Brief interventions for alcohol misuse Training and material for non-specialists

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1 Brief interventions for alcohol misuse Training and material for non-specialists

2 Executive summary This report summarises Swanswell s development of a six-session brief intervention and training programme which allows professionals who aren t specialists in alcohol treatment to screen clients and deliver treatment to those with low to moderate levels of alcohol misuse. Brief interventions are known to be an efficient and cost-effective way of helping people with alcohol problems (Moyer, A. et al, 2002) 1 (Bien, T.H. et al, 1993) 2, especially where these are delivered within familiar situations and surroundings. In one of the largest-ever studies of screening and brief interventions in general healthcare settings (Babor, T.F. and Grant, M., 1992) 3 it was found that people who had received brief interventions had reduced their alcohol intake by an average of 33% at the nine-month follow-up point. In England, around 1.6 million people are moderately or severely dependent on alcohol (DWP, 2010) 4. It s estimated (Ward, M., 2010) 5 that just 6% of these dependent drinkers (and possibly fewer) access specialist treatment for their problems. That means in England alone there is the potential to help 1.5 million dependent drinkers (who wouldn t otherwise seek treatment) tackle their problems using brief interventions in nonspecialist environments. The National Offender Management Service (NOMS) recognised the fact that as part of their daily work, offender managers (OMs) frequently come into contact with people who may have alcohol problems. It also realised that probation staff already possess some of the key skills (such as assessment and motivational interviewing) which are needed to deliver brief interventions. NOMS commissioned Swanswell to develop a training programme and workbook which would give its probation staff the confidence and knowledge to screen clients and deliver brief interventions to those with moderate levels of alcohol problems during the course of their normal interactions. We: developed material which teaches trainees how to screen and assess a client s alcohol problem, and how to deliver a six-session brief intervention to help them delivered 32 1-day training courses to nearly 400 members of Staffordshire and West Midlands Probation Trust (SWMPT) probation staff delivered follow-up train the trainer sessions to 17 members of SWMPT probation staff to allow them to take the whole package away and conduct their own training in future evaluated the effectiveness of the training The reaction to the training was extremely positive. On completing the course we asked delegates to tell us what they thought. 97% told us that they felt their trainer s knowledge was good-excellent 96% said the course content was good-excellent And since then, we ve been hearing great things from the trainees on how they re taking that training and using it in the workplace. In a recent survey (Swanswell, 2011) 6 they told us that: 67% have used the screening tool 65% have used the brief interventions 82% feel confident in using the screening tool and intervention 69% feel the tools have helped their clients We firmly believe that our training and workbook material not only offers a package which can be rolled out nationwide for NOMS, but can also be very easily tailored to train other professionals who come into regular contact with members of the public e.g. general medical practitioners and practice nurses in primary care, physicians and nurses in general hospitals, and social workers. Brief interventions for alcohol misuse Training and material for non-specialists 2

3 Introduction This report summarises Swanswell s development of a six-session brief intervention and training programme and which allows professionals who aren t specialists in alcohol treatment to screen clients and deliver treatment to those with relatively low levels of alcohol misuse. The National Offender Management Service (NOMS) recognised the fact that as part of their daily work, offender managers (OMs) frequently come into contact with people who may have alcohol problems. It also realised that its probation staff already possess key skills (such as assessment and motivational interviewing) which can be applied to delivering brief interventions to treat those problems. Brief interventions are known to be an efficient and cost-effective way of helping people with alcohol problems (Moyer, A. et al, 2002) 1 (Bien, T.H. et al, 1993) 2, especially where these are delivered within familiar situations and surroundings. In one of the largest-ever studies of screening and brief interventions in general healthcare settings (Babor, T.F. and Grant, M., 1992) 3 it was found that people who had received brief interventions had reduced their alcohol intake by an average of 33% at the nine-month follow-up point. In England, around 1.6 million people are moderately or severely dependent on alcohol (DWP, 2010) 4. It s estimated (Ward, M., 2010) 5 that just 6% of these dependent drinkers (and possibly fewer) access specialist treatment for their problems. That means in England alone there is the potential to help 1.5 million dependent drinkers (who wouldn t otherwise seek treatment) tackle their problems using brief interventions in nonspecialist environments. NOMS knows that delivering brief interventions to help people with alcohol problems is something that Swanswell does really well. But we re also great at training too, and are (rightly) proud of our self-developed Beautiful training approach, which continually aims to deliver top-class, evaluated training in an effective, memorable way. With that in mind NOMS commissioned Swanswell to develop a training programme and workbook which would give its probation staff the confidence and knowledge to screen and deliver brief interventions to clients with alcohol problems during the course of their normal interactions. Within that project s remit we: developed a six-session brief intervention to help clients who have problems with alcohol use, for use by offender managers and other non-specialists developed course material which shows trainees how to use the Alcohol Use Disorders Identification Test (AUDIT) screening tool, and how to deliver the interventions delivered 32 1-day training courses to a total of 385 members of Staffordshire and West Midlands Probation Trust (SWMPT) probation staff delivered follow-up train the trainer sessions to 17 members of SWMPT probation staff to allow them to take the whole package away and conduct their own training in future evaluated the effectiveness of the training Brief interventions for alcohol misuse Training and material for non-specialists 3

4 Background on brief interventions and alcohol misuse Brief interventions are short-term, focused and structured episodes of therapy. They range from 5-10 minutes of information and advice to a series of sessions of motivational enhancement or counselling. Many brief interventions are designed to be used by non-specialist staff working in a variety of settings, including general medicine practitioners, practice nurses, physicians, nurses, social workers, and probation staff. Interventions regarding alcohol misuse are often used in conjunction with standardised screening tools, such as AUDIT (Alcohol Use Disorders Identification Test), which determine the level of intervention (if any) needed. The AUDIT tool was developed by the World Health Organisation (Babor, T.F., et al, 2001) 7 to pick up early signs of hazardous and harmful drinking and identify mild dependence. It s widely accepted as a valid tool and is freely available online. The AUDIT asks the client a number of point-scored questions regarding their levels of drinking, drinking patterns and associated effects. The overall score will give an indication of whether the client s drinking represents: sensible/lower risk hazardous/increased risk harmful/higher risk possible dependence Brief interventions for alcohol misuse involve information on alcohol-related problems and nonjudgemental advice on techniques to reduce and/or stop drinking. Self-help materials, such as drink diaries, are often used. One of the most important aspects of alcohol-related brief interventions is the assessment and evaluation of a person s drinking patterns and related problems, usually by looking at drinking history. Appropriate feedback will then be given to help that person improve their understanding and awareness of their alcohol use, which aims to motivate them into making positive changes in drinking behaviour. Research suggests that brief interventions are an efficient and cost-effective way of helping people with alcohol problems (Moyer, A. et al, 2002) 1 (Bien, T.H. et al, 1993) 2, especially where these are delivered within familiar situations and surroundings. In one of the largest-ever studies of screening and brief interventions in general healthcare settings (Babor, T.F. and Grant, M., 1992) 3 it was found that people who had received brief interventions had reduced their alcohol intake by an average of 33% at the nine-month follow-up point. In addition, it seems that they are more effective for those people with more moderate levels of alcohol dependence (Field, C.A. and Caetano, R., 2010) 8. Brief interventions for alcohol misuse Training and material for non-specialists 4

5 Development of six-session brief interventions and training the Swanswell way To develop our six-session brief intervention for NOMS we combined the best bits from a number of proven Swanswell treatment programmes. Once our treatment model was formed, we produced an extensive guide for trainees, which gives them the necessary background information on alcohol and alcohol misuse, tools to assess a person s level of misuse, and clear guidance on what to do in each of the six treatment sessions. Worksheets are provided to help them deliver many of the exercises. The themes of the six sessions are summarised in Table 1. Table 1: Swanswell s brief intervention for alcohol misuse for non-specialists Session What s covered One Getting started Establishing if alcohol is a problem Assessing the level of that problem using the AUDIT screening tool Looking at the person s history of drinking and their current drinking levels Setting a drink diary task for future sessions Two The effects of alcohol Reviewing the drink diary Explaining units Explaining the effects of alcohol on the body Introducing the cycle of change (Prochaska, J.O., and DiClemente, C.C. 1984) 9 and establishing where the person thinks they are on that cycle Quiz to get a feel for the person s level of understanding Continuation of drink diary Three Why I drink Reviewing the drink diary Looking at the client s reasons for drinking Looking at the client s pros and cons for changing Tips for cutting down Continuation of drink diary Four How drinking affects my life Reviewing the drink diary Looking at how drinking affects the client s life and others Ways of changing drinking habits Continuation of drink diary Five Think about change Reviewing the drink diary Considering changes the client needs to make and thinking about alternatives Looking at barriers, obstacles and risky situations Continuation of drink diary Six Managing now Reviewing the drink diary Explaining and understanding cravings and recording them Dealing with triggers and high-risk situations Pointers to other national support agencies Continuation of drink diary Brief interventions for alcohol misuse Training and material for non-specialists 5

6 Beautiful training Once we d established the content of the interventions and the associated workbook, we set about developing the training needed to make sure trainees fully understood the subject matter and practicalities of delivering the treatment. With everything we do at Swanswell, we aim to be best-in-class. And our staff training programmes are no exception. Our in-house developed Beautiful training approach provides a distinct framework which shapes how we design and deliver all of our training. In a nutshell, it: is fun and enjoyable has clear aims and measurable learning objectives puts learners at the centre caters for a variety of learning styles takes places in an environment of trust, respect and openness continually develops through trainee feedback and evaluation In developing our material for NOMS we ensured that we stuck to this framework. The one-day training course we developed for NOMS enables trainees to: explain and understand the effects of alcohol and alcohol misuse use the guide and worksheets we produced for them to assess the impact of a client s alcohol use, and to support them via delivery of the six-session brief intervention The training course is broken down into manageable and interesting chunks as shown in Figure 1. Brief interventions for alcohol misuse Training and material for non-specialists 6

7 Figure 1: Structure of the NOMS training day Welcome Meeting the trainers; groundrules; icebreaker exercise; objectives. Introduction to brief and extended brief interventions What are brief and extended brief interventions; primary target client group; why do this? Introduction to how to carry out brief and extended interventions An introduction to the guide on the brief interventions themselves. Alcohol awareness Understanding alcohol misuse Including exercises on how to calculate units; and effects on the body. Definitions, introduction to AUDIT assessment tool; cycle of change. Intervention session 1: Getting started Aims of session 1; link to cycle of change; potential intervention tools to use; using the AUDIT tool as a starting point. Intervention session 2: Effects of alcohol Aims of session 2; link to cycle of change; potential intervention tools to use; discussing the effects of alcohol with a person to help them start or maintain change. Intervention session 3: Why I drink Aims of session 3; link to cycle of change; potential intervention tools to use; the how of delivering interventions; role play exercises and group discussions. Intervention session 4: How it s affecting my life Aims of session 4; link to cycle of change; potential intervention tools to use; group exercise on the four Ls liver, lover, livelihood and law. Intervention session 5: Thinking about change Aims of session 5; link to cycle of change; potential intervention tools to use; using drink diaries. Intervention session 6: Managing now Aims of session 6; link to cycle of change; potential intervention tools to use; cravings log; practical exercise/game. Recording your work Making sure work is evidential, reflective, and complies with clinical quality standards. Brief interventions for alcohol misuse Training and material for non-specialists 7

8 What do our trainees think? At Swanswell, we re confident that our staff training is very effective. But we don t just leave it at that we always seek out open and honest feedback from trainees once they ve completed our courses so that we can continue the ongoing process of monitoring and improving where necessary. As part of that process all trainees are required to fill in a feedback form before they leave the training venue. So what did our probation service trainees think? Their reaction was overwhelmingly positive. Immediately after completing the day s course: 97% told us that they felt their trainer s knowledge was good-excellent 96% said the course content was good-excellent. And since then, we ve kept in touch with our trainees and have been hearing good things about how, just six months on from the training, they re using what they ve learned in practice during their routine interactions with their clients. In a recent survey (Swanswell, 2011) 6 we learned that: 82% feel confident in using the screening tool and intervention 67% have used the AUDIT screening tool 65% have used the brief interventions 69% feel the tools have helped their clients Also, we re pleased to hear that the flexible nature of the programme has been well and truly embraced. SWMPT has told us that one of their OMs at the West Bromwich probation service which has pioneered the use of group supervision with offenders with great results is adapting the six-session intervention for group work with eight offenders. We ll be following how that goes, and hope to report back in the near future. Brief interventions for alcohol misuse Training and material for non-specialists 8

9 Conclusions and recommendations NOMS commissioned Swanswell to develop a training programme and workbook which would give its probation staff the confidence and knowledge to screen clients and deliver brief interventions to those with relatively low-level alcohol problems during the course of their normal interactions. Our feedback from trainees included some impressive numbers. 97% said their trainer s knowledge was good-excellent 96% said the course content was good-excellent. six months after training, 82% said they feel confident in using the screening tool and interventions Based on that feedback it s safe to say that: they had confidence in the trainers knowledge they were confident of the quality and content of the course material and the intervention workbook they felt well-equipped to put what they d learned into practice post-training we delivered an outstanding training package and intervention scheme that can be understood and used by non-specialist workers In addition, while use of the screening tool and interventions is still in an early bedding in phase, initial feedback is encouraging, in that 67% of trainees have used the screening tool, and 65% of them have used the brief interventions during the course of their normal work with clients. As the scheme continues to bed in, we re looking forward to hearing more from SWMPT on their evaluations of how effective the brief interventions are in practice. We firmly believe (and recommend) that our training and workbook material offers a package which can be rolled out nationwide for NOMS. In addition, and importantly, it can also be very easily tailored to train other professionals who come into regular contact with members of the public e.g. general medical practitioners and practice nurses in primary care, physicians and nurses in general hospitals, and social workers. We re looking forward to doing just that. Brief interventions for alcohol misuse Training and material for non-specialists 9

10 References 1. Moyer, A., Finney, J.W, Swearingen, C.E. and Vergun, P., Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and nontreatment-seeking populations. Addiction, 97, Bien, T.H., Miller, W.R. and Tonigan, J.S., Brief interventions for alcohol problems: a review. Addiction, 88, Babor, T.F. and Grant, M. (Eds), Project on identification and management of alcoholrelated problems. Report on phase II: a randomized clinical trial of brief interventions in primary healthcare. Geneva: World Health Organization. 4. Department of Work and Pensions, State of the Nation Report: Poverty, worklessness and welfare dependency in the UK. 1 st edition. London: HM Government. 5. Ward, M., Investing in alcohol treatment. 1 st edition. London: Alcohol Concern. 6. Swanswell, Survey of a sample of 100 SWMPT offender managers who had previously attended the Swanswell training course. 7. Babor, T.F., Higgins-Biddle, J.C., Saunders, J.B., Monteiro, M.G., The Alcohol Use Disorders Identification Test, Guidelines for Use in Primary Care, 2 nd Edition. Geneva: Department of Mental Health and Substance Dependence, World Health Organization. 8. Field, C.A. and Caetano, R., The effectiveness of brief intervention among injured patients with alcohol dependence: Who benefits from brief interventions?, Drug and Alcohol Dependence. Sep 1; 111 (1-2): Published online 20 May Prochaska, J.O., and DiClemente, C.C., The transtheoretical approach: crossing the traditional boundaries of therapy. Homewood, IL. Dow-Jones/Irwin. Brief interventions for alcohol misuse Training and material for non-specialists 10

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