke resistance.No attempt made to have client accept/admit a diagnostic label.

Does not seek to prove or convince by force of argument.

MET uses other strategies to assist the client to begin devaluing perceived positive benefits of drugs and allows the client (not the therapist) to voice arguments for change.

Client Counsellor Relationship

The quality of the therapeutic relationship accounts for up to 30% of client improvement in outcome studies (Hubble, Duncan & Miller, 2004).

The emphasis on client-counsellor relationship may be related to the positive outcomes achieved by MET in a wide-range of settings and with broad range of behavioural health problems.

Motivational Enhancement Therapy and Stages of ChangeMotivational Enhancement Therapy has been paired successfully with other treatment approaches like cognitive-behavioral therapies and twelve-step models.

When paired with another treatment MET can be used to help clients progress from Pre-contemplation to the resolution of ambivalence in the Contemplation stage. Once the client has made a decision to change other approaches such as twelve-step or CBT can be used in the Action stage to help the client develop and carry out a change plan.

Motivational Enhancement Therapy: Stages

• Each stage has unique problems and tasks.• Individuals moving through a particular stage must

successfully resolve the key task of that stage.• People do NOT go through the stages in a linear way

(one trial learning is very rare in both animals and humans).

• Cyclical experience stages is more representative.• Issue of continuum vs distinct stages remains.• Evidence shows significant differences between

individuals at different stages.

Motivational EnhancementTherapy

Motivational Enhancement Therapy

Evidence suggests that MET is as effective

as CBT and TSF.

MET is significantly cheaper than CBT.

MET works well with clients with anger

problems.

Efficacy of MET

• Motivational Enhancement Therapy has been found to be effective in the treatment of a wide range of behavioural and health related problems. It has been used successfully in addiction treatment in inpatient, outpatient, crisis services and long-term residential settings.

• It has been used to increase compliance with mental health, diabetes, and cardiac medical treatment effectively. It has also been used successfully to improve diet and increase level of exercise but there is mixed evidence of its effectiveness in smoking cessation.

Meta-analysis of Outcome Research in Substance Abuse TreatmentMiller and Hester (2003) conducted a meta-analysis of outcome research from decades of data. They weighted studies based on the quality and statistical power of the research design. They included only randomized studies with a treatment and control group in the analysis.

Brief Interventions, Motivational Enhancement Therapy, Community Reinforcement, Naltrexone and Brief Strategic Couples Therapy were all shown to have positive effects. Relaxation, Confrontation, Psychotherapy, Counseling and Education showed negative outcomes.

For a more thorough review of inclusion criteria and detailed information about each of the studies reviewed see Hester and Miller, Handbook of Substance Abuse Treatment (2003).

Summary• Motivational Enhancement Therapy is a model of treatment based on

humanistic psychology. It is directive and intends to help clients resolve ambivalence in the direction of making a positive change.

• “Spirit” is important and the counsellor’s stance should be warm, empathetic, egalitarian, and should respect the client’s right to self-determination.

• The model includes distinct techniques or strategies for opening the interview, decreasing “sustain-talk” and encouraging “change-talk.”

• The goal is to help the client resolve ambivalence about change and make a commitment to a plan of action.

Summary• Screening and brief intervention (SBI) for hazardous and harmful drinkers

in Primary Health Care is effective in reducing alcohol-related harm.

• SBI is highly cost-effective in terms of reducing future burden on the NHS

• Patients who have a positive screen should be offered simple structured advice.

• If resources permit, brief counselling would benefit harmful drinkers and more ‘interested’ patients.

• Patients with significant alcohol dependence should be referred for more intensive intervention.

Further Reading

 

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

Thank you!