Assessment and screening

Starting a conversation with a person about their drinking can be challenging. Nurses may worry that asking someone about their drinking habits will cause offence and destroy the therapeutic relationship.

Every contact counts

There are a number of ways to start a conversation with a patient to help them begin to make changes. The following brief interventions have a strong evidence base for supporting changes both in the short and longer term. They often have the same level of positive outcome as longer interventions.

Screening

A screening tool can be used as part of the initial assessment process when a person is entering a service or treatment. In this way the screening forms a core part of other questions being asked about the patient's health. This will help to reduce the risk of a person feeling targeted in some way and they will be less likely to be defensive about their alcohol intake.

The AUDIT - Alcohol Use Disorders Identification Test was developed by the World Health Organization (WHO) as a simple method of screening for excessive drinking and to assist in brief assessment. It can help in identifying excessive drinking as the cause of the presenting illness. It also provides a framework for intervention to help hazardous and harmful drinkers reduce or cease alcohol consumption and thereby avoid the harmful consequences of their drinking. 

FRAMES

The FRAMES acronym and approach below uses the Audit tool, which can help to initiate conversations about alcohol in a person-centred way, to ensure a more positive outcome.

Feedback of personal risks or impairment – provide the patient or client with a verbal report card based on the results of your assessment or their score on the AUDIT screen. Many people are unaware that they are drinking at hazardous or harmful levels and highlighting risks linked to current drinking patterns can be a powerful motivator for change. “You’ve scored 16 on the AUDIT which indicates that you are at high risk of harm from your current pattern of drinking…”

Responsibility – emphasise that the decision to change drinking patterns or to continue drinking at the same level is the choice of the person alone. Acknowledgement of personal responsibility has been identified as a key factor in motivating behaviour change. “Nobody can make this choice for you. It’s really up to you to make a change…”

Advice - deliver clear advice to change drinking behaviour. Simple yet expert advice from a medical professional is a potent element in a brief intervention. “…yet as your (doctor, pharmacist, health care worker) I strongly advise you to limit your drinking or stop altogether to reduce the risks.”

Menu – provide a menu of strategies for changing drinking behaviours. Options include behavioural control (e.g. setting personal drinking limits and sticking to it; alternating alcoholic drinks with soft drinks; switching to low alcohol drinks; having regular alcohol-free days; identifying high risk situations for heavy drinking and creating a management plan; engaging in alternative activities to drinking).

Empathy – brief interventions emphasise the development of a therapeutic alliance in the context of a warm, reflective, empathic, and collaborative approach by the practitioner. A confrontational, directive, authoritarian, or coercive stance has no place in a brief intervention and is likely to undermine its effectiveness.

Self-efficacy – support the person's self-efficacy for change, and communicate a sense of optimism. De-emphasise helplessness or powerlessness. “Many people successfully control their drinking or stop drinking all together. With the right support and information I’m confident that you will do it too”. 

Dual diagnosis

Dual diagnosis is a very broad category. It can range from someone developing mild depression because of binge drinking, to someone's symptoms of bipolar disorder becoming more severe when that person abuses heroin during periods of mania. Either substance abuse or mental illness can develop first. 

When working with people with issues with alcohol, it can be challenging to unpick what of their concurrent mental health issues may be. A person's mental health may be due to alcohol abuse or there might be a separate issue exacerbated by the alcohol use. It is often hard to accurately diagnose mental illness, and the extent to which the severity of symptoms is affected by alcohol intake.

The National Institute on Alcohol Abuse and Alcoholism has published a paper which provides guidance in addressing this confusion. The paper also outlines common mental illnesses that are likely to be encountered when working with people with alcohol issues. See: Alcoholism and Psychiatric Disorders: Diagnostic Challenges.

Drinkaware has produced a fact sheet which outlines the effects that alcohol has on mental health, ranging from explaining why after a high level of alcohol intake your memory may be blank, through to links with alcohol and deliberate self-harm, see: Alcohol and mental health. This is a useful resource to print off and give to patients who may have concerns about their own alcohol intake and how that may be affecting their mental health. 

National consortium of consultant nurses in dual diagnosis and substance misuse provide information to improve the support and treatment for individuals who have co-occurring mental health, alcohol and drug (COMHAD) difficulties, dual diagnosis.