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)

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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

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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

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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.

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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?

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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)
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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)

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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

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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.

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Demonstration of BMI

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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.

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Using Motivational Interviewing to Address
Alcohol Use and HIV Risk

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(No Transcript)
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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.

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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.

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Spirit of Motivational Interviewing

• Collaboration Working in Partnership
• Evocation Learning from the patient
• Autonomy Patient is responsible for change

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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.

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A Continuum of Communication Styles
Guiding
Instructing
Listening
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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.

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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.

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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.

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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

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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?

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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)

• 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

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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

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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.

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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

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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?
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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

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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
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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

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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

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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.
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• 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.

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• 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

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• 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

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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

71
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
(No Transcript)
86
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
95
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
97
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?

99
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.

101
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.

105
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.

106
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.

107
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
109
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) _____

112
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.

113
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?

114
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

115
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

117
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.

122
PROS AND CONS MATRIX
Reducing or Stopping Drinking Pros (Good Things) Cons(Downsides)
Drinking the Same
Changing Drinking Habits
123
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
125
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
145
(No Transcript)
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