Brief Intervention

Definition, research summary, essential elements, screening instruments, cultural considerations, objections, step-by-step approach, supporting families

This page has three sections:

1. Background Material that provides the context for the topic

2. A suggested Practice Approach

3. A list of Supporting Material / References

Feedback welcome!

Acknowledgement

Unless otherwise mentioned, the material that follows is based on the free, short course provided by the United Kingdom Royal Society of Public Health (2017). The RSPH, in turn, acknowledges Matua Raki (2012) in New Zealand as its source. Links to both these sources are in the Supporting Material.

Background Material

What is a Brief Intervention?

Definitions of brief intervention

Brief intervention refers to: A short, purposeful, non-confrontational, personalised conversation with a person about an issue related to alcohol, tobacco, other drug use and/or gambling. Brief intervention is most effective for people who are at risk of developing or people who are experiencing harm from addictions.

The key word here is “brief”. Brief intervention generally takes as little as 5 to 15 minutes (in addition to the time needed to establish rapport and engage with the person).

Information about brief interventions

Brief intervention provided in generalist environment is a key component within an effective spectrum of responses. It is particularly important in those environments where the prevalence of problems is known to be high.

Brief intervention is most effective for people who are at risk of developing or people who are experiencing current harms from alcohol, tobacco, other drugs and/or gambling. Brief interventions are not designed to treat people who are dependent or addicted. Those people, with more severe problems, are likely to benefit from more comprehensive assessment and intervention and the role of the brief intervention worker is to refer this group of people to specialist treatment services.

Why a brief intervention should be offered

Problematic drinking, smoking, other drug use and gambling often contribute to other problems such as legal, health, employment, family-related and financial issues. In other words, the issues people present with in social, justice and health service settings are often linked to alcohol, tobacco, other drugs and gambling. Brief intervention provided in these service contexts can have a significant positive impact for service users and can enhance the benefits of the services being provided.

Research into the effectiveness of brief interventions

The conclusions of meta-analyses of research into the effectiveness of brief intervention in reducing gambling, alcohol, tobacco and other drug use, while mixed, show that brief intervention can make a difference in some individuals. Some of the points raised by research into alcohol and other drug use include the following.

• Brief intervention seems to be a cost-effective psychological treatment strategy in reducing harmful or hazardous alcohol use in a variety of settings by various health professionals (Joseph & Basu, 2017). GambleAware (2017) suggest brief intervention is also successful with problem gamblers ready to explore changing their habits.

  • Several reviews (post 2014) examining whether brief intervention delivers significant reductions in alcohol and other drug use are consistent with earlier reviews conducted from 1997 (Beyer, Lynch & Kaner, 2018; Elzerbi, Donoghue & Drummond, 2015; Rogers, 2018).

  • Effect sizes have been small but significant in research studies. For example, Rogers (2018) suggests a reduction in drinking of almost four Australian standard drinks per week while Kaner et al. (2018) found a reduction equivalent to a pint of beer or a third of a bottle of wine. Beyer, Lynch and Kaner (2018) suggest this reduction has the potential to impact on both individual and population levels of consumption with corresponding health benefits.

  • There are gaps in evidence for the efficacy of brief intervention for women, younger and older persons, minority ethnic groups, those with comorbid mental health and drug use conditions, and those living in developing countries. Brief intervention is not effective in people who are already dependent or experiencing severe drug-related harms (Glass et al., 2017).

• Some reviews argue that brief intervention may need to be repeated to be effective (Glass et al., 2017; Rogers, 2018). Glass et al. suggest brief intervention be combined with stepped care (repeated counselling, pharmacotherapy, psychosocial treatments, mutual help and self-help, depending on need and readiness).

  • On the other hand, Kaner et al. (2018) suggest multiple brief interventions provide little additional benefit compared to a single brief intervention.

• Kaner et al. (2018) and Tam, Knight and Liaw (2016) suggest the initial screening conducted as part of brief intervention may, by itself, result in a reduction in alcohol consumption.

  • On the other hand, several well-done studies show brief intervention does not get implemented well or does not retain effectiveness, or both (Glass et al., 2017; Rogers, 2018).

• Brief intervention doesn’t appear to be providing sufficient motivation for those people with moderate to severe disorder to transition to other agencies for intensive treatment (Glass et al., 2017; NCMW, 2018).

Elements of a brief intervention (FRAMES)

All brief interventions share similar underpinning health psychology (social, cognitive, and motivational) theory and a component structure (commonly known as FRAMES). F, A, and M describe what is provided in brief intervention; R, E and S describe how brief intervention is provided (Beyer, Lynch, & Kaner, 2018).

F FEEDBACK about personal risk or level of current harm, as indicated by the screening process.

R RESPONSIBILITY for choices and change sit with the person. It is not the role of the professional to confront or persuade. Respect the person's autonomy.

A ADVICE: increase the person's awareness of the costs and consequences of their behaviour and provide advice to support positive change.

M MENU: outline options or strategies to support positive change; help with goals and action planning if appropriate to the person.

E EMPATHY: listen and reflect; maintain rapport; use an empathic communication style.

S SELF-EFFICACY: convey optimism and strengthen the person's self-belief in their ability to change.

Motivation and the ‘stages of change’

It is useful to understand the 'stages of change' model and motivational interviewing as a background to providing brief intervention. It is not, however, necessary to be overly concerned with assigning people to a stage of change and applying specific motivational techniques. Having a general understanding of the stages of change can help the worker listen for readiness to change and ensure that their response is in step with the person. The stages of change approach is outlined in the Motivational Interviewing content on this website at https://www.thesocialworkgraduate.com/post/practice-model-motivational-interviewing The key principles of motivational interviewing include:

• Express empathy Show acceptance and develop rapport. Ambivalence to change is normal. Listen to and accept what is important to the person. Empathy and rapport make space for gentle change.

• Develop discrepancy Change is motivated by a perceived discrepancy between a person’s current behaviour and their important personal goals and values.

• Roll with resistance Resistance is a signal for the worker to respond differently. Avoid arguing for change.

• Supporting self-efficacy A person’s belief in the possibility of change is an important motivator. If a person believes they can change, the likelihood of change occurring is greatly increased.

Screening as a basis for intervention

Brief intervention is generally provided after a screening process has been undertaken (see the Practice Approach section for an outline of the process and potential screening tools). Screening is a structured process that provides an indication that a problem may exist. The results of a screening process (i) assist the worker to determine whether intervention is required and the level of intervention that is likely to be of most benefit to the person, and (ii) provide an opportunity for a service user to consider the effects of alcohol, tobacco, other drugs and/or gambling on their lives.

Social and Cultural considerations

Throughout the process of screening and brief intervention, workers are encouraged to be mindful of the social and cultural context of the people they are working with. For example, the way a person might express distress; the way in which they might perceive problems or solutions, and/or their communication styles. Clients may have poor literacy. This may mean giving some thought to how screening information is interpreted and communicated.

Overcoming potential objections

Arguments against providing a brief intervention in generalist settings exist. The more prevalent of these are outlined below along with some suggestions as to how these objections can be overcome or managed.

• Causing offence Workers and organisational leaders are often concerned that service users may be annoyed or offended if they are asked about these issues. The evidence suggests that this is rarely the case

• The issue of coercion Brief intervention can be used where users are facing or undergoing legally imposed sanctions, e.g. justice and social service settings.

• Own behaviour and values A worker who also has an addiction issue can use this technique with clients. Using standardised screening tools and a structured approach to brief intervention will help to ensure that the worker’s own values and choices do not prevent them from providing effective brief intervention to service users.

• Outside of the scope of worker’s role Some generalists believe that providing brief intervention is outside the scope of their role. It is important to stress that many people who are at risk of or experiencing harm will never see a specialist and brief intervention provided by a generalist ay be of huge benefit to them.

• Competing priorities The demands on time within a service environment may present one of the most significant barriers to brief intervention. There is no simple answer. It is up to the organisation and the worker to determine what services can be provided within resource constraints.

Practice Approach

(preparation, steps to follow, possible words to use, and providing support to families)

A brief intervention can be used by social workers and other professionals who do not specialise in the treatment of addictions: alcohol, tobacco, other drug use and/or gambling. Brief intervention is most effective for people whose behaviour is hazardous or harmful, in other words people who are at risk of developing or people who are experiencing current harms from alcohol, tobacco, other drugs and/or gambling. Brief interventions are not designed to treat people who are dependent or addicted.

While the research base for the effectiveness of the brief intervention approach has been called into question from time to time, it appears to be an approach that can be incorporated into practice if the social worker detects the client may have an issue with alcohol, tobacco, other drugs and/or gambling. In fact, because these addictions correlate with the clients social workers often speak with, routinely asking about them is recommended by some authors and/or organisations.

The Knowledge Base Supporting Brief Intervention

Prior to using the brief intervention approach social workers should:

• Understand the brief intervention approach.

• Be familiar with the screening processes; practise screening to become familiar with the instrument.

• Have sourced and ready material outlining risks and harms.

• Be aware of simple interventions to reduce harm.

• Know the effects that harmful substance use or gambling can have on the individual and their family and friends.

• Be aware of steps that can be taken to reduce hazardous or harmful behaviour (e.g. self-exclusion, limit setting).

• Have a list of specialist agencies for referring people with significant problems both in the addiction areas, and in mental health.

Sources of Basic Facts

Some sources to assist in acquiring the above knowledge (basic facts):

• Alcohol https://adf.org.au/drug-facts/alcohol/ & https://www.helpguide.org/articles/addictions/overcoming-alcohol-addiction.htm

• Tobacco https://www.health.gov.au/health-topics/smoking-and-tobacco/about-smoking-and-tobacco/what-are-the-effects-of-smoking-and-tobacco & https://www.health.gov.au/health-topics/smoking-and-tobacco/how-to-quit-smoking

• Other drugs https://www.health.gov.au/health-topics/drugs/about-drugs/what-are-the-effects-of-taking-drugs & https://www.healthdirect.gov.au/overcoming-addiction

• Gambling https://www.gambleaware.nsw.gov.au/ & https://www.gamblinghelponline.org.au/making-a-change & https://www.begambleaware.org/

Screening tools

Screening is an important part of the brief intervention. It can occur in a variety of ways, from asking simple questions to administering a screening tool. A standardised screening tool provides more accurate information for the person being screened and can be particularly useful for a generalist who does not have specialist knowledge. The worker has three options after screening:

• No problem indicated - Provide positive affirmation and offer information to support continue no/low risk

• Hazardous or harmful use/behaviour indicated - Provide brief intervention

• Possible dependence or addiction indicated - Advise need for specialist treatment and provide accessible referral options.

Commonly used screening tools include:

• Alcohol Use Disorders Identification Test (AUDIT) https://www.dacas.org.au/clinical-resources/screening-assessment

• Alcohol Use Disorders Identification Test – C (AUDIT – C) https://www.phoenixaustralia.org/wp-content/uploads/2020/01/AUDIT-C-Test.pdf

• The Cannabis Use Disorder Test – Revised (CUDIT-R) https://insight.qld.edu.au/shop/the-cannabis-use-disorder-identification-test-revised-cudit-r-insight-2019

• Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) https://www.who.int/substance_abuse/activities/assist_v3_english.pdf

• Early Intervention Gambling Health Test (EIGHT) https://bpac.org.nz/BPJ/2010/June/docs/addiction_eight_gambling_screen.pdf

• Problem Gambling Severity Index (PGSI) https://learn.problemgambling.ca/PDF%20library/assessment-pgsi-en.pdf

• Concerned Others Gambling Screen (COGS) https://www.acts.co.nz/Downloads/COGS-Mk2.pdf

• Lie/Bet Questionnaire http://www.ncrg.org/sites/default/files/uploads/docs/monographs/liebet.pdf

• NODS-CLIP Short Problem Gambling Screen https://www.naadac.org/assets/2416/2019NWRC_John_Bundrick_Handout3.pdf

• Heaviness of Smoking Index (HSI) https://www.asco.org/sites/new-www.asco.org/files/content-files/practice-and-guidelines/documents/heaviness-of-smoking-index.pdf

• Substances and Choices Scale (SACS) https://optforwellbeing.org/professionals/publications-and-resources/substances-and-choices-scale-sacs

The Details of Providing a Brief Intervention

Step 1: Introduce the subject

In a general setting, where a person is not expecting to talk about an addiction issue, introducing the subject can be the biggest hurdle for the worker. The key is for the worker to be clear, confident, and relaxed in talking about these issues and to normalise the process. The objectives are to respectively obtain consent to explore specific behaviours and then to maintain rapport and convey empathy, regardless of the person’s decision to consent or not.

With young people it is generally important to develop rapport before you introduce the issues, e.g., by talking about topics other than gambling. Clarity about confidentiality is especially important to develop trust.

Action:

Ask permission to talk about the behaviour

"While we're discussing what you like to do with your free time, could we talk about (issue)?" "You sound a bit worried about how much you've been (issue) lately. Could we talk a bit more about that?"

Explain your role in relation to the behaviour’s to be explored

"If you are interested, we can work through a few quick questions. We use a process called a (issue) screen. The screen provides you with your personal result. What you do with that information is your choice."

Clarify confidentiality issues

"We have already discussed confidentiality, but I just want to restate that this discussion will be confidential, in the same way as any other information about you."

Reinforce and respect the person’s choice

“It’s up to you.” “What do you think you might want to do next?”

Step 2: Screen

Action:

Administer the screening tool

“This is the screening tool / (issue) questionnaire. It will give you an indication about whether (issue) might be causing problems for you. Shall we work through the questions together?”

Ask screening questions

Score the screening tool

Step 3: Provide feedback and advice

In this step it is important to provide personalised information about the level of risk and harm by interpreting the screening results. This could lead to a reflection and review of behaviour and advice to assist with reducing risk and/or harm.

Action:

Review the screening data in collaboration with the person

"The PGSI score shows that your (issue) is unlikely to cause problems. If your circumstances change, say you are planning to buy a house, then it might be helpful to stop (issue)."

Check for the level of risk or harm

“The screening test suggests that your (issue) use at a harmful level. This means there are risks for your mental health, your finances, and potentially for your family relationships.”

Provide personalised, brief advice

“Given your result, there would be significant benefits if you were to cut down on (issue). I know it is not an easy thing to do, but there are a number of options that could support you to stop.”

Step 4: Listen for readiness and confidence

Action:

Check how the person is responding

“What are your thoughts about the screening result?’

Explore readiness to make changes

“What are your thoughts at this point? Are there any concerns that you have?”

Does change seem to be worthwhile to the person? Are they confident about their ability to change?

“Can you think of any benefits if you were to stop (issue)?

Try to elicit change talk

"On a scale of 1-10, if 1 is not ready at all and 10 is totally ready, how ready are you to make changes to your (issue)? What are some of your reasons for giving this rating? OR "why did you rate 5 instead of 3?"

If the person is not ready to change, thank him or her for checking their (issue), offer to speak with them again if they ever want to change.

If the person is ambivalent about changing, restate their reasons and ask if, on balance, whether it would be having a go.

If the person wants to change but lacks confidence, ask what would need to happen for the person to become more confident.

Step 5: Provide further information (as appropriate)

Action:

Provide information

"Would you like more information? I have a leaflet here that you could take home. It might be interesting to read about some of the benefits other people have experienced after cutting back."

Facilitate goal setting

"Could you consider setting yourself a goal in relation to (issue)?"

"What are some changes that you are interested in trying out?"

Explore menu options

"Would it be helpful to look at some options that have been helpful for other people? There are some effective strategies available to help people stop (issue), such as (give examples)."

"There are lots of options for cutting down on (issue), you are the best judge of what is likely to work for you. Would it be helpful to talk about some ideas and then, if you want to, set a goal for yourself to try out?"

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Supporting families and affected others

The 5-Step Method is a simple, non-blaming and effective approach for assisting families to develop effective coping strategies and access effective social support. It has helped families to:

• Focus on their own needs

• Be assertive in communication

• Calm down and find different ways of dealing with frustration and anger

• Have a better understanding of their behaviour and the links with their own health

The five-steps are:

1. Listen non-judgementally Listen carefully to the experience of the family member/s to develop an understanding of how they are affected. Explore their concerns. Provide reassurance that others also have these experiences. Convey empathy and non-judgement.

2. Provide information Provide information about the relevant addiction. Provide information about other relevant issues tailored to the concerns raised e.g. childcare, financial assistance etc. Targeted information helps family members to gain a sense of having some control in their lives.

3. Discuss ways of coping Explore coping responses. Research associated with the model has identified three broad coping responses that people/families adopt:

• Engaged - Standing up to

• Tolerant - Putting up with

• Withdrawn - Withdrawing

Explore the current responses and discuss what is effective and what is less effective. Explore alternatives.

4. Explore sources of support Explore social support. Draw a network diagram to determine current support. Work on strategies to increase positive support and decrease negative support.

5. Arrange further help if needed Explore further options for help and support. Check out further needs, provide information, refer as necessary and arrange follow up if required.

Supporting Material / References

(available on request)

Beyer, F., Lynch, E., & Kaner, E. (2018). Brief interventions in primary care: An evidence overview of practitioner and digital intervention programmes. Current Addiction Reports, 5, 265-273. https://doi.org/10.1007/s40429-018-0198-7

Elzerbi, C., Donoghue, K., & Drummond, C. (2015). A comparison of the efficacy of brief interventions to reduce hazardous and harmful alcohol consumption between European and non-European countries: A systematic review and meta-analysis of randomized controlled trials. Addiction, 110, 1082-1091. doi:10.1111/add.12960

GambleAware. (2017). Brief intervention guide: Addressing risk and harm related to gambling. Retrieved from https://www.begambleaware.org/media/1605/gambleaware-intervention-guide.pdf

Glass, J. E., Andreasson, S., … Saitz, R. (2017). Rethinking alcohol interventions in health care: A thematic meeting of the International Network on Brief Interventions for alcohol and other drugs (INEBRIA). Addiction Science and Clinical Practice, 12, 14. doi: 10.1186/s13722-017-0079-8

Joseph, J., & Basu, D. (2017). Brief intervention for risky alcohol use: A critical analysis. International Journal of Psychology and Psychoanalysis, 3(2), 1-6. doi: 10.23937/2572-4037.1510020

Kaner, E., Beyer, F., … Burnand, B. (2018). Effectiveness of brief alcohol interventions in primary care populations. Cochrane Library. https://doi.org/10.1002/14651858.CD004148.pub4

Matua Raki. (2012). Brief intervention guide: Addressing risk and harm from alcohol, other drugs and gambling. Matua Raki, Wellington. https://www.tepou.co.nz/uploads/files/resources/brief-intervention-guidelines.pdf

NCMW: National Council for Mental Wellbeing. (2018). Implementing care for alcohol and other drug use in medical settings: An extension of SBIRT. Retrieved from https://www.thenationalcouncil.org/wp-content/uploads/2020/08/021518_NCBH_ASPTReport-FINAL.pdf?daf=375ateTbd56

Rodgers, C. (2018). Brief interventions for alcohol and other drug use. Australian Prescriber, 41(4), 117-121. https://doi.org/10.18773/ austprescr.2018.031 [Full text free online at nps.org.au/australianprescriber]

Royal Society of Public Health. (2017). Understanding and responding to gambling harms. Retrieved from https://www.rsph.org.uk/our-services/e-learning/courses/online-course-understanding-and-responding-to-gambling-related-harm.html

Tam, C. W. M, Knight, A., & Liaw, S-T. (2016). Alcohol screening and brief interventions in primary care: Evidence and a pragmatic practice-based approach. Australian Family Physician, 45(10), 767-770.