Elements

Screening

It is the first step of the SBIRT process and determines the severity and risk level of the patient’s substance use. Screening for risky alcohol or drug use includes asking questions of all patients to identify those who may misuse alcohol or drugs, or are at risk for developing a problem. The result of a screen allows the provider to determine if a brief intervention or referral to treatment is a necessary next step for the patient, and it is a significant step toward effective intervention.

The Difference Between Screening and Assessment

Why Providers Should Screen Universally

Resources

Brief Intervention

Builds motivation through a collaborative conversation. Brief Intervention is a short conversation between patient and health care provider about the patient’s screening results, information on safe use, and next steps. Brief Interventions are motivation-enhancing discussions focused on increasing insight and awareness of substance use disorders, and decreasing or discontinuing unhealthy alcohol and substance use. The ultimate goal of a brief intervention is to negotiate a plan based on motivational interviewing to change behavior and assist the patient in accessing treatment if needed. About 15 percent of those screened require a brief intervention; those interventions typically take 5 to 15 minutes.

Four Steps to Brief Intervention

Resources

Motivational Interviewing

Motivational interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. “Motivating” often means resolving conflicting and ambivalent feelings and thoughts.

Motivational Interviewing Tasks

Principals of Motivational Interviewing

Core Motivational Interviewing (OARS)

Open-ended questions

When therapists use open-ended questions it allows for a richer, deeper conversation that flows and builds empathy with clients. In contrast, too many back-to-back closed- or dead-ended questions can feel like an interrogation (e. g., “How often do you use cocaine?” “How many years have you had an alcohol problem?” “How many times have you been arrested?”). Open-ended questions encourage clients to do most of the talking, while the therapist listens and responds with a reflection or summary statement. The goal is to promote further dialogue that can be reflected back to the client by the therapist. Open-ended questions allow clients to tell their stories.

Affirmations

Affirmations are statements made by therapists in response to what clients have said, and are used to recognize clients’ strengths, successes, and efforts to change. Affirmative responses or supportive statements by therapists verify and acknowledge clients’ behavior changes and attempts to change. When providing an affirmation, therapists should avoid statements that sound overly ingratiating (e.g., “Wow, that’s incredible!” or “That’s great, I knew you could do it!”). While affirmations help to increase clients’ confidence in their ability to change, they also need to sound genuine.

Reflections

Reflective listening is the primary way of responding to clients and of building empathy. Reflective listening involves listening carefully to clients and then making a reasonable guess about what they are saying; in other words, it is like forming a hypothesis. The therapist then paraphrases the clients’ comments back to them (e.g., “It sounds like you are not ready to quit smoking cigarettes.”).

Another goal in using reflective listening is to get clients to state the arguments for change (i.e., have them give voice to the change process), rather than the therapist trying to persuade or lecture them that they need to change (e.g., “So, you are saying that you want to leave your husband, and on the other hand, you worry about hurting his feelings by ending the relationship. That must be difficult for you. How do you imagine the two of you would feel in 5 years if things remain the same?”). Reflections also validate what clients are feeling and doing so communicates that the therapist understands what the client has said (i.e., “It sounds like you are feeling upset at not getting the job.”). When therapists’ reflections are correct, clients usually respond affirmatively. If the guess is wrong (e.g., “It sounds like you don’t want to quit smoking at this time.”), clients usually quickly disconfirm the hypothesis (e. g. “No, I do want to quit, but I am very dependent and am concerned about major withdrawals and weight gain.”)

Summaries

Summaries are used judiciously to relate or link what clients have already expressed, especially in terms of reflecting ambivalence, and to move them on to another topic or have them expand the current discussion further. Summaries require that therapists listen very carefully to what clients have said throughout the session. Summaries are also a good way to either end a session (i.e., offer a summary of the entire session), or to transition a talkative client to the next topic.

Resources

Referral to Treatment

Directly links patient with appropriate, requested services. Referral to Treatment is provided for patients who have moderate- to high-risk alcohol or drug misuse and who wish to receive further assessment and/or treatment — on average, about 5 percent of those screened. There are a range of different treatments that are appropriate for different uses and should be matched to specific behaviors and health issues.