Welcome back to DIRT FROM THE ROOTS, your monthly blog for discovering new perspectives on interesting, insightful, and obscure topics within the mental health and psychology fields. Today, we will look at a novel way to discuss uncomfortable but important topics such as substance use and risky behaviors in a way that reduces judgment and fosters autonomy, perhaps the key factor of thriving mental health.
TOPIC OF THE MONTH
SBIRT and MOTIVATIONAL INTERVIEWING
“Not I, nor anyone else can travel that road for you. You must travel it by yourself.”
-Walt Whitman
When it comes to talking with others about their mental health– particularly with more controversial or stigmatized issues– it is not uncommon to be met with defensiveness, guarded response, or even hurt feelings around just the breaching of the topic. While this can become incredibly frustrating for both parties, the initial intention is often with genuine hope for improvement and, though my status as a therapist may leave me biased here, crucial towards creating an opportunity for actual improvement.
Difficult as this process may be, we can gain clarity towards improving these types of conversations by breaking down the interaction into isolated pieces. While humans may have emotionally defensive reactions to facing their most troubling issues, this is likely more connected to the sensitivity and fear of having to face them. However, even if this assumption is generally correct, humans prefer to face things autonomously, and that small but significant piece of others telling us what we “need” to do can become one of the largest barriers regardless of how badly an individual does indeed want to make changes. When teasing this part out of the equation when discussing issues, we are left with two main issues that create roadblocks in an individual’s comfort and safety around conversing mental health issues: potential for judgment and lack of personal choices.
Enter SBIRT and Motivational Interviewing, two effective counters to these two barriers, respectively. This is a very developed and extensive program, so further resources to SBIRT information will be included at the end of this article.
MOTIVATIONAL INTERVIEWING
This leads us to motivational interviewing, the mechanism by which we can ask questions with reduced bias and perhaps the very ground foundation of my own therapeutic practice.
Motivational interviewing is actually very simple: the goal is to inquire about how an individual is perceiving their situation, behavior, or pattern in a way that reduces our own biases as the one asking. This is an evidence-based approach with specific aims to support individuals in an empathetic, empowering, and individualized fashion. Core principles of this guiding communication include listening to client perceptions followed by reflective advice and information pertinent to how the client is feeling. The key facets of this style are empowering autonomy, respect, and non-judgmental curiosity when discussing issues to keep the client in the decision making position through a supportive, open, and collaborative environment. Should this respect be attained, self disclosure and comparison of the differences in answer between the individual and the person asking can also become beneficial in repairing gaps in understanding and miscommunications.
We can apply this technique to virtually any issue by asking four basic questions:
What are the positives for you if you continue this behavior?
What are the negatives for you if you continue this behavior?
What are the positives for you if you change this behavior?
What are the negatives for you if you change this behavior?
We can see that this framework allows for the individual being questioned to give their own emotional perceptions of each query with hope that this will create a sense of autonomy in decisionmaking, and also unearth all of the emotional perspectives that may come from a decision. Asking for a personal response helps the individual feel heard and gives more specific information, all while still breaching the topic which may be very difficult or controversial in their perceptions. The individual can now “stay in the driver's seat”, as accusational phrases turned to neutral questions allows for a full, genuine answer about one’s own reflections on the same information that may prove impossible to attain through other methods.
The application of Motivational Interviewing then fits perfectly with the goals of the Brief Intervention stage of SBIRT: we are asking individuals what they think would happen if they stopped using, what would happen if they continued using, how they feel about stopping, and why they may want to continue. We unfortunately will ultimately abide by the old saying of “one can lead a horse to water but can’t make it drink”, but an individual is also going to end the conversation facing personal decisions rather than a deterrent feeling of misunderstanding or judgment.
SO WHAT IS SBIRT?
The SBIRT method was initially created with direct intention to discuss risky behaviors around substance use, particularly with teenagers in mind. SBIRT is an acronym for Screening, Brief Intervention, Referral to treatment. This may sound extremely standard for substance use treatment– and it certainly is– but the approach of this method is focused around how these steps are proceeded upon rather than just making sure the steps are reached. The end goal of SBIRT is to create a more quick and efficient method of pre-screening individuals for substance use in efforts to reduce the need to go through full healthcare treatment and reach more individuals who may have fallen through the cracks. SBIRT is considered a billable method for mental health professionals to use, but it is my personal belief that this strategy is equally effective when used by the general population.
SCREENING
The screening process involved in SBIRT can best be described as “casual”. The goal of this step is simply to assess someone’s habits around substance use in a nonjudgmental way. It is important to remain far away from accusational wording: “What are your opinions on smoking marijuana?” is going to be received much differently than “why are you smoking marijuana?”, and “how do you feel drinking affects people?” is going to be received much differently than “don’t you know that drinking is bad for your health?”.
When in this step, the key considerations could be broken down to asking ourselves:
“Could this question be answered if the person had never used substances before?”
“Is this question leading?” It is important not to convey personal opinions in the query
“Does this question allow the person to give their own organic answer?”
Successful screening will lead into a conversation– notably NOT an “accusation”, an “interview” or even a “deposition”– that will have the individual discussing their own perceptions and views of their issue. This creates a much easier environment for honesty and self reflection, as steps have been taken to reduce feelings of judgment and increase autonomous control help by the individual.
BRIEF INTERVENTION
Brief assessment refers to the second step in which we can allow the person to determine FOR THEMSELVES whether or not substance use may be problematic. SBIRT uses a simplistic 3-tiered scale to determine level of harm derived from possible addictive behaviors, which breaks behaviors into the following categories:
Substance Use
Use is simply use. Engaging in consumption of a substance– importantly, regardless of actual substance– may not be problematic. If a person is using substances but seeing no negative effects on life in comparison to sobriety, the scale does not consider this to be grounds for intervention (though exposure to this scale will certainly provide good insight for personal monitoring!). Very notably, this could be anything that an individual has a bond with, and is not just limited to substances.
Example: any drug use that does not have negative ramifications to the individual’s quality of life. Someone spending a lot of time with a new significant other may still have healthy relationship patterns. An Individual takes a month of vacation, but without ramifications to work.
Substance Abuse
Abuse describes substance use that leads to problems for an individual, but does not go so far as preventing or harming other important relationships or responsibilities. An individual abusing substances may see that there are negative repercussions, but that does not indicate dependence. The key distinction from the next level is that this experience is perceived as a regression, a poor decision, something that can be used to gain wisdom rather than something out of control. An individual is able to see that their choices correlate to negative consequences, and would like to avoid that in the future.
Example: Someone who is experiencing a “comedown” from a substance (such as a hangover) or feeling negatively about their behaviors while on a substance is experiencing the effects of abuse. An attempt of reduction/cessation of intake after that experience is a signal that this is an example of abuse rather than dependence. For a non-substance example, we could say someone playing video games to the point to where they are forgetting responsibilities at work would be considered “abuse”
Substance Dependency
Dependence describes the most extreme relationship that individuals may have with substances, and is characterized by individuals who choose substance use over their important relationships or responsibilities. I personally feel that a helpful way to look at the term “addiction” is to view it as a strong bond with something– in the same way that we have our strongest bonds within our intimate relationships due to their reliability to us, the same connection can form with substances as well as activities, behaviors, and virtually any other facet of life that we can create an attachment to. If the bond with the suspected substance/item/action creating the addiction reaches ‘dependence’ levels, we can unfortunately begin to see the individual’s life begin to suffer large consequences in collateral as this bond overtakes all others. While it can be tricky to separate heavy abuse from dependence, this is where we must rely on the very principles of SBIRT and let the person being questioned make this determination themselves. While certainly the majority of people are going to respond poorly to being accused as “an addict”, we tend to see more realistic and helpful responses if our concerns are framed in a nonjudgmental, question-based method.
Example: Continued substance use despite realistic threat of (or proceeding to use after) losing job/relationships, an individual exercises to the point of losing friends from lack of communication and begins damaging body, an individual chooses to gamble with money that is typically allocated towards paying bills
REFERRAL TO TREATMENT
Once we have asked these questions, we have officially concluded our screening and brief assessment, and are ready to proceed to potential treatment referral. The first thing to consider is that most issues in this realm recover by themselves, particularly if the individual is in the use or abuse category. This being said, studies have found that up to 89% of individuals with substance use disorders have also shown to have comorbid traumas, and therefore an individual may actually benefit from services for reasons aside from substance use as well. Should we feel that an individual may benefit from less intensive care, such as outpatient therapy (weekly meetings) or joining a support group, suggestions of this option may come with less judgment and more helpful intent after completing the first part of the SBIRT method.
Though more rare, clients suffering from extreme addiction to alcohol or opiates may require detox services as soon as possible for their safety. It is paramount to remember that individuals suffering dependence to either of these substances also develop a chemical dependence, and this requires scaffolding tolerance down rather than a “cold turkey” approach, which may be fatal. If detox is not available, inpatient therapy (overnight, extensive therapy services) hospitalization may be the best option.
And of course, an individual may still refuse treatment even if they meet all qualifications. While this can be the most difficult piece of the equation for the person who is intervening, we must hold self-affirmation that we have communicated what we needed to communicate in a manner which has accounted for potential barriers and encourage the individual to keep their mind open to the options should they feel ready.
WHY IS SBIRT A MORE EFFECTIVE APPROACH?
Foremost, when considering the focus on substance use particularly, this method was developed to combat the extremely high percentage of individuals with SUD that will not seek treatment. We have to consider that this method is designed to broach topics which we do not typically address, and so potential for use with other conditions such as personality disorders and mild but treatable mental health issues is also promising.
SBIRT is designed to more efficiently traffic referrals to the appropriate intervention method, and this results in better patient outcomes and higher satisfaction with mental health services which, with hope, is a great dent in reduction of mental health stigma. SBIRT aims to make discussing these topics more casual, approachable, and digestible in efforts to reduce suffering and damage caused by difficult conditions to address, and also has a conscious awareness of issues within healthcare, as the aim to minimize actual services that may be needed as well as the costs and utilization of those services.
CRITIQUES ON SBIRT
Unlike the theories of Spiral Dynamics and Terror Management discussed in previous months, critiques of this method are a bit difficult to find– certainly not a bad thing when considering that a six-month followup of a study using SBIRT intervention on substance users found a 68% reduction in illicit drug use and a 39% reduction in problematic drinking amongst participants. What may be even more promising is that most critiques came at the beginning of implementation (in the first half of the 2010s) and were focused on the immediate inefficacy of the method. Further assessment seems to show that the method may actually be becoming more effective.
A structural critique on SBIRT may come from individuals who abide by an abstinence-exclusive (individuals must be entirely sober for recovery) view on substance treatment, as naturally the decision is coming from the harm-reduction (an individual can begin recovery by using less and less) perspective as it is the individual’s choice on whether they continue using substances or not. While this strategy could technically be utilized with abstinence options, the very nature of harm reduction techniques are more aligned with the concept of an individual making choices for themselves and also reduces the splitting involved with thinking “I am either sober forever or controlled by substance issue forever”.
APPLICATION OF SBIRT TECHNIQUES IN OTHER REALMS
While many examples used here apply to substance use particularly, here are some examples of where we can use the principles of the technique in broader realms:
If concerned about out-of-character problematic behaviors: asking someone about their perceptions on their life and relationships lately, asking the benefits of acting out behaviors, asking the ramifications of acting out behaviors, asking if an individual feels their behaviors are any different from how they acted before
If concerned about risk-taking behaviors: asking someone about their positive experiences in risky situations, asking about negative experiences in risky situations, determining whether an individual feels the need to take risks organically or in response to the lack of other stimulating emotions, asking how someone might feel if they couldn’t participate in risky behaviors or finding out what feelings they may be gaining from participating in them
If concerned about sexual behaviors: asking someone about their perceptions on sex, what they think safe sex is, what they think about boundaries, asking their perceptions on media portrayal of sex, asking what they enjoy/disenjoy about sexuality, processing what they feel is a healthy sexual encounter
CONCLUSION
While this method is obviously designed for substance use particularly, the same principles can be applied when discussing similar risky behaviors– or really, any behavior that may be difficult to address at all. Perhaps what makes this method most intriguing is just its reasoning for conception: a realistic approach that genuinely looks at removing what may not be working while retaining the crucial pieces that address the condition and communicate our concern for others in a manner that fosters a better reception. While the end result may be as frustrating as any other method– perhaps more frustrating if we feel we executed perfectly with no result– the statistical evidence has suggested that this strategy has shown more effective in long-term reduction of behavior. While we are all differing individuals, we will likely all feel better when we make decisions about our lives ourselves rather than feel others have made decisions for us. While it may seem simple, this basic change in our approach to these situations may actually make a world of difference through response.
WHAT’S COOKING FOR NEXT MONTH
GREIF: THE GREAT MISUNDERSTOOD
Next month, Nick will discuss lesser-known perspectives around grief and death and offer new ways to look at one of the most misunderstood and unfortunately most inevitable facets of the human emotional experience at large.
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SBIRT and MOTIVATIONAL INTERVIEWING
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