How To Do Brief Intervention Brief Negotiated Interview

How To Do… Brief Intervention Brief Negotiated Interview (BNI) & Motivational Interviewing BNI-ART Institute BU School of Public Health & Boston Medical Center

SBIRT Toolbox Outline • Motivational Interviewing principles and skills practice • Brief Negotiated Interview algorithm • Live demonstration • Practice SBIRT with case studies

WHY DO SBIRT? • 200 Homeless patients with alcohol dependence MGH ED in 1962 Chafetz et al. Establishing treatment relations with alcoholics. . J Nerv Ment Dis 1962; 134: 390 -410.

Two Approaches to talking to patients about alcohol or drugs Doctor A Doctor B

Blaise Pascal: Pensées “People are generally better persuaded by the reasons which they have themselves discovered than by those which have come in to the mind of others. ”

Motivational Interviewing (MI) • Patient-centered • Goal-directed (behavior change) • Helps resolve ambivalence A-C-E • affirms client’s Autonomy • Collaboration between pt & practitioner • Elicits patient’s intrinsic motivation & reasons for change

Standard of Care Motivational Interviewing

Brief Negotiated Interview: Patient Voice and Choice A collaborative conversation about health promotion (shared agenda) • patients as expert in their lives • listening not telling – silence – OARS • open-ended questions, affirmations, reflective listening, summaries

OARS: Closed v. s. Open Questions CLOSED • Are you worried OPEN • What worries you about your current most about your situation? current situation? • Have you noticed changes? • Do you care about your health? • What changes have you noticed? • How so?

OARS: Affirmations Ø Statements and gestures that recognize strengths and acknowledge behaviors that lead in the direction of positive change – I am really impressed with the way you…. – That’s great how you’ve reached your goal of cutting back on your drug use. – Using protection shows that you have real respect for yourself and your partners.

Communication Model From Thomas Gorden 2 The Words the Speaker Says The Words the Listener Hears 3 1 What the Speaker Really Means What the Listener Thinks the Speaker Means 4

OARS: Reflective Listening 3 Levels • Repeat - restate using the same words • Rephrase - use synonyms • Paraphrase - infer meaning behind the words or emphasize emotional aspects Client: “I got jumped outside the bar. They probably saw me as an easy mark because I was stumbling a little bit. It really sets me off. ” Practitioner: “You don’t like being unable to defend yourself. ”

OARS: Summaries • Transition or ending statements • Collect “change talk” statements • Present bouquet of patient’s own reasons for change Summary Intros: “Here is what I’ve heard so far…. . What did I miss? “We’ve gone over quite a bit. Let me make sure I am understanding you…”

Brief Negotiated Interview: Patient Voice and Choice • Guiding not directing – avoid the “righting reflex” • Client as decision maker

OARS Tally

In His Own Words Dr. Miller explains MI http: //vimeo. com/20901845

The BNI Algorithm

BNI ALGORITHM 1. Build rapport Would you mind taking a few minutes to talk about your [X] use? Before we go further, I’d like to learn a little more about you. What is a typical day like for you? Where does your [X] use fit in? 2. Ask about Pros & Cons Help me understand through your eyes the good things about using [X]? What are some of the not so good things about using [X]? Summarize So on the one hand you said <PROS>, and on the other hand <CONS>.

BNI ALGORITHM 3. Feedback Ask permission Give information Elicit reaction I have some information on low-risk guidelines for drinking, would you mind if I shared them with you? We know that drinking • 4 or more (F)/ 5 or more (M) in 2 hrs • more than 7(F)/14(M) in a week • use of illicit drugs can put you at risk for illness and injury. It can also cause health problems like [insert medical information]. What are your thoughts on that?

BNI ALGORITHM 4. Readiness to Change This Readiness Ruler is like the Pain Scale we use in the hospital. On a scale from 110, with one being not ready at all and 10 being completely ready, how ready are you to change your [X] use? Readiness ruler You marked ___. That’s great. That means you’re ___% ready to make a change. Reinforce positives Why did you choose that number and not a lower one like a 1 or 2? 1 2 3 4 5 6 7 8 9 10

BNI ALGORITHM Create action plan What are some options/steps that will work for you? What do you think you can do to stay healthy and safe? What will help you to reduce things you don’t like about using [X]? Identify strengths & supports Tell me about a time when you overcame challenges in the past. What kinds of resources did you call upon then? Which of those are available to you now?

BNI ALGORITHM 5. Prescription for Change Write down action plan Those are great ideas! Is it okay for me to write down your plan, your own prescription for change, to keep with you as a reminder? Will you summarize the steps you will take to change your [X] use? I’ve written down your plan, a prescription for change, to keep with you as a reminder.

BNI ALGORITHM Seal the deal Give referrals if appropriate: -Outpatient counseling -Suboxone, methodone clinic -Needle exchange -NA/AA -Primary Care -Mental Health -Shelter -Handouts/Information Thank the patient Thank you for sharing with me today.

The BNI in practice Having a conversation with a heroin user