Tools for Workers to use Providing Screening and Brief Alcohol Advice

Considering the burden excessive drinking has on health, well being and our society as a whole, helping to reduce these problems is a priority. (Investing for Health, Priorities for Action)

“If alcohol problems are to be reduced significantly, the distribution of these problems in the population suggests that a principal focus of intervention should be on persons with mild or moderate alcohol problems.” (1990).

Front line workers are in a unique position to identify and help people whose drinking is hazardous or harmful to their health and well being.

  • Screening and brief advice across the workforce has a significant contribution to make
  • Screening and brief advice is everybody’s business
  • Screening and brief alcohol advice should be in the toolbox of everyone working with people in the South Eastern Trust area

Brief advice is not the same as alcohol counselling and can be effectively delivered by a range of health professionals in a range of settings.


Screening

Screening is the first step. Practitioners can identify who could benefit from brief advice or in need of more help through screening.
How does screening differ from assessment? Screening is a process for evaluating the possible presence of a particular problem. The outcome of screening is normally a simple yes or no.

Assessment is a process for defining the nature of that problem, determining a diagnosis, and developing specific treatment recommendations for addressing the problem or diagnosis.

The AUDIT questionnaire is the preferred resource for screening as it gives well defined cut of scores for differing levels of risk.

The Alcohol MOT has been developed following the advice of Rose et al (2008) who encouraged a two stage approach. (Can be downloaded below.)

  • Use the AUDIT C initially (The first 3 questions of the AUDIT that look at consumption)
  • Followed by the full AUDIT for those scoring in the hazardous range of the AUDIT C.

In Emergency Departments time may be a factor. The Paddington Alcohol Test may be preferred as it can be more easily be administered verbally. It includes a key question, “do you think you being here is related to alcohol?”

Further training in brief intervention, behaviour change and Motivational Interviewing is available through the Health Promotion Department, South Eastern Trust.For more information contact Ed Sipler Ed_Sipler@dltrust.n-i.nhs.uk

Brief advice

Alcohol brief advice is a short, evidence-based, structured conversation with a client about their drinking. Its purpose is to motivate and support the individual to think about and/or plan a change in their drinking behaviour.

Brief advice is more than giving someone a leaflet and telling them to read it.
Providing brief advice has a structure and style that distinguishes it from simply advising a person to drink less.

When delivering brief interventions the sprit of its delivery is as important as its content. The spirit a brief intervention is critical as this form of intervention is designed to trigger a person’s internal motivation to change.

Brief advice for alcohol misuse can use motivational interviewing (MI) techniques, but does not require specialist expertise in MI.

Motivational interviewing is a collaborative style of conversation that practitioners can use to help someone explore and resolve their mixed feelings about behavioural change in a way that enhances their motivation.

The acronym FRAMES captures the elements of a brief intervention.

  • Feedback: about personal risk or impairment.
  • Responsibility: emphasis on personal responsibility for change.
  • Advice: to cut down or abstain
  • Menu: alternative options for changing drinking patterns and the person setting their own goals.
  • Empathic interviewing: listening reflectively without cajoling or confronting; exploring the person’s reasons for change as they see their situation.
  • Self efficacy: an interviewing style which enhances peoples’ belief in their ability to change.

The MOT part 2 has been developed by the PHA to deliver brief advice.

Tools to provide Screening and brief advice:
MOT part 1 
MOT part 2

 


 Using the Stages of Change Model, can be particularly useful with people do not see anything wrong with their drinking or ambivalent. (Feeling two ways about it).

The main goal of intervention is to move the person forward. This can be supported by a non-judgemental, empathetic, yet directive style that supports the person in what can be a difficult and significant behaviour change.

The Stages of Change
Stages people pass through in changing behaviour

  • Precontemplation – Sees no need to change
  • Contemplation - Has thought about change but has not initiated action
  • Preparation - Has made determined decision to change and gets a plan how to do it.
  • Action - Has initiated change.
  • Maintenance - Has reached goal and is maintaining change.
  • Relapse - Has fallen back to a previous stage

Change is more likely if people are helped to make decisions for themselves rather than being told what to do. Use of a guiding style, which is a simplified form of motivational interviewing, may facilitate such decisions.


Key points

  • Just telling people they are at risk is rarely sufficient to change behaviour.
  • When workers use a guiding style, they step aside from persuasion and instead encourage people to explore their motivations and aspirations.
  • The guiding style is more suited to consultations about changing behaviour because it harnesses the internal motivations of the person.

The spirit of motivational interviewing

  • Collaboration
  • Evocation
  • Autonomy

Four guiding principles

  • Resist the righting reflex
  • Understand their motivations
  • Listen
  • Empower Skills

Asking, informing, and listening can be thought of as core tools or skills used by practitioners in different combinations of either directing or guiding.

  • Asking involves the use of questions.
    Paying careful attention to choice of words, timing, tone of voice, and the ambiguities and contradictions often elicited in replies will engage patients more actively.
  • Informing is more directive and involves providing information, advice, or feedback. Always ask permission to give information.
  • Listening involves hearing what a person says and ensuring that their meaning is understood. Responding appropriately, sometimes by conveying understanding through empathic or reflective listening, engages people constructively.

Shifting from a directing to a guiding style requires workers to change their attitude about who is responsible for solving the problem and how the momentum and the direction of the discussion is controlled. One practitioner described it thus: "It's a shift from `Do this, do that' to `Nudge, listen, summarise; nudge, listen, summarise.'" The ability to switch between the skilful use of these styles, even within the same consultation, is a marker of good practice.

Adapted from Consultations about changing behaviour: Stephen Rollnick, professor of healthcare communication1, Christopher C Butler, professor of primary care medicine1, Jim McCambridge lecturer in prevention2, Paul Kinnersley, reader1, Glyn Elwyn, professor of primary care medicine1, Ken Resnicow, professor