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Brief Motivational Intervention

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Title: Brief Motivational Intervention


1
A Culturally Relevant Adaptation of Evidence
Based Practice
2
Brief Motivational Intervention (BMI)Participant
Manual
  • A Training Workshop for
  • Health-Care Workers

3
Collaborating Agencies
4
Logistics
  • Restrooms
  • Cell Phones
  • Lunch
  • Evaluations

5
Training Objectives
  • By the end of this training, participants will
  • Be able to screen for heavy alcohol usage, and
    deliver an effective brief motivational
    intervention
  • Have developed or refined basic Motivational
    Interviewing communication skills that can be
    used to address multiple health behaviors
  • Have access to tools and resources that will help
    them assess alcohol use among patients

6
Agenda
  • Importance of Alcohol Screening
  • Introduction to Brief Motivational Intervention
    (BMI)
  • Demonstration of BMI
  • Introduction to Motivational Interviewing
  • BMI Practice

7
Alcohol Screening Exercise

8
Introduction to Brief Motivational Intervention
(BMI)

9
Brief Motivational Intervention (BMI)
  • Combines Brief Intervention with Motivational
    Interviewing
  • Targets patients who have not sought help for
    alcohol or drug problems
  • Included as a part of normal health care services

10
Brief InterventionMotivational Interviewing
  • Feedback of Personal Risk
  • Responsibility of the Patient
  • Advice to Change
  • Menu of Ways to Reduce Drinking
  • Empathetic Counseling Style
  • Self-efficacy

11
How can I remember all this when I am working
with my patients?
  • During this training you will learn a short
    script that will address these elements and more.
  • You will be given a pocket guide to help, if you
    dont remember what to say.
  • A copy of the pocket guide may be given as a
    handout to patients to help them remember what
    you discussed with them.

12
Other Questions you may have
  • Will this method really help my patients?
  • Is it going to take too much of my time?
  • Will it be hard to learn?
  • What do I do if I have problems integrating it
    into my practice?

13
BMI Evidence of Effectiveness
A recent review of 361 controlled research
studies on treatment of alcohol disorders had
this finding
Out of 87 Treatment methods studied The top
ranked treatment modalities were the most
effective 1. Brief Interventions 2.
Motivational enhancement
1 Miller Willbourne, 2002)
14
How many patients will benefit from this?
  • On average, one person will reduce their alcohol
    consumption for every 8 that receive brief
    intervention1.
  • That means, if you use it with 8 people every
    day, by the end of the week you will have
    successfully helped 5 patients to reduce their
    drinking.
  • (Also, some of those who didnt change their
    drinking will start thinking about it, and be
    motivated to change later)
  • 1Moyer et al (2002)

15
How much time does it take?
  • 5 minutes of advice and discussion (following
    screening) is as effective as more extended
    counseling
  • and
  • A single session is effective
  • (as are multiple sessions)
  • 1 Babor Grant, 1992)
  • 2 Poikolainen, 1999 Berglund 2005

16
BMI What is it?
  • 7-10 minute intervention
  • Three Components
  • Screening for heavy drinking
  • Feedback and advice about cutting back
  • Motivational interaction using rulers to assess
    readiness, talking about change based on
    readiness, and goal setting if the patient is
    ready.

17
Demonstration of BMI

18
Administrative Questions to Think About
  • How do you see this kind of intervention fitting
    into your work with patients?
  • What kind of patients should receive this
    screening and intervention?
  • What changes may be needed in your agency to
    adopt this procedure as a part of normal clinic
    services?
  • We will come back to these questions later.

19
Using Motivational Interviewing to Address
Alcohol Use and HIV Risk

20
(No Transcript)
21
Motivational Interviewing (MI)
  • Definition
  • A directive, patient-centered counseling style
    that enhances motivation for change by helping
    patients clarify and resolve ambivalence about
    behavior change.
  • Goal
  • To identify and resolve discrepancies between
    current behavior and broader values and goals.

22
Motivational Interviewing
  • Stems from working with people who had problems
    with drinking alcohol.
  • 1980s - William Miller, PhD Stephen Rollnick,
    PhD
  • Conclusion
  • Brief interactions can be effective when
    patients concerns and needs are elicited and
    messages are tailored to address these concerns
    and desires.

23
Spirit of Motivational Interviewing
  • Collaboration Working in Partnership
  • Evocation Learning from the patient
  • Autonomy Patient is responsible for change

24
More About the MI Philosophy
  • Empowerment
  • Help patients take ownership over their own
    health management by creating an informed,
    activated patient who
  • is willing to work in partnership with the health
    care system,
  • feels capable of making healthy choices to
    achieve his or her own goals.

25
A Continuum of Communication Styles
Guiding
Instructing
Listening
26
Basic Assumptions of MI
  • Motivation is a state of readiness to change
  • that fluctuates with time and situations.
  • Motivation often involves an interaction.
  • People who consider making a change often have
    mixed feelings, known as ambivalence.
  • Ambivalence is a normal part of the change
    process.

27
Motivational Interviewing
  • Each patient has a powerful potential for change.
  • Believing that your patients can change helps
    them believe this, too.
  • Setting high expectations of what your patients
    can achieve will help them strive towards meeting
    this expectation.

28
Motivational Interviewing
  • The task of the counselor is to
  • Tap into the patients potential for change,
  • Guide the natural change process already within
    the individual,
  • Impart hope, belief in, and confidence that the
    patient can make desired changes.

29
Predictors of Behavior Change
  • Patient Statements
  • Desire
  • Ability
  • Reasons
  • Need

Commitment Language
Behavior Change
30
Motivational Interviewing
  • Five General Principles
  • Develop Discrepancy
  • Express Empathy
  • Acknowledge Accomplishments
  • Roll with Resistance
  • Support Self-Efficacy

31
Core MI Strategies
  • Four Early Strategies OARS
  • Open-Ended Questions
  • Affirming
  • Reflective Listening
  • Summarizing

Elicit Positive Change Talk
32
Open Questions to Promote Change
  • Problem Recognition
  • How do you feel about your current alcohol use
    (or health)?
  • Expression of Concern
  • What worries do you have about your alcohol use
    (health)?
  • Intention to Change
  • What would you like to do about this?
  • Optimism
  • What makes you feel that now is a good time to
    get started?

33
Turning Closed into Open Questions
  • Do you drink a lot of alcohol in the evening?
  • How much alcohol do you drink in the evening?
  • Do you want to reduce your drinking?
  • How do you feel about making changes in your
    drinking?
  • What might make you want to reduce your drinking?
  • Do you know that too much alcohol can be harmful?
  • What do you know about the risks of drinking too
    much alcohol?

34
Exercises
  • Reflective Listening
  • Is a process of
  • Hearing what the speaker has to say,
  • Making a guess at what she means,
  • Giving voice to this guess in the form of a
    statement.

35
Forming Reflections
  • For starters
  • It sounds like you are not ready to stop
    drinking.
  • It seems that you are having a problem
    remembering things.
  • It sounds like you are feeling guilty about your
    drinking.
  • From what you are saying, you are having trouble
    limiting your drinking.
  • As you improve, you can shorten the reflection.
  • Youre not ready to stop drinking.
  • Youre having a problem remembering things.
  • Youre feeling guilty about your drinking.
  • So youre having trouble limiting your drinking.

36
Levels of Reflection
  • Sustained Reflective Listening
  • Repeating Repeats what patient says
  • Rephrasing Begins to add new meaning
  • Paraphrasing Extends what patient is saying
  • Reflecting Feeling Reflects a deeper level
  • General Rule of Thumb
  • Begin with simpler reflections and delve into
    deeper reflections as understanding increases.

37
Reflective Listening Exercise
  • In pairs, talk about a behavior that you have
    been wanting to change, yet are struggling with.
  • One person is the listener, the other speaks.
  • At the end of 1.5 minutes, the listener uses
    reflective statements to summarize what the
    person has been saying, including at least one
    feeling statement.

38
The Value of Reflective Listening
  • Lets the person know that you are listening and
    encourages him/her to tell you more,
  • It is perceived as neutral and lacking judgment,
  • It allows patients to hear you repeat/rephrase
    what they are saying for further consideration,
  • It allows the person to clarify his/her thoughts.

39
Finding the Potential for Change
  • I know I should probably not drink so much. I
    often feel a bit fuzzy the next day, and
    sometimes I forget things that I need to do. But
    drinking helps me relax at the end of the day,
    and it helps me forget my pain.

40
Reflections to Promote Change
  • So if you could find a way to relax without
    alcohol, you might feel better.
  • Drinking alcohol gets in the way of your doing
    things that you need to do.
  • Youre worried that if you dont do something
    about your drinking, you might forget something
    really important.
  • Youre in a lot of pain and need to find a way
    to make things better.

41
Finding the Potential for Change
  • Why should I stop drinking? Sometimes I wonder
    if I should not drink so much, but then I always
    find myself drinking with my friends. We all do
    it. Sometimes I try to limit myself to one drink,
    but then I always have another. Im not sure if
    Im strong enough to give it up.

42
Reflections to Promote Change
  • So you tell yourself to cut back on drinking
    sometimes.
  • Youre afraid that something really bad might
    happen to you if you continue to drink so much.
  • Youve tried to cut back on your drinking, but
    you werent able to limit yourself.
  • Youre wondering how you could cut back on your
    drinking when all of your friends drink.

43
BMI Handout
44
Brief Motivational Intervention (BMI)
  • 1. Screening
  • -Amount frequency of drinking
  • 2. Assessment, Education and Feedback
  • -Discuss risky limits and health risks.
  • 3. Behavior Change
  • -Assess readiness to change alcohol use.
  • -Offer assistance, based on readiness to change
    alcohol use.
  • -Set realistic goals with the patient

45
Screening
  • Ask about drinking (amount frequency)
  • Do you ever drink alcohol?
  • When was the last time you had 5(4) or more
    drinks in one day?
  • On how many days a week do you drink?
  • When you drink, how many drinks do you usually
    have?
  • Calculate total

46
ScreeningDemonstration Practice
  • Screening
  • Do you ever drink alcohol?
  • When was the last time you had _X_ or more drinks
    in one day?
  • (X 5 for men, 4 for women)

  • - - if three months ago or less, continue - -
  • ? On how many days a week do you drink? ____
  • When you drink, how many drinks do you usually
    have ? ____
  • (calculate weekly total) _____

47
Assessment, Education, Feedback
  • Discuss risky limits and health risks
  • Risky limits for men are gt 5 in any one day or 15
    or more during a week
  • Health risks due to alcohol are very high if any
    of these apply to you
  • HIV positive
  • ARV medications
  • Pregnant, or likely to become pregnant
  • Loss of memory and control when drinking
  • Engage in sex while intoxicated
  • Your level of drinking may be more than what is
    medically safe.

48
Assessment, Education, FeedbackDemonstration
Practice
Risky Drinking Limits are 5 or more in a day,
OR 15 per week (men) 4 or more in a day, OR
8 per week (women) Any Alcohol use carries high
risk if these apply to you ? HIV positive ?
ARV medications ? Pregnant or likely to
become pregnant ? Engage in sex after
drinking ? Loss of memory or control when
drinking Your drinking is greater than is
medically safe. As your healthcare provider, I
recommend that you cut back to a level that is
below risky drinking limits. What do you
think about this?

49
Behavior Change
  • Assess readiness to change alcohol use
  • In thinking about your alcohol use and related
    risk, how ready are you to change your drinking?
  • Use rulers to assess aspects of readiness and
    motivation

50
Behavior Change
  • Offer assistance, based on readiness
  • If in (pre)contemplation Encourage patient to
    continue to think about change explore
    ambivalence and have future discussions with
    healthcare worker
  • If in preparation Help patient create a plan
    set goals.

51
Behavior Change
  • If in action Reinforce change efforts and assist
    in continuing to modify the plan by exploring the
    process
  • If in maintenance Support change and explore
    continued support needs

52
Behavior Change
  • Explore patients Goals
  • Explore patients desired outcomes, hopes and
    expectations.
  • What are your goals What would you like to see
    happen?
  • Help patient identify specific, achievable goals.
  • How will change impact whats most important to
    the patient?
  • Explore options and resources for change.
  • Find ongoing support from family, friends,
    community, and appropriate referrals.
  • Follow-up and clarify understanding of plan

53
Motivation Rulers Importance and
ConfidenceDemonstration Practice
Importance
  • How important would you say it is to cut back
    below risky drinking limits?
  • Why did you pick a ___ and not a (lower number)?
  • What concerns do you have about your drinking?

Confidence
? If you were to decide right now to cut back,
how confident are you that you could succeed? ?
Why did you pick a ___ and not a (lower
number)? ? What would help you to have a higher
number?
54
Motivation Rulers ReadinessDemonstration
Practice
  • Readiness

Finally, how ready are you right now, to cut
back below risky drinking limits?
? If Not Ready, or Thinking about it, I
encourage you to keep in mind how your drinking
may be affecting you and others. Be alert for
problem signs. ? If Planning, My goal is to cut
back to _______ drinks, ____ times a week. To
prepare for this I will __________________________
___ ? If Actively working or Already made the
change, Congratulations on your change, keep up
the good work!
55
Goal Setting
  • Specific
  • Measurable
  • Achievable
  • Realistic
  • Timeframe

56
Shaping Behaviors Toward Goals
  • Nothing breeds success like success"
  • Helping patients set a series of goals that move
    them ahead in small steps is the best way to
    reach a distant point
  • Helping patients find ongoing rewards for
    achieving these steps can help them want to keep
    the change process going.

57
PROS AND CONS MATRIX
Reducing or Stopping Drinking Pros (Good Things) Cons(Downsides)
Drinking the Same
Changing Drinking Habits
58
PROS AND CONS MATRIX
Reducing or Stopping Drinking Pros (Good Things) Cons(Downsides)
Drinking the Same It helps me relax I can forget my pain I forget things that I need to do. Makes me tired Lack energy and motivation
Changing Drinking Habits Would not forget things Would feel better Have more energy I would feel more pain I would be bored or have nothing to do in the evenings. All guys drink
59
Presenting Behavioral Options
What would you like to do to improve your health?
EAT MORE HEALTHFULLY
SAFE SEX
TAKE MY MEDICINE
YOU CHOOSE/ OTHER
REDUCE UNHEALTHY HABITS
COPE WITH STRESS
60
The Key to Success
  • Be Present,
  • Compassionate
  • and Listen.
  • And Never Give Up

61
Website References
  • Motivational Interviewing
  • www.motivationalinterview.org
  • Southern Africa - Health Information
  • www.sahealthinfo.org
  • http//ifrpafrica.org/ifrpafrica.org5Fnon5Fssl/A
    bout/
  • Addiction Technology Transfer Center
  • http//www.nfattc.org/publicationsNewsResources/pu
    blications.aspx

62
Trainers Guide Brief Motivational Intervention
(BMI) for Healthcare Workers Need for an Alcohol
Intervention Many healthcare patients have
increased HIV related risk due to heavy use of
alcohol. Under the influence of heavy drinking,
these patients often do not make safe decisions
about sexual practices, or other health
behaviors. They are more likely to engage in
risky sexual behaviors and thus be more likely to
become infected or transmit infection to others,
or to fail to adhere to their medication schedule
if taking anti-retroviral medications. Alcohol
abuse is regarded by many as the primary reason
for medication non-adherence. The
Intervention Screening, Brief Intervention
strategies, and Motivational Interviewing are
methods that are often used together and have
strong evidence of effectiveness in brief
clinical encounters. To address the above need,
we developed a brief, motivational intervention
(BMI) for health workers to use with patients in
various settings. This BMI pocket guide begins
with three screening questions to assess levels
of alcohol use. Levels are categorized into high
and low risk. Patients who are considered
high-risk drinkers are provided with direct
advice to cut back or quit. Patients are further
asked about how important this change is to them,
and their confidence. Lastly, they are assessed
for their readiness to change, and if ready, the
patient is invited to set specific goals for
reduced drinking. Patients who are not ready to
make changes are encouraged to think more about
their drinking and its impact on their health and
daily living. This intervention is recommended
for use with all patients as part of regular
assessment routine and specialized healthcare
settings. Research evidence indicates that brief
interventions are effective immediately for one
in eight heavy drinkers in helping them reduce
their drinking to within safe levels. The BMI
is intended as a stand alone intervention and has
shown the biggest impact in reduction among
moderate to heavy drinkers, with less of an
effect on dependent drinkers. When dependent
patients are identified, they are encouraged to
seek treatment if available, quit drinking
completely, to connect with AA groups, and to
enlist family members or other supportive persons
in helping them work on their long term
recovery. Motivational Interviewing Motivational
Interviewing (MI) is a directive,
patient-centered communication style that aims to
enhance the patients internal reasons for
change. At its core, MI provides a respectful
tone for partnering with patients to empower them
to play a more active role in their own health
and self-care. The core strategies include
asking open questions, reflective listening,
affirming patients views and actions, and
summarizing the patient encounter. These
strategies involve basic and advanced skills that
require attention, practice, and ongoing training
to ensure that the spirit and methods of
motivational interviewing are effectively
implemented.
63
  • Feasibility of Incorporating BMI within the
    Practice of Healthcare Workers
  • This method is quick (7-10 minutes). The core
    components are in a Pocket Guide that the
    healthcare worker can use as a reference when
    talking with patients). One side guides the
    drinking assessment and brief intervention and
    the other side guides assessment of the patients
    motivation to change. . A paper copy may be given
    to the patient as a record of their discussion
    and a reminder of their readiness ratings, goals
    and plans. During initial and follow-up trainings
    for this method, healthcare workers are able to
    observe others model using the BMI pocket guide
    and have their own practice until they are
    comfortable with using it.
  • Implementation Support
  • As with any change in professional practice,
    administrative and clinical support is necessary
    to ensure the change is successfully implemented
    and sustained. Follow-up training or technical
    consultation is very helpful, when possible.
    Peer networking is also a good way to provide for
    implementation support.
  • Training Objectives
  • By the end of this training, participants will
  • Be able to screen for heavy alcohol usage and
    deliver an effective brief motivational
    intervention
  • Have developed or refined basic Motivational
    Interviewing communication skills that can be
    used to address multiple health behaviors
  • Have access to tools and resources that will help
    them assess alcohol use among patients
  • Using the Trainers Guide
  • This workshop was designed as a continuing
    education course for health care workers. It
    will particularly assist health care workers who
    provide services related to HIV/AIDS, presenting
    basic knowledge around the intersection of
    HIV/AIDS and AOD, as well as a the introduction
    to a tool that helps screen, assess alcohol use,
    and work with patients toward behavior change.
    The primary focus of the workshop is on
    screening, brief advice and motivational
    enhancement with the assumption that a foundation
    of HIV/AIDS and AOD exist for the worker.
    Experienced health care workers can incorporate
    the intervention into their current work.
    However, basic educational information on AOD and
    HIV/AIDS is also provided in the trainers
    package so that a foundational training can be
    lead and health care workers who dont have this
    information can begin the process of addressing
    these concerns with individuals they come in
    contact with in their work.
  • The basic process and content of the workshop are
    captured in this trainers guide and the
    companion participants manual, which form an
    integrated training package.
  • The trainers guide is specified for a one day
    training, however when more time is available the
    expansion of this training is encouraged.
    Extending the practice exercises, particularly
    role play sessions, is extremely helpful to
    participants as it increases understanding of the
    material and therefore stronger delivery of the
    intervention. Exercises are described and
    suggested for this optional second day at the
    back of the trainers guide. However, trainings
    should be adapted based on participant level,
    participant needs and time available.

64
  • Participants Manual
  • As a first step in preparing for training the
    course, it is suggested that the trainer read
    through the participants manual in sequence,
    without reference to the trainers guide. This
    reading will highlight the key concepts and
    information on which to focus the training.
    Follow this first review with a study of the
    trainer text in the trainers guide and of the
    handouts included in the participants manual.
  • Next, walk yourself through the participants
    manual to take note of how the information
    connects from one segment to the next (and
    overall) and how participants are supposed to be
    using the material. Try to walk yourself through
    the exercises and take notes (again, without
    reference to the trainers guide). Highlight key
    words throughout the manual that establish
    connections and points that require
    clarification, from the perspective of a training
    participant.
  • Finally, use the participant manual to review the
    process instructions provided. By this time, you
    should have gained a mental picture of what
    participants will have before their eyes as the
    training is delivered. Use this picture to shape
    the deliveryso that the verbalizations are
    consistent with what participants are seeing in
    their manuals.
  • Trainers Guide
  • The training notes in this guide are a
    step-by-step script for workshop delivery.
    Although they are not intended to be read
    word-for-word, the notes do supplement the
    process of the training rather precisely with
    instructions and talking points for each slide.
    Instructions should, therefore be interpreted
    quite literally. Guidance for each slide follows
    a copy of the slide, in order to make the
    trainers guide more user-friendly. In addition,
    if a handout or activity instructions are needed
    for a certain section, it will be noted.
  • Process preparation using the trainers guide
    should proceed through each discrete instruction
    in the outline, with the participant manual
    slides. As a necessary part for each
    instruction
  • transfer into the guide those highlights or notes
    of key words and clarification needs that were
    marked in the participant manual
  • draw up a separate list of special resources to
    be gathered and
  • recollect and take notes on personal anecdotes or
    examples relevant to the material to be used when
    training.
  • Next, rehearse delivery of the outline, paying
    close attention to the time frames allotted.
  • When you are satisfied that you can deliver the
    training as outlined and have selected the most
    instructive personal detail to meet intended
    objectives within the timeframe, be sure your
    notes are in a brief format and easy to take cues
    from. Beware of writing copious notes on your
    outline, relying on pages of additional notes for
    delivery. (Experience indicates that such
    efforts usually lead to a self-defeating paper
    shuffle.) Finally, gather and/or draw up
    handouts and other training resources on your
    list.

65
  • Trainer Credentials
  • This course is designed to be delivered by one or
    two trainers, each should have solid training
    skills and ability to accommodate delivery to
    varying learner needs, group process,
    facilitation and platform delivery. It is
    critical that the trainer(s) be able to assess
    their audience and be able to deliver these
    concepts in a culturally sensitive and easily
    understandable format. This trainers text
    contains the information necessary however the
    trainer must tailor the information to fit the
    needs of the audience. The trainer(s) will also
    need the ability to use examples from either
    their own life and work experience.
  • Even if the trainer is seasoned, proper skills
    building and training on this curriculum are
    important for all trainers prior to delivery of
    this material. The trainers guide is not
    intended as a replacement of attending a training
    of trainers, but instead as a supplement once the
    trainer has become appropriately skilled. It is
    preferable that trainers have an up-to-date
    working knowledge of the following
  • gtAlcohol and other Drugs (AOD), HIV/AIDS, and the
    intersection of the two.
  • This includes knowledge of signs and symptoms
    prevention, intervention and treatment concepts,
    types and modalities etiology statistics and
    resources. This expertise is helpful for
    trainers to be able to personalize the workshop
    by providing specific examples that promote
    learning. The focus of this course is not
    specifically on all details of AOD and HIV/AIDS.
    However, knowledge in this area is important due
    to the connection of behavior change and how
    health care workers will be using this
    information in their work.
  • gtBehavior change, specifically Stages of Behavior
    Change, Brief Intervention and Motivational
    Interviewing techniques.
  • gtThe BMI intervention script.
  • Pre-Training Preparation
  • Prior to arriving at the training site, the
    trainer's) should confer with the site
    coordinator to arrange for
  • Room set-up
  • A flexible training room that accommodates needs
    of 15-20 participants
  • A room that can accommodate both work for small
    groups in addition to large group set up

66
  • Material Needs
  • Participant Manuals for each participant and a
    few extra
  • PowerPoint cd
  • Participant handouts, role play scenarios and
    reference materials
  • All other materials such as resource directories,
    brochures or any local information that may
    enhance the information in the course
  • Resource Needs
  • Arrange for a local/regional representative to
    provide information regarding substance abuse
    resources for adults and children and how to
    access care in the area
  • If the above resources can not be made available,
    prepare newsprints with resources that are
    available.
  • Collect local or regional information on drugs of
    abuse and HIV/AIDS
  • The following individuals are acknowledged for
    their assistance in the creation of this
    curriculum.
  • Acknowledgements
  • Richard Spence, University of Texas at Austin
  • Jacki Hecht, The Miriam Hospital/Brown Medical
    School
  • Stephanie Howard, University of Texas at Austin

67
Brief Motivational Intervention (BMI)Trainers
Guide
  • A Training Workshop for
  • Health-Care Workers

68
Collaborating Agencies
69
Logistics
  • Restrooms
  • Cell Phones
  • Lunch
  • Evaluations

70
Training Objectives
  • By the end of this training, participants will
  • Be able to screen for heavy alcohol usage, and
    deliver an effective brief motivational
    intervention
  • Have developed or refined basic Motivational
    Interviewing communication skills that can be
    used to address multiple health behaviors
  • Have access to tools and resources that will help
    them assess alcohol use among patients

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Agenda
  • Importance of Alcohol Screening
  • Introduction to Brief Motivational Intervention
    (BMI)
  • Demonstration of BMI
  • Introduction to Motivational Interviewing
  • BMI Practice

72
Alcohol Screening Activity

73
Introduction to Brief Motivational Intervention
(BMI)

74
Brief Motivational Intervention (BMI)
  • Combines Brief Intervention with Motivational
    Interviewing
  • Targets patients who have not sought help for
    alcohol or drug problems
  • Included as a part of normal health care services

75
Brief InterventionMotivational Interviewing
  • Feedback of Personal Risk
  • Responsibility of the Patient
  • Advice to Change
  • Menu of Ways to Reduce Drinking
  • Empathetic Counseling Style
  • Self-efficacy

76
How can I remember all this when I am working
with my patients?
  • During this training you will learn a short
    script that will address these elements and more.
  • You will be given a pocket guide to help, if you
    dont remember what to say.
  • A copy of the pocket guide may be given as a
    handout to patients to help them remember what
    you discussed with them.

77
Other Questions you may have
  • Will this method really help my patients?
  • Is it going to take too much of my time?
  • Will it be hard to learn?
  • What do I do if I have problems integrating it
    into my practice?

78
BMI Evidence of Effectiveness
A recent review of 361 controlled research
studies on treatment of alcohol disorders had
this finding
Out of 87 Treatment methods studied The top
ranked treatment modalities were the most
effective 1. Brief Interventions 2.
Motivational enhancement
1 Miller Willbourne, 2002)
79
How many patients will benefit from this?
  • On average, one person will reduce their alcohol
    consumption for every 8 that receive brief
    intervention1.
  • That means, if you use it with 8 people every
    day, by the end of the week you will have
    successfully helped 5 patients to reduce their
    drinking.
  • (Also, some of those who didnt change their
    drinking will start thinking about it, and be
    motivated to change later)
  • 1Moyer et al (2002)

80
How much time does it take?
  • 5 minutes of advice and discussion (following
    screening) is as effective as more extended
    counseling
  • and
  • A single session is effective
  • (as are multiple sessions)
  • 1 Babor Grant, 1992)
  • 2 Poikolainen, 1999 Berglund 2005

81
BMI What is it?
  • 7-10 minute intervention
  • Three Components
  • Screening for heavy drinking
  • Feedback and advice about cutting back
  • Motivational interaction using rulers to assess
    readiness, talking about change based on
    readiness, and goal setting if the patient is
    ready.

82
Demonstration of BMI

83
Administrative Questions to Think About
  • How do you see this kind of intervention fitting
    into your work with patients?
  • What kind of patients should receive this
    screening and intervention?
  • What changes may be needed in your agency to
    adopt this procedure as a part of normal clinic
    services?
  • We will come back to these questions later.

84
Using Motivational Interviewing to Address
Alcohol Use and HIV Risk

85
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Motivational Interviewing (MI)
  • Definition
  • A directive, patient-centered counseling style
    that enhances motivation for change by helping
    patients clarify and resolve ambivalence about
    behavior change.
  • Goal
  • To identify and resolve discrepancies between
    current behavior and broader values and goals.

87
Motivational Interviewing
  • Stems from working with people who had problems
    with drinking alcohol.
  • 1980s - William Miller, PhD Stephen Rollnick,
    PhD
  • Conclusion
  • Brief interactions can be effective when
    patients concerns and needs are elicited and
    messages are tailored to address these concerns
    and desires.

88
Spirit of Motivational Interviewing
  • Collaboration Working in Partnership
  • Evocation Learning from the patient
  • Autonomy Patient is responsible for change

89
More About the MI Philosophy
  • Empowerment
  • Help patients take ownership over their own
    health management by creating an informed,
    activated patient who
  • is willing to work in partnership with the health
    care system,
  • feels capable of making healthy choices to
    achieve his or her own goals.

90
A Continuum of Communication Styles
Guiding
Instructing
Listening
91
Basic Assumptions of MI
  • Motivation is a state of readiness to change
  • that fluctuates with time and situations.
  • Motivation often involves an interaction.
  • People who consider making a change often have
    mixed feelings, known as ambivalence.
  • Ambivalence is a normal part of the change
    process.

92
Motivational Interviewing
  • Each patient has a powerful potential for change.
  • Believing that your patients can change helps
    them believe this, too.
  • Setting high expectations of what your patients
    can achieve will help them strive towards meeting
    this expectation.

93
Motivational Interviewing
  • The task of the counselor is to
  • Tap into the patients potential for change,
  • Guide the natural change process already within
    the individual,
  • Impart hope, belief in, and confidence that the
    patient can make desired changes.

94
Predictors of Behavior Change
  • Patient Statements
  • Desire
  • Ability
  • Reasons
  • Need

Commitment Language
Behavior Change
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Motivational Interviewing
  • Five General Principles
  • Develop Discrepancy
  • Express Empathy
  • Acknowledge Accomplishments
  • Roll with Resistance
  • Support Self-Efficacy

96
Core MI Strategies
  • Four Early Strategies OARS
  • Open-Ended Questions
  • Affirming
  • Reflective Listening
  • Summarizing

Elicit Positive Change Talk
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Open Questions to Promote Change
  • Problem Recognition
  • How do you feel about your current alcohol use
    (or health)?
  • Expression of Concern
  • What worries do you have about your alcohol use
    (health)?
  • Intention to Change
  • What would you like to do about this?
  • Optimism
  • What makes you feel that now is a good time to
    get started?

98
Turning Closed into Open Questions
  • Do you drink a lot of alcohol in the evening?
  • How much alcohol do you drink in the evening?
  • Do you want to reduce your drinking?
  • How do you feel about making changes in your
    drinking?
  • What might make you want to reduce your drinking?
  • Do you know that too much alcohol can be harmful?
  • What do you know about the risks of drinking too
    much alcohol?

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Exercises
  • Reflective Listening
  • Is a process of
  • Hearing what the speaker has to say,
  • Making a guess at what she means,
  • Giving voice to this guess in the form of a
    statement.

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Forming Reflections
  • For starters
  • It sounds like you are not ready to stop
    drinking.
  • It seems that you are having a problem
    remembering things.
  • It sounds like you are feeling guilty about your
    drinking.
  • From what you are saying, you are having trouble
    limiting your drinking.
  • As you improve, you can shorten the reflection.
  • Youre not ready to stop drinking.
  • Youre having a problem remembering things.
  • Youre feeling guilty about your drinking.
  • So youre having trouble limiting your drinking.

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Levels of Reflection
  • Sustained Reflective Listening
  • Repeating Repeats what patient says
  • Rephrasing Begins to add new meaning
  • Paraphrasing Extends what patient is saying
  • Reflecting Feeling Reflects a deeper level
  • General Rule of Thumb
  • Begin with simpler reflections and delve into
    deeper reflections as understanding increases.

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Reflective Listening Exercise
  • In pairs, talk about a behavior that you have
    been wanting to change, yet are struggling with.
  • One person is the listener, the other speaks.
  • At the end of 1.5 minutes, the listener uses
    reflective statements to summarize what the
    person has been saying, including at least one
    feeling statement.

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The Value of Reflective Listening
  • Lets the person know that you are listening and
    encourages him/her to tell you more,
  • It is perceived as neutral and lacking judgment,
  • It allows patients to hear you repeat/rephrase
    what they are saying for further consideration,
  • It allows the person to clarify his/her thoughts.

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Finding the Potential for Change
  • I know I should probably not drink so much. I
    often feel a bit fuzzy the next day, and
    sometimes I forget things that I need to do. But
    drinking helps me relax at the end of the day,
    and it helps me forget my pain.

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Reflections to Promote Change
  • So if you could find a way to relax without
    alcohol, you might feel better.
  • Drinking alcohol gets in the way of your doing
    things that you need to do.
  • Youre worried that if you dont do something
    about your drinking, you might forget something
    really important.
  • Youre in a lot of pain and need to find a way
    to make things better.

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Finding the Potential for Change
  • Why should I stop drinking? Sometimes I wonder
    if I should not drink so much, but then I always
    find myself drinking with my friends. We all do
    it. Sometimes I try to limit myself to one drink,
    but then I always have another. Im not sure if
    Im strong enough to give it up.

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Reflections to Promote Change
  • So you tell yourself to cut back on drinking
    sometimes.
  • Youre afraid that something really bad might
    happen to you if you continue to drink so much.
  • Youve tried to cut back on your drinking, but
    you werent able to limit yourself.
  • Youre wondering how you could cut back on your
    drinking when all of your friends drink.

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BMI Handout
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Brief Motivational Intervention (BMI)
  • Screening
  • -Amount frequency of drinking
  • 2. Assessment, Education and Feedback
  • -Discuss risky limits and health risks.
  • 3. Behavior Change
  • -Assess readiness to change alcohol use.
  • -Offer assistance, based on readiness to change
    alcohol use.
  • -Set realistic goals with the patient

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Screening
  • Ask about drinking (amount frequency)
  • Do you ever drink alcohol?
  • When was the last time you had 5(4) or more
    drinks in one day?
  • On how many days a week do you drink?
  • When you drink, how many drinks do you usually
    have?
  • Calculate total

111
ScreeningDemonstration Practice
  • Screening
  • Do you ever drink alcohol?
  • When was the last time you had _X_ or more drinks
    in one day?
  • (X 5 for men, 4 for women)

  • - - if three months ago or less, continue - -
  • ? On how many days a week do you drink? ____
  • When you drink, how many drinks do you usually
    have ? ____
  • (calculate weekly total) _____

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Assessment, Education, Feedback
  • Discuss risky limits and health risks
  • Risky limits for men are gt 5 in any one day or 15
    or more during a week
  • Health risks due to alcohol are very high if any
    of these apply to you
  • HIV positive
  • ARV medications
  • Pregnant, or likely to become pregnant
  • Loss of memory and control when drinking
  • Engage in sex while intoxicated
  • Your level of drinking may be more than what is
    medically safe.

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Assessment, Education, FeedbackDemonstration
Practice
Risky Drinking Limits are 5 or more in a day,
OR 15 per week (men) 4 or more in a day, OR
8 per week (women) Any Alcohol use carries high
risk if these apply to you ? HIV positive ?
ARV medications ? Pregnant or likely to
become pregnant ? Engage in sex after
drinking ? Loss of memory or control when
drinking Your drinking is greater than is
medically safe. As your healthcare provider, I
recommend that you cut back to a level that is
below risky drinking limits. What do you
think about this?

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Behavior Change
  • Assess readiness to change alcohol use
  • In thinking about your alcohol use and related
    risk, how ready are you to change your drinking?
  • Use rulers to assess aspects of readiness and
    motivation

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Behavior Change
  • Offer assistance, based on readiness
  • If in (pre)contemplation Encourage patient to
    continue to think about change explore
    ambivalence and have future discussions with
    healthcare worker
  • If in preparation Help patient create a plan
    set goals.

116
Behavior Change
  • If in action Reinforce change efforts and assist
    in continuing to modify the plan by exploring the
    process
  • If in maintenance Support change and explore
    continued support needs

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Behavior Change
  • Explore patients Goals
  • Explore patients desired outcomes, hopes and
    expectations.
  • What are your goals What would you like to see
    happen?
  • Help patient identify specific, achievable goals.
  • How will change impact whats most important to
    the patient?
  • Explore options and resources for change.
  • Find ongoing support from family, friends,
    community, and appropriate referrals.
  • Follow-up and clarify understanding of plan

118
Motivation Rulers Importance and
ConfidenceDemonstration Practice
Importance
  • How important would you say it is to cut back
    below risky drinking limits?
  • Why did you pick a ___ and not a (lower number)?
  • What concerns do you have about your drinking?

Confidence
? If you were to decide right now to cut back,
how confident are you that you could succeed? ?
Why did you pick a ___ and not a (lower
number)? ? What would help you to have a higher
number?
119
Motivation Rulers ReadinessDemonstration
Practice
  • Readiness

Finally, how ready are you right now, to cut
back below risky drinking limits?
? If Not Ready, or Thinking about it, I
encourage you to keep in mind how your drinking
may be affecting you and others. Be alert for
problem signs. ? If Planning, My goal is to cut
back to _______ drinks, ____ times a week. To
prepare for this I will __________________________
___ ? If Actively working or Already made the
change, Congratulations on your change, keep up
the good work!
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Goal Setting
  • Specific
  • Measurable
  • Achievable
  • Realistic
  • Timeframe

121
Shaping Behaviors Toward Goals
  • Nothing breeds success like success"
  • Helping patients set a series of goals that move
    them ahead in small steps is the best way to
    reach a distant point
  • Helping patients find ongoing rewards for
    achieving these steps can help them want to keep
    the change process going.

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PROS AND CONS MATRIX
Reducing or Stopping Drinking Pros (Good Things) Cons(Downsides)
Drinking the Same
Changing Drinking Habits
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PROS AND CONS MATRIX
Reducing or Stopping Drinking Pros (Good Things) Cons(Downsides)
Drinking the Same It helps me relax I can forget my pain I forget things that I need to do. Makes me tired Lack energy and motivation
Changing Drinking Habits Would not forget things Would feel better Have more energy I would feel more pain I would be bored or have nothing to do in the evenings. All guys drink
124
Presenting Behavioral Options
What would you like to do to improve your health?
EAT MORE HEALTHFULLY
SAFE SEX
TAKE MY MEDICINE
YOU CHOOSE/ OTHER
REDUCE UNHEALTHY HABITS
COPE WITH STRESS
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The Key to Success
  • Be Present,
  • Compassionate
  • and Listen.
  • And Never Give Up

126
Website References
  • Motivational Interviewing
  • www.motivationalinterview.org
  • Southern Africa - Health Information
  • www.sahealthinfo.org
  • http//ifrpafrica.org/ifrpafrica.org5Fnon5Fssl/A
    bout/
  • Addiction Technology Transfer Center
  • http//www.nfattc.org/publicationsNewsResources/pu
    blications.aspx

127
Appendix
128
Alcohol Use, Abuse and Dependence
129
Myths and Misunderstandings
  • Common misconceptions about alcohol use,
    HIV/AIDS, and the connection between the two in
    your society
  • An alcohol problem is a sign of moral weakness.

130
Drug Categories
  • Stimulants
  • Depressants
  • Inhalants
  • Hallucinogens
  • Marijuana
  • Opiates

131
  • What problems are associated with alcohol?
  • How do problem drinkers affect your work?

132
Alcohol
  • For most people who drink, alcohol is a pleasant
    accompaniment to social activities.
  • Moderate alcohol use up to 2 drinks per day for
    men and 1 drink per day for women and older
    people is not harmful for most adults.
  • However, a large number of people get into
    serious trouble because of their drinking.
  • These patterns include binge drinking and heavy
    drinking on a regular basis.
  • Risky drinking limits are 5 or more drinks for
    men and 4 or more drinks for women in one day.

133
Equal?
134
Standard Drink
  • This term is used to simplify the measurement of
    alcohol consumption.

135
Individual Reactions
  • Individual reactions to alcohol vary, and are
    influenced by many factors, including but not
    limited to
  • Age
  • Gender
  • Ethnicity
  • Physical condition (weight, fitness level, etc)
  • Amount of food consumed before drinking
  • How quickly the alcohol was consumed
  • Use of drugs or prescription medicines
  • Family history of alcohol problems

136
Impaired Judgment and Loss of Control
  • Alcohol use affects brain functioning and can
    alter thoughts and behaviors
  • This impairment can result in poor decision
    making such as high risk behaviors

137
Continuum of Use
  • Alcohol consumption ranges along a continuum
    from no use to dependence. Many factors,
    including the environment and genetics, determine
    where an individuals alcohol use falls on this
    continuum. Personal choice plays a key role in
    the decision to use or abstain from alcohol.

ABSTINENCE
MODERATE USE
ABUSE
DEPENDENCE
138
Alcohol Abuse
  • Alcohol abuse is defined by the following
    symptoms
  • Failure to fulfill major work, school, or home
    responsibilities
  • Drinking in situations that are physically
    dangerous, such as while driving a car or
    operating machinery
  • Having recurring alcohol-related problems, such
    as physically hurting someone while drunk
  • Continued drinking despite having ongoing
    relationship problems that are caused or worsened
    by the drinking.

139
Alcohol Abuse
  • A person can abuse alcohol without actually being
    dependenthe/she may drink too much and too often
    but still not be dependent on alcohol.
  • Alcohol abuse does not include an extremely
    strong craving for alcohol, loss of control over
    drinking, or physical dependence like alcohol
    dependece does.

140
Alcohol Dependence
  • Symptoms of Alcohol Dependence-
  • Craving- A strong need, or urge, to drink.
  • Loss of control- Not being able to stop drinking
    once drinking has
  • begun.
  • Physical dependence- Withdrawal symptoms, such as
    nausea,
  • sweating, shakiness, and anxiety after
    stopping drinking.
  • Tolerance- The need to drink greater amounts of
    alcohol to get drunk.

141
Alcohol and Women
  • Alcohol affects women differently than men
  • Women become more impaired than men do after
    drinking the same amount of alcohol
  • Women's bodies have less water than men's bodies.
    Because alcohol mixes with body water, a given
    amount of alcohol becomes more highly
    concentrated in a woman's body than in a man's
  • The recommended drinking limit for women is lower
    than for men
  • Women risk serious harm to a developing fetus if
    drinking while pregnant

142
Cutting Back or Quitting
  • There are health benefits from reducing or
    stopping alcohol consumption.
  • Even chronic diseases, like liver cirrhosis, can
    rapidly improve with reduction

143
Dependence as a Brain Disease
  • Alcohol dependence can be treated, but recovery
    may last a lifetime.
  • Scientific advances over the past 20 years have
    shown that drug and alcohol dependence is a
    chronic, relapsing disease that results from
    prolonged effects on the brain
  • Alcohol dependence has little to do with
    willpower. People who are dependent on alcohol
    experience a powerful craving, or uncontrollable
    need, for alcohol that overrides their ability to
    stop drinking.

144
Limbic System
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146
Relapse
  • Even if a person previously dependent on alcohol
    hasn't been drinking for a long time, he or she
    can still suffer a relapse.
  • Relapses are very common and do not mean that a
    person has failed or cannot recover from alcohol
    dependence.
  • If a relapse occurs, it is very important to try
    to stop drinking once again and to get whatever
    additional support needed to abstain from
    drinking.

147
Treatment
  • What treatment options exist for those who have
    problems with alcohol in your area?
  • What other sources of help are available for
    alcohol-related problems?

148
AA
  • Alcoholics Anonymous (AA) is a fellowship of men
    and women who share their experience, strength
    and hope with each other so that they may solve
    their common problem and help others to recover
    from alcohol dependence.
  • The only requirement for membership to this self
    help group is a desire to stop drinking.
  • The primary purpose is to stay sober and help
    others achieve sobriety.

149
HIV/AIDS Basic Fact Sheet HIV stands for Human
Immunodeficiency Virus AIDS stands for Acquired
Immune Deficiency Syndrome HIV is the virus that
causes AIDS. HIV is found in the following
fluids Blood, Semen, Vaginal Fluids and Breast
Milk Most people get HIV by -Having unprotected
sex with an infected person -Sharing a needle
with someone whos infected -Being born when
their mother is infected or drinking the breast
milk of an infected woman HIV cannot be
transmitted through sharing utensils or drinking
after someone, hugging or mosquito bites. Using
protection, such as a latex barrier, when
performing sex (vaginal, oral or anal) lowers the
risk of HIV transmission. Biologically women are
more susceptible to HIV. Birth control pills and
patches do not protect women from HIV. Signs and
symptoms of HIV are different from person to
person. The only way to know if someone is HIV
positive is by testing. You can get infected
with HIV from anyone who is infected, even if
they don't look sick and even if they haven't
tested HIV-positive yet. The blood, vaginal
fluid, semen, and breast milk of people infected
with HIV can have enough of the virus in it to
infect other people. Some HIV people may feel
sick right away and others may have
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