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
70%
65%
60%
50%
40%
40%
BI Group
Controls
30%
20%
10%
5%
0%
0%
showed for
treatment
kept 5 appts
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
 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 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?
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 the 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