Brief Intervention Brief Negotiated Interview (BNI) & Motivational Interviewing

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

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

3. 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.

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

5. 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.”

6. 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

7. Motivational Interviewing Standard of Care

8. Brief Negotiated Interview: 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 Patient Voice and Choice

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

10. OARS: Affirmations 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.

11. Communication Model From Thomas Gorden 2

12. OARS: Reflective Listening3 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.”

13. 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…”

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

15. OARS Tally

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

17. The BNI Algorithm

18. BNI ALGORITHM 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? • Build rapport 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]? So on the one hand you said <PROS>, and on the other hand <CONS>. Summarize

19. BNI ALGORITHM 3. Feedback • 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 2hrs • 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? Ask permission Give information Elicit reaction

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

21. 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 the things you don’t like about using [X]? 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? Identify strengths & supports

22. BNI ALGORITHM 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. 5. Prescription for Change Write down action plan

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

24. The BNI in practice Having a conversation with a heroin user