Brief Lifestyle Counselling Tool
The SIPS Brief Lifestyle Counselling (BLC) Tool was developed for the purpose of the SIPS programme. It was based on the “How much is too much?” Extended Brief Intervention tool developed as part of the UK version of the Drink-Less BI programme (McAvoy et al 1997) from a prototype used as part of a World Health Organisation collaborative study on alcohol screening and brief intervention (Centre for Drug & Alcohol Studies, 1993).
The BLC tool was designed to provide practitioners in various settings (primary care, accident and emergency, and probation services) with a prompt on which to structure and deliver 20 min of BLC to hazardous and harmful drinkers.
How it was developed
The content of the SIPS BLC tool was closely related to the “How much is too much? Extended Brief Intervention” tool. It was modified in line with the principles of Rollnick et al.’s (2004) Health Behaviour Change manual. Modifications included: 1) emphasis on the typical drinking day as a means of opening a dialogue with clients about drinking, 2) an information exchange section to elicit patient concerns and provide information about alcohol risk, 3) a small amount of rephrasing of questions about importance and confidence designed to elicit self motivational statements. Otherwise the tool was as per the earlier version.
Introduction - confidentiality was discussed, introduction to the aims of the session and introduction of the patient and practitioner. The patient was asked to tell the practitioner ‘what had led to him/her coming today’. This was an invitation to the patient to tell the practitioner about his/her own perception of the events that led to the appointment with the Alcohol Health Worker.
Typical Day –This stage was concerned with gaining clarity as to the patient’s alcohol consumption and to begin to receive cues as to how this impacted upon the patient and how they viewed their own alcohol use.
Information Exchange – the patient was asked if they had any questions or concerns with regard to their alcohol use and for the practitioner to summarise and feedback what had been revealed so far. This included a summary of the amount the patient had been drinking and how this compared with different levels of alcohol risk.
Importance & Confidence – within this stage the patient was asked to consider how much importance they attributed to reducing their alcohol intake and the level of confidence they had in achieving this. This discussion allowed for the introduction of obstacles to be overcome to achieve change, which frequently links to the ‘pros and cons’ of change.
Pros & Cons – Patients were asked to consider some of the ‘not so good things’ that may come from reducing his or her alcohol use, followed by the ‘good things’ that were likely to come from reducing his or her drinking. The wording of this question was deliberate in that the practitioner began with the negatives of change, in order to conclude with the positives of change. Many of these messages had already been received by the practitioner by this stage therefore it was important to summarise and reflect what the patient had said thus far.
Strategies – Patients were then asked to think of ways that they may begin to make changes in relation to drinking, how to prepare for difficulties and indentify sources of support.
The session was then summarised by the practitioner to provide conclusion and clarity.
How it was used in SIPS
Practitioners participating in the study in each of the settings (GPs and practice nurses in primary care, and Alcohol Health Workers (AHWs) in other settings) were trained to deliver BLC following the format of the BLC tool. The intervention was designed to be 20 minutes in duration with the aim of covering all areas of the BLC tool. However, with some clients who were particularly pre-contemplative the emphasis was more on building a rapport, developing discrepancy and eliciting self motivational statements rather than insisting on working through the whole tool as this may have been unrealistic. The tool needed to be used by practitioners who have been through the training programme described below, as it involved an understanding of motivational interviewing techniques and health behaviour change counselling. In other words it was not a simple script that an untrained practitioner could use without sufficient training. Following screening and consent the practitioner delivered 20 minutes of BLC according to the standard protocol, using the BLC tool as a prompt. The practitioner used the tool as a visual guide for clients. Depending on the progress of the intervention, the practitioner might have assisted the patient in completing the plans outlined in the tool for reducing their drinking during the sessions, otherwise the patient was encouraged to make the plans in their own time. All patients/clients who were referred for BLC had already received a session of Brief Advice along with the Patient Information Leaflet (How much is too much?) .Click here to download the tool in pdf
Watch the demo video and PowerPoint presentation
Ruth McGovern is the SIPS senior Alcohol Health Worker
Bibi Rogers is the actor playing "Jen"
Actor's script: "Jen"
Jen is a young female law student who enjoys socialising with her friends. They go to the local bars and clubs on a Monday and Wednesday night. Before they go out Jen shares a bottle of wine with her house mate and sometimes drinks a further ½ bottle of wine. Whilst out around the bars they choose their drinks according to the specials available which on average consisted of six double vodkas or gins and sometimes a skittle (single vodka and gin with orange). On a Friday and Saturday night Jen usually goes out with the girls or goes for a meal with her boyfriend. When she goes out at the weekend with the girls she tends to drink less (usually 6 x doubles each night) as she works during the day on a Saturday and Sunday. When she goes for a meal with her boyfriend she tends to drink less again. Jen knows that her alcohol use is above the recommended amount however she does not feel the need to change at this time. Jen is not overly concerned for her health at this time and she is managing her studies at present.
This comprises a 1-2 hour training session, followed by tape recorded practice with actors, feedback and clinical supervision delivered by an experienced alcohol practitioner as part of the SIPS project team. The SIPS Alcohol Health Workers (AHWs) were trained by clinicians experienced in delivery of motivational interviewing and brief lifestyle counselling. The AHWs deliver BLC for accident and emergency and probation referred patients/clients. The AHWs train staff in primary care to deliver BLC in their setting. Aims To provide practitioners with the training necessary to effectively deliver BLC in the particular clinical session in which they work. The role play and actor practice sessions provide practitioners with an opportunity to observe a BLC session delivered by an experienced AHW and to practice delivery of BLC until an appropriate level of competence is achieved. How it has been developed The training is based on the work of Rollnick et al. (2004) and experience from an earlier trial of alcohol screening and stepped care intervention in primary care (STEPWICE; Drummond et al., 2003). There is a strong emphasis on experiential learning in order to properly understand and utilise the counselling techniques required. This is supplemented by an introductory classroom session for practitioners to explain the purpose, principles and practice of BLC. An interactive PowerPoint presentation has been developed for this purpose (Appendix 10). The presentation was developed by experienced alcohol clinicians. As the training is being delivered by different AHWs across multiple sites, a standard presentation with scripts has been developed to standardise training. How it is used in SIPS A standard interactive Powerpoint presentation is used to deliver the training (Appendix 10), with some introduction/orientation interaction. This is followed by an interactive role play session in which a demonstration video is shown (Appendix 11), followed by a real life demonstration role play by an AHW and some practice role plays (time permitting), with some post-training discussion to enable the session to come to a comfortable end. The session is presented to small groups of clinicians, usually in groups of about 3-4, who are encouraged to interact with the trainer and ask questions and comment on the content. During the demonstration video and role plays, practitioners, guided by the AHW, are encouraged to consider and comment on the techniques being used. After trainees have received the interactive training package for BLC, the SIPS programme employs the use of actors to complement the classroom training and supervision. This is closely based on the experience of training primary care nurses in the STEPWICE project (see above). The use of actors has been pivotal in successfully training the Alcohol Health Workers as well as the PHC staff randomly allocated to deliver the BLC in their setting. Several credible, real life scenarios have been developed by the SIPS team, covering various types of hazardous and harmful drinkers across different age groups, ethnicity and gender for the actors to use in their sessions (Appendix 12). All the actors are trained and experienced in improvisational acting and they are encouraged to draw on personal life experience to bring into the session. An appointment is made for the actor and practitioner to meet for a 20 min session. In practice this is organised so that each actor will meet with several practitioners in the same practice in one morning or afternoon. The practitioners are aware that they are meeting an actor and that the session is being tape recorded. In practice many of the practitioners in primary care have undergone this type of training in the past to deliver counselling of various types, and so it was relatively straightforward to recruit practitioners to undertake the training. Indeed some practices fully expected this to be part of their training in order to deliver the intervention competently. Before each session the actor is given a script which is age, gender and ethnicity appropriate to the actor. The practitioner is not informed of the script to which the actor is working. All sessions are tape recorded on MP3 recorders and are then rated by two experience clinicians using the BECCI rating scale detailed below (section 4.2). Individual written and oral feedback is then provided to the practitioners on areas requiring attention and a further session with the actor then booked if required. The practitioner then conducts further sessions until the required level of competence is achieved, based on the rating scale. Overall, it has taken an average of four sessions with the actors for the Alcohol Health Workers to achieve the level of competence required. Finally, after the training package is completed and the practitioners have reached the required level of competency to deliver BLC, AHWs then provide weekly supervision for practitioners delivering BLC in the clinical setting to provide feedback on intervention sessions, troubleshoot problems, build confidence, and provide support and further training. AHWs responsible for delivering interventions in the study sites also receive this level of supervision from experienced alcohol clinicians.