Basic Scripts for Screening and Brief Interventions

Appendix I

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Basic Scripts for Screening and Brief Interventions

Brief interventions are commonly administered in non-clinical settings where clients are not necessarily seeking help for alcohol or other substance related problems. Many clients may not be using alcohol at a level that requires specialised treatment and may be unwilling to participate. Some clients, particularly older adults, may attach stigma to seeking or engaging in specialised treatment as opposed to general health care or other services.

If screening is used as part of the normal assessment and information gathering process, then those considered to have risky patterns and levels of alcohol consumption can receive a brief intervention lasting only five minutes and which can be followed up in other five minute segments during subsequent contacts.

The following steps constitute the way in which a brief intervention is conducted and is based upon AS+BI Determining Action model shown in Session 6.

Step 1 Introducing the issue in the context of the client’s health

In this step you will be building rapport with the client, defining the purpose of the session, helping the client to understand the reasons for the intervention and gaining permission to proceed. You may need to stress confidentiality at the same time clearly stating the focus and subject of the intervention. Avoid using labels and be non-judgemental.

Scripts for Step One:

"To adequately assess your health profile, we need to look at your alcohol use, along with the other factors such as smoking, physical activity and nutrition. This will remain confidential, so is it all right with you if we take a few minutes to talk about alcohol?"

"In discussing all the other problems you’re having, I have to get a clearer picture of some of the main health factors and risks. Alcohol is one of these factors, so can we have a look at that? Whatever we talk about will be confidential."

"What you’re eating and drinking may be important here. So would it be OK with you if we started by talking about alcohol consumption?"

Step 2 Screening, Evaluating and Assessing

This is a process of gaining information on the issue of alcohol use. Most of this information can be obtained from using the AUDIT screening instrument. In addition you may ask clients other questions as part of the process if they are relevant and justified. For instance if clients are screened positive you may also be asking some additional questions about medical, behavioural and social problems. If they are high-risk drinkers you may inquire about previous intervention or treatment.

Before you begin, decide how much information you have time to obtain. Be ready for some defensiveness or resistance and avoid pushing too hard.

Scripts for Step Two:

"You may not drink any more than anyone else, but this short questionnaire will determine where you fit in comparison to other people. Do you want to try it?"

"The AUDIT is a World Health Organisation screening instrument to determine safe or risky drinking. It’s pretty good, so if you want to try it, we can see if alcohol is part of the health equation for you."

"The AUDIT questionnaire will give both of us a pretty clear picture of how safe your alcohol consumption is. You need to be pretty straightforward with yourself but I’m sure you can do that"…

"Before I talk about your answers on the AUDIT, there’s a few other questions about alcohol I’d like to ask you, if that’s OK?" (This statement can go with any of the above three)

Step 3 Providing Feedback on AUDIT results

This process involves highlighting aspects of the client’s alcohol consumption and behaviour that are identified in the screening process. It should involve an interactive dialogue or discussion with the client and not be simply driven by the worker. In this respect, feedback can be given in small amounts; one specific piece to which the client responds; and so on. Feedback could sometimes be one single sentence, whereas at other times it could be a much longer process.

Using the AUDIT, specific information can be fed back concerning the person’s personal risk or impairment. You may locate the clients score in the Drinkers Pyramid (see Appendix F), as a comparison with the general population. You may take each domain of the AUDIT and discuss the score for that domain and its implications.

At this point it may be appropriate to provide some information and advice as part of feedback. The information may be in relation to:

(i) standard drinks and how to calculate them;

(ii) low-risk drinking,

(iii) the Australian Alcohol Guidelines,

(iv) the clients’ risk levels in relation to these Guidelines and;

(v) the connection between consumption levels and problems described by questions 7 to 10 of the AUDIT.

Scripts for Step Three

"Your AUDIT score is 15 and I’ll just explain what that means. People who score in that range are usually drinking at hazardous or risky levels, but you may not have to do much to get down to low risk levels………"

and

"There is some good factual information which may help. If you like I’ll give you this leaflet which explains what standard drinks are and gives the guidelines for low risk drinking……….."

"The National Health and Medical Research Council have worked out safer levels for alcohol consumption and you may like to compare those with your result on the AUDIT."

Step 4 Talking about Change and Setting Goals

No matter what the stage of change clients are in, it is still useful talking about the possibility of behaviour change. How you approach the subject and phrase it, does, however depend mainly on the stage the client has reached.

For example in Pre-contemplation clients are made aware of the consequences of risky drinking and helped to change their views of those consequences. In contemplation they are helped to resolve their ambivalence about changing drinking and move on to a firm decision. In Preparation you may be reviewing some of the menu of options with clients and perhaps encouraging them to try some out. In Action the emphasis is on planning, removing any barriers and avoiding risky situations.

You need to assess the client’s readiness to change and if you are getting a lot of resistance then you may be moving too quickly. There may still be a lot of benefits for your client in maintaining his present level of drinking. It may be useful to do a motivational balance with your client, i.e. "What are the advantages and disadvantages of continuing to drink at your present level?", and, " What are the advantages and disadvantages of changing your drinking?"

You may ask the client what concerns they have about the "disadvantages" or "less good things about drinking". Concentrate on their particular concerns rather than yours. The more uncomfortable they become with these concerns the more likely they will make some changes to their drinking. You may also like to explore the discrepancy between their level of drinking and other goals or aspirations, like spending more time with their family or getting fit and healthy.

You should offer change options that match the client’s readiness for change. Recommend the ideal change (ie. low risk drinking), but be realistic and accept whatever the client is prepared to do. For example, if this is reducing drinking from 10 standard drinks per day to 6 standard drinks, then this is a significant reduction in harm and may not only help to lower resistance, but could be positive enough to build the client’s self-efficacy and lay the ground for further change.

Scripts for Step Four

"You obviously enjoy drinking, so tell me what the good things are for you about drinking, what do you like about it………….all right, lets turn the coin over, are there any things that are not so good for you about drinking?"

" You’ve mentioned that both your wife and your doctor have suggested you cut down your drinking and you’re worried about the effect of alcohol on all the medication you’ve got to take now. Are there other concerns you have about your drinking?"

"Well, we’ve seen that your AUDIT score is in the risky category, and you’ve said that you have some concerns about your health, drink driving and feeling the effects a bit more, but at the same time you still enjoy a drink with your mates. So what do you think are the options here?"

then

"From what you say it sounds like things can’t stay the way they are now, so what are you going to do?"

"What does this mean about your drinking?"

"What do you think has to change?"

then

"Are there any problems or concerns you have about changing your drinking?"

then…

"I don’t know if this would work for you, but I can give you an idea of what works for other people."

"Let me describe some methods for reducing drinking and you can tell me which of these you think might work for you"

"So if your goal is to stop drinking, what do you think could go wrong with this plan?"

Step 5 Summarising and reaching closure

This step involves a summary of the discussion and a review of the agreed upon changes. If no agreement was reached, review the positive action that the veteran took during the intervention. Talk about any follow-up, which could be another meeting, a phone call or even a voice message. Discuss possible referral points and make sure the veteran has the appropriate information and knows where to get further help.

The goal is to leave the veteran feeling positive and confident in following through with any changes. The idea is to tailor the closure to the veteran and the particular circumstances of the brief intervention.

Treat any resistance in a positive light. That is, if the veteran has been unwilling to commit to any changes, thank them for their willingness to consider the issue and express hope that they may continue to consider the options. Make sure that they are going away with some information and knowledge that will be useful if or when they do decide to change. Don’t think that the intervention has been a failure – it may be all that is necessary or appropriate at this time. For people who are in the pre-contemplation stage, you would just strike more resistance if you tried to pressure them into treatment

Scripts for Step Five

"Just to sum this up, you’ve recorded an AUDIT score of … and you’d like to lose weight and stay fit by drinking a bit less. You’ve decided to have two alcohol free days per week, drink light beer and have no more than six standard drinks on any one occasion. You seem pretty positive and confident about this, is there any more help you might need with it?"

"OK, after looking at your drinking, you decided that you could probably cut down a bit to make it more healthy and enjoyable. So you’re going to look at some of those options and even try out a few. I’ll follow up with you next time I see you, to see how you’re going. I’m sure after you read through the rest of this information, it won’t seem too difficult at all. Great! You’re off and running."

"Let me just finalise this. We found with the AUDIT that you’re in the high-risk category for alcohol and this fits with some of your own concerns and the problems you’ve been having. I’ve given you some information that will be useful, but we’re going to refer you on to the specialist services with some support from VVCS. This is the first step and you’ve done really well in making these decisions."

"Even though you may not want to change your drinking at this time, I’m glad you took the time to look at it. The information I’ve given you, especially the low risk guidelines, should be useful if you decide later to rethink it. It might be interesting just to check out with your mates what they’re doing in relation to alcohol, you may get a few surprises."