Screening, Brief Intervention, Referral to Treatment

Transcription

1 Screening, Brief Intervention, Referral to Treatment Kalea Benner, PhD, MSW, LCSW Cassie Brown, MSW, LCSW Funded by SAMHSA, Grant #TI

2 Rationale SBIRT research and implementation has primarily been in general medical settings. This is intentional as it reflects a concerted effort to expand access to care beyond the traditional and very limited specialized addiction treatment system. Offering SBIRT education with non-medical providers (counselors, social workers, psychologists) represents a cutting edge effort to bring this powerful approach to other clinical settings such as community and private mental health practices. As with medical settings, capacity for identifying and addressing substance use issues in mental health practice is limited. SBIRT offers providers in both settings a cost effective and clinically effective pathway for systematic identification and treatment of at risk and high risk substance use.

3 Agenda SBIRT Overview and Role in Substance Use Assessment Transtheoretical Model of Change Motivational Interviewing Basics and Techniques Case vignette and role play with Motivational Interviewing Small group discussion of assessment of risk, use of MI to facilitate change and referral to treatment

4 Brief Intervention Key Concepts Brief intervention is based on two interrelated and critical elements: Stages of Change Many people go through various stages before they are ready to make important changes in their behavior. Recognizing and addressing where patients are in the process is critical to facilitating behavior change. Motivational Interviewing MI is a set of intervention techniques to help patients move through stages of change and develop their own internal motivation. It is also a philosophy of care that recognizes and respects individual autonomy and self determination.

5 Role of MI in Change Motivational Interviewing (MI) is a directive, patient-centered counseling style for eliciting behavior change by helping patients to explore and resolve ambivalence. MI recognizes that patients may be at different stages of awareness and readiness to change. Even when patients recognize the need to change, they may be ambivalent and their motivation to change may ebb and flow during the course of intervention. A central goal of MI is to increase the intrinsic motivation to change that arises from internal forces rather than external pressures.

6 Motivational Interviewing Blaise Pascal: People are generally better persuaded by the reasons which they have themselves discovered than by those which have come into the minds of others. Miller and Rollnick (2012): Motivational Interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

7 MI Objectives Engage the client Facilitate and/or identify personal motivation for change Includes resolving conflict and ambivalence Negotiate plans

8 Steps of MI 1) Engage ask questions, affirm, use empathy 2) Focus reflect, summarize, develop discrepancies 3) Evoke motivation, concerns, reluctance 4) Plan raise the subject, support self efficacy, identify and address essentials of change

9 Principles Empathy (listening and expression) Develop discrepancies Roll with resistance Support self efficacy Miller, Zweben, DiClemente, Rychtarik (1992)

10 Most Common Strategies Developing Discrepancies and rolling with resistance Decisional balance leverages costs vs. benefits; accept all answers Readiness ruler on a scale of 1 10, how ready for change? Reflective discussion with client find personal and compelling reasons for change and make that commitment to change

11 Eliciting Change Talk Looking forward How would you like your life to look a year from now? What will be different in a year if you stop using? Query Extremes What is the worst that could happen if you quit/cut down? What is your worst fear about quitting or cutting down? What is the best thing that could happen if you quit/cut down?

12 MI Summary Motivation has to be an intrinsic process for change to occur Ambivalence is normal Motivation arises from resolving ambivalence change talk facilitates change

13 Vignette You are the single mom of a 10 year old son who is at risk of being retained in 3 rd grade. Your son Ryan was also retained last year for second grade. He is consistently late to school and misses altogether frequently as well. While sometimes there are legitimate reasons for missing school, primarily it s due to your inability to get out of bed in the morning. Often Ryan misses the bus so you have to take him. However, the first bell rings at 8:00 am which is early. You hold a part time job from 10 3 most days and usually can drop Ryan off on your way to work. If you are running late however, Ryan ends up staying home. After you get off work, you usually meet Ryan at home when he gets off the bus at 4:15 pm. You feel like you re a good mom but have a hard time relaxing and once you get home, it s mama time when you can enjoy a cocktail or two. You used to drink Dt. Coke with whiskey but the mixer became too expensive so now you drink Evan Williams on the rocks. A handle usually lasts you a week. While you know it s not the best way to relax, you re a single mom and doing much better than you feel your parents did for you.

14 Role Play How can you empathize with this mom? What resistance did you see? How did you roll with it? What motivation does mom have to reduce use? How did you join with the client? Validate? What goals did you set?

15 Vignette You are a 63 year old man who came to the public health clinic hoping to find some relief for pain in your shoulder. You typically do have aches and pains which are usually helped by Tylenol-3 or some such variation. Over the counter medications usually do not help your pain which then worsens resulting in lack of sleep, etc. So you were on top of things and came right away when the pain started that morning. You don t know why your shoulder hurts but it was bad enough you couldn t raise your coffee cup this morning. You did not fall nor do you have a history of injuries. A cardiac evaluation is done and apparently clear. If the social worker asks about prescribed drug use, you can acknowledge having needed some in the past. You feel that s probably due to having been in Vietnam and sustained injuries that resulted in a purple heart. You guess that your pain now is a small price to pay for serving your country.

16 Role Play How can you empathize with this client? What resistance did you see? How did you roll with it? What motivation does he have to reduce use? How did you join with the client? Validate? What goals did you set?

17 Final Thoughts?