7.10.1
Context
An extended brief intervention typically takes 20-30 minutes to deliver and can involve a small number of repeat sessions. It should be directed towards harmful drinkers whose levels of alcohol-related harm indicate a need for it and who are willing to accept it. It may also be suitable for hazardous drinkers in the contemplation stage of change, who are ambivalent about their drinking and
wish to discuss it with a healthcare professional, or for those who do not respond to simple advice and want further assistance in reducing drinking to safer levels. Earlier studies of brief intervention involved a condensed form of cognitive behavioural therapy and particularly of behavioural self-control training (Hester, 1995: see chapter eight). This type of approach relies on:
• Detailed self-monitoring of alcohol consumption
• Identification of high-risk situations for excessive
drinking
• Development of plans to deal with high-risk situations
without excessive drinking
• Formulation of simple rules to limit consumption during
drinking sessions
• Discussion of alternatives to drinking as part of a
healthier lifestyle
• Feedback of blood test results, usually GGT (see
section 5.4.2.1), can also be useful.
More recently, attention has turned to brief forms of motivational interviewing (Rollnick, Heather and Bell, 1992), an approach which is typically based on the stages of change model. However, Rollnick, Mason and Butler (1999) have argued that extended brief intervention of this kind should not be confused with motivational interviewing as such, since the latter requires a high level of skill and training from practitioners and more time than is usually available in generalist settings. They prefer to call it “patient-centred and directive negotiation of health behaviour change” and describe a generic method, applicable to all forms of health-related behaviour change, based on the principles and techniques of motivational interviewing (Miller and Rollnick, 2002) and consistent with the principles of patient-centred medicine.
Rollnick and colleagues also argue against a “mechanical” application of the stages of change model to interventions in which service users judged to be in different stages are given different forms of intervention; they believe that motivation to change is more fluid and subtle than implied by this model and must be handled accordingly. They describe short-cut methods of assessing “importance”, “confidence” and “readiness to change” and these assessments form the basis for further discussions with the patient.
The level of training required to carry out this form of brief intervention effectively is substantially greater than that for
simple advice and should involve much more emphasis on experiential learning. Rollnick, Mason and Butler (1999) provide guidance on how this training should be
delivered.
7.10.2
Evidence
Compared with five minutes simple advice, the WHO collaborative study found no evidence for the greater effectiveness of an additional 15 minute brief counselling or of extended counselling over three more sessions (Babor and Grant, 1992). Also, in their meta-analytic review, Ballesteros et al. (2004a) found no clear evidence for a “dose-response” relationship, meaning that there were no firm grounds for concluding that longer or more intensive brief interventions were superior to minimal interventions.
Other studies, however, have found increased benefits for more extended brief interventions over simple advice (Richmond et al., 1995; Israel et al., 1996; Poikoloainen, 1999). Although not involving a comparison with a simple brief intervention, several well-known trials have reported very promising effects of interventions consisting of two or three consultations with a primary healthcare physician or nurse (Wallace, Cutler and Haines, 1988; Anderson and Scott, 1992; Fleming et al., 1997). A recent analysis by Berglund (2005), based on the data collected by the Swedish Technology Assessment (Berglund, Thelander and Jonsson, 2003), showed that, compared with the robust and stable effect across studies of single-session brief interventions, studies of repeated sessions showed a larger average effect but this was not uniform across studies. In the WHO Collaborative Study (Babor and Grant, 1992), it was found that simple advice worked better for men who recognised a recent alcohol-related problem, while extended brief interventions worked better for men who had not had a recent problem, suggesting that extended brief interventions were better suited to men in the contemplation stage of change.
Therefore, although there is some evidence to support the use of extended brief interventions, the questions of the optimal intensity of interventions, for which types of drinker and in what circumstances, are perhaps the most urgent issue in this area of research. Meanwhile, the additional offer of extended brief interventions to harmful drinkers following simple advice can be justified on pragmatic grounds. Some may ask for further discussion of their drinking or help in cutting down, while others may
show a level of harm that the clinician judges would benefit from more prolonged interventions if drinkers were willing to accept it. Therefore, a cautious and conservative implementation of brief interventions in healthcare settings would be to offer extended brief interventions to harmful drinkers following simple advice. Whether or not extended brief intervention can be offered in a specific service obviously depends on the human resources available.
7.10.3
Conclusions
• There is mixed evidence on whether extended brief
interventions in healthcare settings add anything to the effects of simple brief intervention, ie, simple,
structured advice (IA)
• The offer of extended brief intervention to some
hazardous and harmful drinkers can be justified on pragmatic grounds (IA)
• There is some evidence that extended brief
intervention is effective among male hazardous or harmful drinkers in the contemplation stage of change (IB).