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Alcohol Identification

and Brief Advice (IBA)

The World Health Organisations Global Burden of Disease Study identifies


alcohol as the third most important risk factor, after smoking and raised blood
pressure, for European ill-health and premature death.1 Brief interventions
have been shown to be one of the most effective approaches to helping
people reduce their drinking to below harmful levels.2 This one-day course is
designed to ensure you have background information and skills needed to
offer effective alcohol brief interventions.

The World Health Report, 2002. Reducing Risks, Promoting Healthy Life. WHO, Geneva.

Raistrick, D., Heather, N. and Godfrey, C (2006). Review of the Effectiveness of Treatment
for Alcohol Problems. National Treatment Agency for Substance Misuse, London.

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Alcohol Identification
& Brief Advice
One day training course
An evidence based intervention that can be used in a wide range of settings.
Practitioners develop confidence to raise and respond to alcohol issues in a
straightforward and effective way. This course will encourage you to be
curious about alcohol; the history, the effects it has, and how our culture
responds and embraces it. Using current evidence and practice, you will
develop a toolbox to help individuals reduce their drinking risk.
Learn how to identify alcohol users who may benefit from a brief intervention
using the AUDIT screening tool. Practice skills and techniques to deliver
simple advice and more extended interventions.
Course aim:

To equip participants with knowledge about alcohol and develop


techniques to help individuals adopt lower risk drinking behaviour.

Course objectives:
By the end course participants will have had opportunities to:

Recognise the risks alcohol can present to an individuals health


and wellbeing
Understand units as a way of measuring alcohol content
Describe the definitions of drinking patterns including dependency
Identify alcohol users who may benefit from brief interventions
Practice and become familiar with three tools to screen, provide
simple advice and deliver an extended motivational intervention
Identify advice on the changes which can be made to drinking
behaviour to improve health, wellbeing and personal safety.

Maximum group size:

18 people

Mapped to DANOS unit:

AH10

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Agenda
Time

Session Content

Methods

9.30

Introductions, training agreement and domestics

Large group
discussion

9:45

How often do you see people who drink at risky or harmful


levels?

Exercise in pairs
Thoughtstorm

10:00

Understanding peoples drinking

Group exercise

10:10

The risks and harms of alcohol use

Presentation

11:00

Break

11:15

Delivering Brief Interventions; the evidence

Presentation

11:30

The stages of a Brief Intervention

Presentation

11:45

Step 1: Raising the issue

Exercise in pairs

12:10

Step 2: Screen and give feedback

Discussion

Understanding units and AUDIT case studies

Small group
exercise

12:40
1:30

Lunch
Step 3: Listen for readiness to change
Introducing the stages of change

2:00

Presentation and
discussion

Step 4: Choose a suitable approach


Interventions: Information & Advice, Enhancing motivation,
Menu of options, Building confidence, Coping Strategies

Small group
exercises

Tools practice
2:30
3:15

Break

3:30

Signposting and local resources

4:00

How will you be putting IBA into practice?

Small group
exercises
Discussion

4:15

Evaluation and round up

4.30

Close

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Coursebook Contents
Course aims, objectives and agenda

Introductions

Understanding peoples drinking

The downside of drinking

Understanding the risks of drinking

The scale of the problem

Diagnostic criteria for alcohol dependence syndrome

10

Young People Risk and Resilience

11

Alcohol in Plymouth

12

The Cost of Alcohol

14

Alcohol interactions

15

Delivering Identification and Brief Advice

17

Evidence of the effectiveness of Brief Interventions

18

FRAMES

20

Stages of a brief intervention

21

Step 1: Raise the issue

22

Who to Ask and Teachable moments

23

Step 2: Screen and give feedback

24

Alcohol Units

25

AUDIT C

26

Remaining AUDIT

27

AUDIT Case studies

28

Step 3: Listen for readiness to change

32

Communication skills for Health behaviour change

33

Understanding their world

36

Step 4: Choose a suitable approach

37

Information and Advice

38

Safer drinking

39

Enhance motivation

41

Menu of options and Build confidence

42

Coping strategies

43

Tool practice

44

Step 5: Exit strategy

46

Putting Alcohol IBA into practice

47

Useful resources

48

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Introductions
How often, in your current work, do you see people who drink
alcohol at risky or harmful levels?
Hardly ever
1

Very often
3

10

What has been your experience of working with alcohol users in


your current role?

How important is it for you to be able to offer alcohol brief


interventions to these people?
Not at all important
1

Very important
4

10

How confident are you that you can offer effective brief
interventions to these people?
Not at all confident
1

Very confident
4

10

What information about alcohol and related issues do you need to


know to increase your confidence and provide a more effective
service?
Is there anything you would regret not having asked about or
discussed at the end of the training session?

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Understanding peoples drinking


Why do some people drink at risky or harmful levels? To help
people address their drinking, it helps to understand what attracts
them towards it.
What is attractive about drinking alcohol?

There are two sides to drinking on one side the attractions, on


the other all the problems. So that is what we turn to next.

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The downside of drinking


Alcohol is a contributing factor in more than 40 medical conditions and a
wide range of social, legal and behavioural problems. Helping someone
recognise the harm that drinking may cause, is causing, and has caused, can
help motivate them to address this issue. It is useful to consider four areas of
risk/harm.

Physical

Behavioural & psychological

Social impacts

Legal

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Understanding the risks of drinking


It is helpful to think of three levels of alcohol problems as defined
by the World Health Organisation:
Hazardous drinking (Increasing risk) - a pattern of alcohol
consumption that increases someones risk of harm. The more you drink
the greater the risk. The Department of Health refer to Increasing risk and
Higher risk drinking

Harmful drinking (Higher risk) - a pattern of alcohol consumption


that is causing someone harm.

Dependent drinking - here someone may have such a strong desire


to drink that they experience difficulties controlling their drinking and
persist despite harmful consequences.

Hazardous drinking
Many people drinking at hazardous levels dont see themselves as having a
problem. Like with raised blood pressure, the problem is that the numbers (in
this case, units of alcohol) are too high, thus putting them at increased risk of
a wide range of problems.
The table below3 shows some of the health risks for men drinking more than
7.5 units per day, or women drinking more than 5 units per day which is higher
risk drinking.

Condition

Men

Women

Liver cirrhosis

13 times

13 times

Mouth cancer

5.4 times

5.4 times

Larynx cancer

4.9 times

4.9 times

Oesophagus cancer

4.4 times

4.4 times

Hypertension

4.1 times

2.0 times

Liver cancer

3.6 times

3.6 times

Haemorrhagic stroke

3.6 times

3.3 times

Ischaemic stroke

3.0 times

2.7 times

Cardiac arrhythmias

2.2 times

2.2 times

Breast cancer (women)

1.6 times

Coronary heart disease (CHD) in


middle age

1.7 times

1.3 times

Department of Health, 2008. Safe, Sensible, Social Consultation on further action, p.10

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The scale of the problem


8% of men and 5% of women are estimated to drink at higher-risk levels
(i.e. for men, regularly drinking more than 50 units per week or more than
8 units per day; for women, regularly drinking more than 35 units per
week or more than 6 units per day) which equates to 2.7 million people in
England (DoH, 2008)4.
31% of men and 20% of women (about 10 million people) drink at
increasing-risk (regularly drinking more than lower-risk levels) or higherrisk levels (DoH, 2008).

*Regularly here means every day or most days of the week


(not just drinking at these levels once a week)

Department of Health, 2008. Safe, Sensible, Social Consultation on further action, p.61

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Diagnostic Criteria for the Alcohol Dependence


Syndrome5
Any 3 or more of the following in the preceding 12 month period:
A strong desire or sense of compulsion to drink alcohol.
Difficulty in controlling drinking in terms of its onset,
termination, or level of use.
A physiological withdrawal state (e.g. tremor, sweating, rapid
heart rate, anxiety, insomnia, or, less commonly, seizures,
disorientation, hallucinations) when drinking has ceased or
reduced, or drinking to relieve or avoid such a withdrawal
state.
Evidence of tolerance, such that increased doses of alcohol
are required in order to achieve effects originally produced by
lower doses.
Progressive neglect of alternative pleasures or interests
because of drinking, and increased amounts of time
necessary to obtain or take alcohol, or to recover from its
effects.
Persisting with alcohol use despite awareness of overtly
harmful consequences.

World Health Organisation, 1992. International Classification of Diseases (ICD-10)

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Young People
Warning signs that alcohol is causing harm in young people:

Being drunk more often than in the past


Taking the day off because of a hangover
Having arguments or accidents because of drinking
Getting into trouble (fights, drink- driving)
Regretting and feeling guilty about behaviour whilst under the influence
Worsening performance at school
Loss of interest in sports or other activities
Lying about drinking levels
Covering up drinking and the cost of it

Risk and Resilience


It is recognised that particular groups of young people may be more
vulnerable to substance misuse. Vulnerable and disadvantaged children and
young people aged under 25 who are at risk of misusing substances include:
those whose family members misuse substances
those with behavioural, mental health or social problems
those excluded from school and truants
young offenders
looked after children
those who are homeless
those involved in commercial sex work
National Institute for Health and Clinical Excellence, 2007
Not all young people from vulnerable groups will develop drugs and alcohol
misuse problems at all. This is due to a number of protective factors. For
example:

The young person has a positive temperament


They have a supportive family environment
They are linked in to a good social support system
They have a caring relationship with at least one adult
They are in education, training or employment
They are able to learn from difficult experiences and are able to resist
pressure

It is now understood that protective factors do not have to be opposite to


particular risk factors to promote resilience. Indeed there is a shift from seeing
prevention as needing to be focused on particular and/or independent
problems to recognition that improving protective factors per se is effective in
reducing risk (Coomber, 2004).

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11

Alcohol in Plymouth
How many people in Plymouth drink in a risky way?

Increasing risk drinkers 24.2% or 24,200 per 100,000 population aged


16 years and above. This equates to 50,447 hazardous drinkers in
Plymouth.

High risk drinkers 3.8% or 3800 per 100,000 population aged 16 years
and above. This equates to 7,921 harmful drinkers in Plymouth.

Dependent drinkers 2.6% or 2,600 per 100,000 population aged 16 years


and above. This equates to 5,420 dependent drinkers in Plymouth.

It is estimated that between 5% - 8% of dependent drinkers in the city currently access


structured treatment each year.

The health impact of risky alcohol in Plymouth


Between 2002 and 2010 admissions to hospital as a result of alcohol use
increased by over 71%.
There has been a 20% increase in deaths from chronic liver disease and
cirrhosis in under 65s between 2000 and 20096.
People living in the most deprived areas of the city are nearly twice as likely to
be admitted to hospital because of alcohol as those living in the least deprived
areas7.

The impact on crime from alcohol use in Plymouth


Overall numbers of recorded alcohol related crimes have fallen over the last
three years
During 2011-12 there were over 2,500 alcohol related crimes recorded in the
city.
Violence accounts for 70% of all alcohol related crime. Alcohol is a consistent
feature in more than 40% of domestic offences and incidents.8
There is a strong correlation between sexual assault and rape and alcohol use
by perpetrators and victims.9

Chief Medical Officer Annual Report: Volume One, 2011

8
9

Alcohol Attributable Hospital Admissions in Plymouth, South West Public Health Observatory, 2012
Devon and Cornwall Police Alcohol Harm Profile 2011
Plymouth Community Safety Partnership Strategic Assessment (Crime and Disorder) 2011/12

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Economics
It estimated that Plymouths overall economic night time economy supports
approximately 6,400 employees and was worth around 93.2 million in terms of Gross
Value Added (GVA). Licensed clubs, pubs and bars accounted for 2,000 of those
employees and the largest share of the GVA at 28.6 million.

The cost of alcohol related harm within Plymouth is estimated at


approximately 80million a year10.
Alcohol has an approximate cost to the health economy of Plymouth
9,630,00011.
Based on police data the estimated annual cost of alcohol related crime in
Plymouth is in the region of 27million12.

Young people and alcohol

Young people in Plymouth are more likely to drink alcohol than national
counterparts.
During 2011/12 young people in treatment in Plymouth were more likely to
drink at harmful levels than young people in comparator areas.
Plymouths Hidden Harm needs assessment estimates that between 3,900
and 6,500 children are affected by parental alcohol misuse.13

10

Plymouth Alcohol Joint Strategic Needs Assessment (2012): based on data from the Department of Work and Pensions

11

Department of Health 2007

12

Plymouth Alcohol Joint Strategic Needs Assessment (2012): based on data from Devon and Cornwall Constabulary

13

Plymouth Safeguarding Children Board (2008). Hidden Harm Working Group Analysis of Need

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The Cost of Alcohol


Cost to NHS14
6% of all hospital admissions
Up to 35% of all A&E attendance and ambulance costs may
be alcohol-related
Up to 70% of A&E attendances at peak times on the
weekends (between midnight and 5am) may be alcoholrelated
Alcohol misuse is calculated to cost the health service 2.7
billion per year

Costs of Alcohol related crime5


Estimated at 9 15 7billion per year

Costs of Accidents15
23 35% of deaths from falls are linked to alcohol
30 38% of deaths from drowning are linked to alcohol
38 45% of deaths from fire injuries are linked to alcohol

14

Department of Health, 2008. Safe, Sensible, Social Consultation on further action,


impacts assessment
15

Institute of Alcohol Studies - Alcohol and Health Factsheet

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How does alcohol interact with other


substances?
Alcohol is a depressant drug.
The changes which heavy drinking can cause in the liver, can result in some
drugs becoming toxic and damaging the liver and other organs.
Alcohol reacts with a wide range of other drugs.
SPECIFIC INTERACTIONS16

Minor tranquilisers eg valium (diazepam) and normisum (temazepam)


Many of the drugs in this group will have a sedative effect and when
mixed with alcohol, are likely to cause extreme drowsiness with an
increased risk of accidents.

Antibiotics
If taken with alcohol some antibiotics can cause nausea, vomiting,
headache and possible convulsions.

Antidepressants
Many people with alcohol problems also feel depressed and may be
prescribed anti-depressant drugs. There are a number of potential
difficulties with this combination:
o alcohol itself is a depressant drug and thus will reduce the
potential benefits of the prescribed anti-depressant drug.
o some anti-depressants also have a sedative effect and alcohol
will increase this sedative effect. This increases drowsiness and
the likelihood of accidents.
o there are also the effects on your liver, when it has to break
down alcohol and a drug.

Antihistamines are used to treat allergic symptoms, hay fever and


insomnia.
Some are available without prescription.
Alcohol may cause a more intense sedation when taken with these
drugs. These drugs may cause excessive dizziness and drowsiness in
older people and when combined with alcohol this effect will be
increased.

Pain Relievers
Opiate pain killers such as morphine and codeine when combined with

16

Alcohol Focus Scotland

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15

alcohol will increase the sedative effects of both substances.


Essentially there is an increased risk of death from overdose in this
instance.
Aspirin and a variety of other over the counter remedies have the ability
to cause bleeding and inflammation in the stomach lining. The use of
alcohol with these substances can increase the risk of this kind of
bleeding.

Anticoagulants
Warfarin is prescribed to thin the blood.
Having a drink or a few drinks over an evening can increase the risk of
internal bleeding.
Regular heavy drinking can have the opposite effect by reducing the
effectiveness of Warfarin.

Stimulant Drugs
Examples of these drugs include cocaine, ecstasy and amphetamine.
People who take stimulants and alcohol together may end up drinking
more than they intend. This is because the stimulant drug covers up
the depressant effect of the alcohol i.e. you dont notice how drunk you
are getting.
o Stimulants together with alcohol, can result in the blood pressure
going up.
o Alcohol & cocaine creates a third drug in the body
cocaethylene. This is more toxic to the liver than either on their
own.

Anti-psychotic medications
Anti-psychotic drugs are prescribed to people with mental health
problems. Some difficulties:
o Having a drink or a couple of drinks over an evening with this
kind of medication may result in impaired co-ordination and
serious breathing difficulties.
o Further side effects are low blood pressure, dizziness, fainting.
o Regular heavy drinking along with some anti-psychotic
medications can result in liver damage.

Cardiovascular medication
This group of drugs includes many different medications prescribed for
heart and circulatory system problems.
Regular heavy drinking along with propanolol (Inderol) used to treat
high blood pressure will reduce the drugs effectiveness.
Alcohol use along with many of these drugs will cause dizziness,
fainting.

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16

Delivering
Brief Interventions
Using IBA approach
(IBA = Identification and Brief Advice)

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17

Evidence of the effectiveness of Brief


Interventions
There is consistent evidence from a large number of studies that brief
interventions can reduce total alcohol consumption and episodes of binge
drinking. Within the literature the terms brief and minimal cover a range of
interventions from one five-minute interaction to several 45-minute sessions.
Brief interventions, of various forms and delivered in a variety of settings, are
effective in reducing alcohol consumption among hazardous and harmful
drinkers to low-risk levels. Effects of brief interventions persist for periods
up to two years after intervention and perhaps as long as four years17

NNT a measure of effectiveness


One way of assessing the effectiveness of an intervention is to consider the
number of people who need to be treated in order to bring about one positive
outcome. This is known as the NNT, or number needed to treat. For
example, between 40 and 125 people with hypertension need to be treated
with medication in order to prevent one heart attack over a five year period.
Seven to nine people need to be given a brief intervention to achieve a
reduction of drinking to non-hazardous levels in one patient. This makes brief
interventions to reduce hazardous drinking one of the most effective
preventative interventions known. 18

Cost effective
Because the harms from alcohol use are so costly to society, it has been
calculated that 5 is saved for every pound spent on treatment. 19

17

Raistrick, D., Heather, N. and Godfrey, C (2006). Review of the Effectiveness of Treatment
for Alcohol Problems. National Treatment Agency for Substance Misuse, London.
18

The Management of Harmful Drinking and Alcohol Dependence in Primary Care, Scottish
Intercollegiate Guidelines Network.
19

Raistrick, D., Heather, N. and Godfrey, C (2006). Review of the Effectiveness of Treatment
for Alcohol Problems. National Treatment Agency for Substance Misuse, London. p3

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18

Evidence of IBA effectiveness with young


people
There is limited evidence on the effectiveness of alcohol brief interventions for
young people under the age of 16.
For mature 15 year olds and upwards an extended Intervention up to an
hour long, using motivational techniques rather than 10 minutes of simple
advice is more likely to be effective.
The evidence suggests that the same kinds of treatment are effective for both
adults and younger people, but it is the social needs of young people that are
often different to adults.
(Tevyaw and Monti, 2004) NTA review of effectiveness of treatment for alcohol 2006

NICE recommends the use of a validated alcohol screening questionnaire


such as AUDIT, when working with young people aged 16 and 17 who are
thought to be at risk from their alcohol use.
With young people under the age of 16 there is no specific NICE guidance
relating to the use of identification tools, however it is evident that some
professionals are using identification tools with younger people.
In Plymouth DUST (Drug Use Screening Tool) is the agreed substance
misuse screening tool for under 16s. This gives an indication of risk around a
young persons drinking. An AUDIT screen could be used to further
understand the young persons alcohol use.
There is no weighting on the AUDIT tool, so a 16 year old consuming 15 units
a week would elicit the same score as a 45 year old consuming the same
amount.
When using AUDIT with under 18 year olds, it is advisable to use your
professional experience and understanding to consider the level of risk
threshold.
An approach could be:
0 - 5 could be lower risk
6 - 13 could be increasing risk
14 - 17 could be higher risk
18 or more could indicate possible dependence
Screening tools provide guidance. Continuing to use your professional
judgement and experience is key.
Providing an alcohol brief intervention for young people under the age of 15
can be much more informal. You could consider using interactive materials
such as beer goggles, unit wheels, drink diaries and unit measures. Also dont
forget to think about the language being used to ensure it is appropriate for
different age groups.

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19

Frames
In a review of factors associated with effectiveness in brief
interventions, Bien, Miller and Tonigan (1993) used the acronym
FRAMES to summarise six key elements.20 These are:

Feedback: about personal risk or impairment

Responsibility: emphasis on personal responsibility for change

Advice: to cut down or abstain if indicated because of severe


dependence or harm

Menu: of alternative options for changing drinking pattern and,


jointly with the patient, setting a target; intermediate goals of
reduction can be a start

Empathic interviewing: listening reflectively without cajoling


or confronting; exploring with patients the reasons for change as
they see their situation

Self efficacy: an interviewing style which enhances peoples


belief in their ability to change

20

Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief interventions for alcohol problems: A
review. Addiction. 1993; 88:315-336

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20

3ource21

Exit strategy remember you or the patient can choose not to

21

NHS Health Scotland, 2011. Delivering alcohol brief interventions in the primary care setting.
Briefing paper 2: How?

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Step 1
Raise the issue
Do you drink at all?
In pairs please discuss how you could approach the subject of alcohol and
offering a brief intervention to people who use your service.

Here are some examples:


As a practice we are asking everyone with X condition about their drinking habits
because alcohol sometimes makes a difference to your condition. Is now a good time
for you for me to ask you about your drinking?
We have been talking about your low mood/ anxiety/ weight/ relationship problems.
Sometimes this sort of problem can be affected by alcohol Do you mind if I ask you
a question about your drinking behaviour?
Some people use alcohol as a way of trying to cope with Can I ask you about
your use of alcohol?

Please give at least 2 examples of different questions or statements you could


use:

Build an alliance for more effective consultations


Positive outcomes and higher retention rates have been found to be related to
workers capacity to establish an alliance, as well as to other facets of interpersonal
functioning, such as their warmth and friendliness, affirmation and
understanding, helping and protecting, and an absence of belittling and
blamingignoring and neglecting and attacking and rejecting (Najavits & Weiss, 1994)

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Who will you be asking about their drinking?


The citys 2012 Joint Strategic Needs Assessment identifies the following groups as
those at most risk of harm from alcohol in Plymouth

Adults 40 64 (peak 40-44 women and 45-49 men)


Offenders
Single homeless
Young Adults (18 -25) including students
People with mental health problems
Children affected by parental alcohol misuse /alcohol misusing parents
(including pregnant women)

It also identifies other at risk groups

Young People (under 18)


Older People
Service men and women and veterans
Street drinkers
Victims and perpetrators of domestic violence and abuse
People involved in risky sexual behaviour
Neighbourhoods with high levels of deprivation

Teachable moments.
The best time to talk to someone?
The best place?

When might be the best opportunity in your work to talk with someone about alcohol?
Where it will have the most impact?

What opportunities are there for it to become routine practice?

What makes you credible? What gives you the right to ask this question?

What kind of relationship do you need to have with someone?

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23

Step 2
Screen and give feedback
Drinking at these levels carries a greater risk of X
Do you think that applies to you at all?
Levels of screening
Level one involves simple screening questions that you could ask anyone.
For example: Do you drink alcohol? If so, how often and how much in a typical
drinking day?
Making this part of our routine data collection reduces any stigma around asking. It
also reinforces the message that alcohol is an important health issue. Use the
response to this question to calculate units, as this gives a reference point to assess
risk.
Units
Calculating weekly or daily units with the person could give them a practical way of
measuring their consumption and help them monitor it more closely in the future.
Units can be measured by this formula:
Volume (mls) multiplied by ABV (Alcohol By Volume (%) and divide by 1000
e.g.

A 1000ml (litre) bottle of vodka at 40% will be 40 units


A 500 ml can of cider at 5% will be 2.5 units

There are various unit calculators available. Consider people with learning and
literacy difficulties who may not be able to read the calculators easily.
You can simply calculate the average number of units that the person drinks in
a week.
The AUDIT (Alcohol Use Disorders Identification Test) questionnaires first three
questions (known as Audit-C) is an alternative simple first stage screening that asks
about frequency and quantity of consumption.
Level two involves asking further questions if Level One screening suggests drinking
may be at a levels increasing risk of harm. For example: Have you ever had any
concerns about the effects of your drinking?
The AUDIT questionnaire is designed so that the final seven questions need only be
asked if responses to the first three questions suggest the need.
Level three involves taking more detailed alcohol history to help you and the client
develop more of an understanding of their pattern of drinking (e.g. is there
dependence?), as well as to identify any harmful consequences.

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24

Taken from http://www.nhs.uk/livewell/alcohol/pages/alcohol-units.aspx

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AUDIT C
Scoring system
Questions
0
How often do you have a drink containing
alcohol?

How many units of alcohol do you drink


on a typical day when you are drinking?
How often have you had 6 or more units if
female, or 8 or more if male, on a single
occasion in the last year?

Never

1
Monthly
or less

1 -2

3-4

Never

Less
than
monthly

2-4
times
per
month

2-3
times
per
week

4+
times
per
week

5-6

7-9

10+

Weekly

Daily
or
almost
daily

Monthly

Your
score

Scoring:
A total of 5+ indicates potential increasing or higher risk drinking,
so the final 7 AUDIT questions will need to be completed:

A score of 4 or below indicates lower risk drinking.

SCORE

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SCORE

Score from AUDIT- C


(Carry forward from previous
3 questions on the other side)

Remaining AUDIT questions


Scoring system
Questions

How often during the last year have you


found that you were not able to stop drinking
once you had started?
How often during the last year have you
failed to do what was normally expected
from you because of your drinking?
How often during the last year have you
needed an alcoholic drink in the morning to
get yourself going after a heavy drinking
session?
How often during the last year have you had
a feeling of guilt or remorse after drinking?
How often during the last year have you
been unable to remember what happened
the night before because you had been
drinking?
Have you or somebody else been injured as
a result of your drinking?
Has a relative or friend, doctor or other
health worker been concerned about your
drinking or suggested that you cut down?

Never

Less
than
monthly

Never

Less
than
monthly

Never

Less
than
monthly

Never

Less
than
monthly

Never

Less
than
monthly

Monthly

Monthly

Monthly

Monthly

Monthly

Weekly

Daily
or
almost
daily

Weekly

Daily
or
almost
daily

Weekly

Daily
or
almost
daily

Weekly

Daily
or
almost
daily

Weekly

Daily
or
almost
daily

No

Yes, but
not in
the last
year

Yes,
during
the last
year

No

Yes, but
not in
the last
year

Yes,
during
the last
year

Your
score

Scoring: 0 7 Lower risk, 8 15 Increasing risk,


16 19 Higher risk, 20+ Possible dependence

TOTAL

Total AUDIT C plus remaining AUDIT questions

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AUDIT Practice Case Study 1


Jo
Age 39
Works in retail
Monday: Half a bottle of wine (13%) with a meal
Tuesday: No alcohol
Wednesday: 2 pints of cider (5%) in a bar with friends
Thursday: No alcohol
Friday: 4 bottles (500ml) of cider (5%) at home
Saturday: 4 pints of cider (5%) and 2 double rum and cokes in a bar
Sunday: 2 glasses (250ml) of wine (13%) at lunch time, no alcohol in the
evening

GUESS

CALCULATED

How many units

How many units

The drinking pattern

The drinking pattern

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AUDIT Practice Case Study 2


Ali
Age 15
School
Monday: No alcohol
Tuesday: 1/3 rd 75cl bottle of vodka out with friends (equivalent to 10 shots)
Wednesday: 2 cans (440mls) cider with friend
Thursday: No alcohol
Friday: 4 cans supermarket lager with friends
Saturday: 1 bottle of cider (500ml; 7.5%) at home in bedroom
Sunday: No alcohol

GUESS

CALCULATED

How many units

How many units

The drinking pattern

The drinking pattern

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AUDIT Practice Case Study 3


Les
Age 48
Works for the council
Monday: 2 pints lager (5%)
Tuesday: 4 pints lager (5%)
Wednesday: 4 pints lager (5%)
Thursday: 2 pints lager (5%)
Friday: 4 pints lager (5%)
Saturday: 5 pints lager (5%)
Sunday: No alcohol

GUESS

CALCULATED

How many units

How many units

The drinking pattern

The drinking pattern

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AUDIT Practice Case Study 4


Mo
Age 66
Retired
Monday: 1 glass (175ml) wine (13%) at home
Tuesday: 3 glasses (175ml) wine (13%) with friends
Wednesday: 2 double whiskeys at social club
Thursday: 1 glass (175ml) wine (13%) at home
Friday: 2 glasses (175ml) wine (13%) at home
Saturday: 1 glass (175ml) wine (13%) at home
3 double whiskies at social club
Sunday: 1 glass (175ml) wine (13%) at home

GUESS

CALCULATED

How many units

How many units

The drinking pattern

The drinking pattern

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Step 3
Listen for readiness to change
What are your feelings about your drinking?
What would be helpful to you right now?
Feeding back the result of the screening tool will raise awareness in the client .
For example you may say:
Increasing risk means - you are more likely to run into trouble with some aspect of
your life it might be physical but it is more likely at first to affect your emotions, your
personal life, relationships, sleep and energy.
Higher risk means you are already likely to be harming yourself in a variety of ways
and your risks of doing so in the future are higher.
How has that left you feeling?
What are your thoughts on the AUDIT result?

How does your client know when their alcohol use is a problem?
There are several stages involved in recognising something as a problem and
making a decision to tackle it. Reflecting on our own experience of making changes
can help us deepen our understanding of the factors influencing someones
readiness to change.
Self-Reflection Exercise
Think of a significant change you made in the last few years after deciding to do this.
e.g. giving up a habit, starting a new hobby, moving home, changing job etc.
Mark on the line below:
a) When you first started thinking about making this change
b) When you decided to make this change
c) When you first made the change
a)

b)

c)

Time

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Communication Skills for Health Behaviour


Change
When doing brief interventions, youll be exchanging information with people about:

their risks

giving advice

encouraging people to make changes.

Sometimes these conversations go well: people are keen to hear your advice, seem
full of enthusiasm and follow your suggestions. But there may also be times when
you wonder how interested they are, they appear passive, resistant or unsure.
Here are some principles that can help these consultations:
1) Recognise that we can influence resistance
Can you remember times when someone pressured you to do something in a way
that got your back up and made you more resistant?
Think of what provokes resistance (e.g. arguments, being overly confronting or
bossy, not listening etc), and then aim to do the opposite of this.
2) Help people make their own argument for change
If you could choose which mouth the strongest reasons for change came out of,
which would it be - yours or the clients? Why?
Reasons
for change

Reasons for
change

Client

Professional

When people hear themselves describe why something is important to them, they
reinforce their motivation.
The more you can support people to make their own argument for change, the more
your conversations with them will have a motivating effect. This principle can guide
your consultation.
You can still give information, but more to build on what they already know. This
makes the next principle important.
Remember most of us feel ambivalent about change. Lack of motivation is often
ambivalence.

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3) Start by finding out what they know, how they feel and what they want
When people describe the health risks they are already aware of, they are starting to
make their own argument for health promoting change.
It is worth checking out whether they have any concerns or worries, as these are
hooks that can strengthen motivation.
Asking what theyd like to find out gives you a better starting point for any information
giving.
4) After giving information, check how it lands
If youve just told somebody they are at higher risk of a serious condition, check what
their response to this is; this is an opportunity to draw out more motivation
strengthening conversation and help the information sink in.
e.g. Im aware Ive just told you some things that might be quite disturbing.
How has that left you feeling?
or
What are your thoughts on what Ive said so far?
Do you buy this idea that your drinking/ the way you use alcohol might be a
problem?
Do you think anything on this sheet/ in this box/ that we have been talking
about - fits with/ is relevant to/ is about YOU?
5) Aim for progress rather than perfection
Think of change as a journey: your goal is to have a conversation that helps nudge
people to take the next step.
The stages of change model is helpful here; the diagram on the next page
represents the journey of moving through these stages as similar to passing through
a revolving door.
If someone isnt even thinking about change (the pre-contemplation stage), then
raising awareness in a way that starts them thinking is a positive step.
People can get stuck at any of these stages, or stuck in a loop of going round the
door (see Fig.1 below).
It helps to have an understanding of common blocks and also to have ways of
helping people through these.
Skilfulness in behaviour change consultations is based on being able to recognise
where the patient is at, and aiming for a step of progress from that point.

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BEFORE CHANGE

AFTER CHANGE

R
Relapse

PC

Pre-contemplation

Not even thinking about it

Maintenance

Action

Contemplation

P
The Decision Threshold

Preparation

When someone crosses this,


they start looking for how to
change

Fig 1: The stages of change model of Prochaska and Diclemente

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Understanding their world


People view their alcohol use in different ways.
For example:
A person may consider how they drink to be fine for themselves even if it could cause
a problem for others because they have weighed up the risks.
or
They see their drinking and how they behave when drinking as a badge of identity it
is who they are
or
They lack sufficient knowledge about the problems and risks that can occur with
alcohol use so dont think change is necessary for them
or
They feel hopeless about change and overwhelmed by the energy required. They
may have had help many times before or have tried repeatedly to quit on their own to
no avail.

What needs to be in place for someone to move from thinking about change to
making a decision and carrying it out?

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Step 4
Choose a suitable approach
If you have more time with someone these are some of the approaches
you can follow

Information and
advice

Enhance
motivation

Would you like


more information?

What are the


pros and cons of
your drinking just
now?

Coping
strategies

Menu of options
What goals might
work for you?

How can you


prepare to avoid
problems and
difficult situations?

Build
confidence
How confident do
you feel?
What might help?

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37

Information and Advice


Would you like more information?
Information Exchange
The person is more likely to hear and heed your advice if you have permission to
give it
There are three forms of permission:
1. The patient offers it (e.g. asks for advice)
2. You ask permission to give it
Theres something that worries me here. Would it be all right if I..
Would you like to know?
Do you want to know what I would do, if I were in your situation?
I could tell you some things other people have done that worked.
3
You preface your advice with permission to disagree/disregard
This may or may not be important to you
I dont know if this will make sense to you
You may not agree
I dont know how youll feel about this
Tell me what you think of this
Its often better to offer several options, rather than suggesting only one.

Your options:
Linking their concerns to the advice you give is key
You could say:
Do you think you get any of these symptoms?
What does your partner think? would they agree you have no problem with your
drinking.
Why do you think I think you might have a problem?

Go through the NHS simple advice leaflet with them or give it to them to take away
Refer to the safer drinking guidelines in this workbook

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38

10 easy steps for safer drinking


Eat before you drink
Food helps absorb alcohol and so limits how quickly what you drink will get into your
bloodstream.

Eat while you drink


Giving your stomach something other than alcohol also prevents the drink irritating
your so much .

Drink water or soft drinks before during and after


Try and avoid alcohol to quench your thirst. Have a soft drink first. Alternate between
alcoholic and soft drinks. That way, you can spin your alcohol quota out for longer.
It'll stop you getting dehydrated too and lessen the chance of having a hangover in
the morning.

Don't drink every day


The human liver is an incredible (and vital!) organ. Not only does it deal with all kinds
of poisons for us, including alcohol, it can also repair itself. Drinking alcohol causes
changes in some liver cells and kills off others. But you have to give it a chance. Give
yourself a 'liver detox' by making sure you have at least two alcohol free days every
week. If you drink over twice the recommended unit amount in a day giving your liver
48 hours off from alcohol to recover is recommended.

Reduce the units per drink


Low alcohol drinks or more diluted alcohol such as spritzers

Reduce the available money


Take out a certain amount of money with you or set a budget when shopping or
going out

Involve people to prevent sabotage


Who can support and encourage you?

Sit down / put glass down


Standing and holding on to a glass encourages faster drinking

Change your routine or change the position you would normally be


in when you drink
A simple change like moving the chair you would normally sit in or moving to a
different chair can help you change your habits.

Set targets
Maximum number of weekly units
Times that you wont drink before or after
Identify days when you wont drink
Could you add any more?

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39

What advice should I give to a person who has


complex needs or is dependent on alcohol?
Many of those who are mildly dependent may benefit from simple discussion
about their drinking, and provision of information and advice on cutting down
or stopping (as per IBA)
Moderately or severely dependent drinkers, and those drinking despite
alcohol-related problems, are more likely to benefit from referral to a local
specialist alcohol treatment provider and the provision of information on
mutual aid groups such as AA or SMART Recovery.
High risk drinkers who do not show signs of dependency but have complex
needs such as co occurring drug use or severe vulnerabilities will also be
more likely to benefit from more specialist services.
Whilst waiting for specialist assessment, advise the person

to reduce alcohol consumption where possible but not to stop


suddenly if they drink to relieve withdrawal symptoms, as this
can be dangerous
Avoid activities where alcohol misuse may be hazardous (e.g.
caring for children, swimming, driving).
To consider involving friends and family in the treatment
process, where possible.

My referral agencies are:

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Enhance motivation
What are the pros and cons of your drinking just now?
Important elements of motivational interviewing22
Expressing empathy
Empathy as a key ingredient in successful behaviour change consultations.
Expressing empathy involves first aiming to understand your client by giving
them room to express their view, and then accurately reflecting back or
summarising what youve heard. A useful prompt for this is Nudge, listen,
summarise. A good question can invite or nudge the client into describing
their view, making space through active listening can draw this out, and by
summarising you show youve listened, can check youve understood their
view correctly, and also help the consultation move on.
Developing discrepancy
clients are helped to see the gap between the drinking and its
consequences and their own goals/values - the gap between where I
see myself, and where I want to be
enhancing their awareness of consequences, perhaps adding feedback
about medical symptoms and test results: How does this fit in?
Would you like the medical research information on this?
weighing up the pros and cons of change and of not changing
progressing the interview so that clients present their own reasons for
change.
Avoiding argument (rolling with resistance)
resistance, if it occurs (such as arguing, denial, interrupting, ignoring) is
not dealt with head-on, but accepted as understandable, or
sidestepped by shifting focus
labelling, such as I think you have an alcohol problem is unnecessary,
and can lead to counterproductive arguing.
Supporting self efficacy
encouraging the belief that change is possible
encouraging a collaborative approach (clients are the experts on how
they think and feel, and can choose from a menu of possibilities)
the client is responsible for choosing and carrying out actions towards
change.
Facilitating and reinforcing self motivating statements
recognising that alcohol has caused adverse consequences
expressing concern about effects of drinking
expressing the intention to change
being optimistic about change.
People believe what they hear themselves say
22

Miller and Rollnick, 2002

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Menu of options
What goals might work for you?
Helping the person set targets for themselves is part of the process.
Suggested drinking targets might be the safer drinking guidelines of 2-3 units
per day for women and 3-4 units per day for men with two 24 hour breaks.
However, this target needs to be realistic and important to the person you are
with.
Here are some questions that can be used in goal setting techniques:
1. Identify the smart goal
2. What makes this goal important to you?
3. What single daily action do you need to put in place?
4. What will be your reward?
5. What is a realistic first step you could take?
6. Where and when will your goal happen?

7. Who will you be when you achieve this goal?

Build confidence
What might help?
The scaling question in the Brief Lifestyle Counselling tool will help you
explore this with your client.
Helping your client find support and getting them to make a realistic plan for
themselves will help build their confidence that they can make changes
Here are some suggested questions that can be used to explore
confidence:

What would make you more confident about making these changes?

How can I help you succeed?

Is there anything you found helpful in any previous attempts to change?

If you were to decide to change what might your options be? Are there
any ways you know about that have worked for other people?

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Coping strategies
How can you prepare for and avoid difficult times and
situations?

Your options:
Go through the NHS simple advice leaflet
Go through the Brief Lifestyle Intervention tool
Use parts of or all of the Brief Lifestyle Intervention tool to enhance motivation:
Ask the pros and cons question
Ask the scaling questions on importance and confidence
Check the support available to your client
Find out what targets you client wants to aim for
Develop a plan of action with your client
Decide on a follow up

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43

Practice the Brief Lifestyle InterventionTool


using motivational techniques
There are 3 roles: CLIENT, PROFESSIONAL and OBSERVER.
The goal is for the PROFESSIONAL to find out how the CLIENT views their drinking,
drawing out any concerns and offering brief advice where appropriate. The words
NUDGE, LISTEN, SUMMARISE offer a useful guide; and the following questions,
and the SIPS Brief Lifestyle Intervention tool are useful starting points.
In groups of three, 5 minutes for the exercise & 5 minutes for feedback.
You are likely to be able to repeat this at least once.
Assume the professional has already engaged the client, carried out AUDIT
and a score indicating increasing risk or higher risk has been fed back. The
client has agreed to at least consider the possibility of changing their drinking
behaviour.
Perhaps start with: So far, we have agreed that you may be drinking in ways
that are unsafe for your health....
Typical drinking day
Would you describe for me a typical drinking day?
This is a useful reflection question. You are looking for when they drink, what they
drink, who with, what time etc.
Have you any concerns about your drinking? Is there anything you are
unhappy with?
This is an opportunity for information exchange so you can provide some information
for them and answer any concerns they have
Scaling Questions great for assessing readiness for change
One way to gauge the clients state of mind is a scaling question. In answering
these, the client usually thinks aloud e.g. On a scale of 1-10, how important is it
to you to be cutting down your drinking? . Professional pauses & listens to
client response.
Also: on a scale of 1-10, how confident do you feel about making a change?
Pros and cons
When they talk about the cons of reducing their alcohol use dont argue with them;
just let them say all their fears or concerns about reducing their use.
When asking about the good things about cutting down encourage them and prompt
them with: What else?

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Follow up
We recommend at least stating, I will make a note of it and ask you next time
we meet. You may agree to something more formal.
OBSERVER RECORD
Please tick if skill achieved (they do not need to be achieved in this order!).

Client reflected on drinking


Information exchange between client and professional
Importance scaling question e.g. on a scale of 1-10, how important
is

Confidence scaling question e.g. on a scale of 1-10, how confident are


you that

Explore with client what are the benefits of cutting down?


Check what the client feels
Client happy to go on to making a plan
Follow up arrangements; monitor progress; review.

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Step 5
Exit strategy
Remember you or the client can choose not to continue at any
point.
Close the conversation: It is fine if you dont want to discuss
this now. I will leave this leaflet with you.
Signpost or refer

Will they come back?


Have you left it open for them to come back?

The client may choose not to continue at any point


This is not about pushing and nagging people but offering them the
choice
This is one step in the journey

Have you referred or signposted?

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46

How will you be putting alcohol IBA


into practice?
When might you offer screening and brief advice?

How will you record this?


Consider confidentiality and data protection policies

Who will you get supervision and support from?


Managers briefing available for you to take away

Where might you get more leaflets/tools?

Where might you signpost people to for more help?


Develop a menu of options:
Harbour Drug and Alcohol Services
Harbour provide drug and alcohol treatment services across Plymouth, for
adults and young people living in Plymouth or with a Plymouth GP.
Services include brief interventions (1-3 sessions); extended brief
interventions (3-6 sessions); and longer term psycho-social interventions
which are care planned, reviewed regularly and may include community or
inpatient alcohol detox.
ASP (Alcohol Service for Parents) is rapid response service working
with parents with alcohol related problems and works closely with Young
Carers, Hidden Harm workers DV services and Childrens Social Care.
Access to ASP is via the main Harbour phone line.
Hamoaze House offers support, counselling and security for you and your
family. If you are struggling with problematic alcohol or drug use and want
help to change your life, to leave the chaos behind, we can help you. This
is your opportunity for change. We can offer a safe, calm place to help
you to rebuild your life with new skills and coping mechanisms. We offer
support, counselling and security for you and your family.
Broadreach House is an innovative and dynamic registered charity,
offering treatment and support services for men and women whose lives
have been adversely affected by addiction.

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47

Alcoholics Anonymous in Plymouth. The only requirement for membership


is a desire to stop drinking. For help and support please call 0845 769
7555.
Tel: 01752 566100 www.hamoazehouse.org.uk
Tel: 01752 434343 www.harbour.org.uk
Tel: 01752 566245 www.broadreach-house.org.uk
Local GP
Self-help books e.g. Lets Drink to Your Health, Heather & Robertson
Self-help controlled drinking programme at www.downyourdrink.org.uk
Helplines (see useful resources)

Next steps

Useful resources
NHS choices
www.nhs.uk/livewell/alcohol/Pages/Alcoholhome.aspx
Drinkaware
Unit wheel calculators, drink diaries and unit cup measurers are available from
their resource department; you can receive 85 worth of resources free when
you register with them. This organisation is funded by the drinks industry.
www.drinkaware.co.uk
Down your drink
This is a website designed to use evidence based interventions online. It gives
people the information they need to make careful choices about the role
alcohol plays in their life.
www.downyourdrink.org.uk
PHE Alcohol Learning Resources
This is a Public Health England resource which provides online resources and
learning for those working to reduce alcohol-related harm.
www.alcohollearningcentre.org.uk
It includes a free e-learning training course on alcohol Identification
and Brief Advice, accredited by the RCGP.
www.alcohollearningcentre.org.uk/elearning/IBA/
Alcohol concern
Provide a series of factsheets on alcohol and related issues. Have a library of
information available.
www.alcoholconcern.org.uk
Motivational Interviewing website

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48

A useful site for practitioners who want to find out more about motivational
interviewing.
www.motivationalinterview.org

National helplines
Drinkline - 0800 917 8282
Alcoholics Anonymous - 0845 769 7555
www.alcoholics-anonymous.org.uk
Families Anonymous - 0845 120 0660
www.famanon.org.uk
Al-Anon Family Groups - 0207 403 0888
www.al-anonuk.org.uk
National Association for the Children of Alcoholics - 0800 358 3456
www.nacoa.org.uk

Further Recommended Reading


1) Stephen Rollnick, Pip Mason and Chris Butler (1999), Health Behaviour
Change a guide for practitioners, Churchill Livingstone. This is the key text
in this field.
2) Stephen Rollnick, William Miller and Chris Butler (2008), Motivational
Interviewing in Healthcare, Guildford Press.
3) Stephen Rollnick and William Miller (2013), Motivational Interviewing,
Helping People Change, Guildford Press.

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