For a patient in the Severe zone, the aim of the brief intervention is to enhance the patient’s motivation to accept a referral to treatment for an initial appointment/assessment.

Step 1 – Raise the Subject

If a patient scores in Zone 4, he/she is likely to have some “initial” awareness of consequences related to substance use as evidenced by the items marked on the DAST. 

- Explain your role; ask permission to discuss alcohol/drug use screening forms 

- Ask about alcohol/drug use patterns: “What does your alcohol/drug use look like in a typical week?”

- Ask about the patient’s concerns about substance use: “I’m interested in finding out what concerns you have about your alcohol/drug use?”

- Listen carefully and provide reflections of change talk.

Step 2 – Provide Feedback

 - Provide feedback on the AUDIT and/or DAST: “Your score on the screening form puts you in the Severe Zone. Individuals who score in that Zone are usually experiencing significant consequences related to their alcohol/drug use. They often benefit from more assessment and assistance (than I can offer).”

Review low-risk drinking limits.

- Elicit the patient’s reaction – “What do you think about that?”

- Explore connection to health/social/work issues (patient education materials): “What connection might there be...?”

Step 3 – Enhance Motivation

Provide a summary and express concern:

- “As we just talked about, your alcohol/drug use puts you in the Severe zone. I am concerned about how your alcohol/drug use may be impacting your health, and it sounds like you have some concerns too. I would like to [have you talk to our behavioral health specialist or refer you to a treatment program], to assess together what might be most helpful for you.” 

- Explore the patient’s reaction to the information; listen closely and reflect.

-  If the patient doesn’t express “significant” concerns or seem interested in a referral, explore pros/cons:

“What do you like about your alcohol/drug use? What don’t you like?” then explore readiness

“On a scale of 0-10, how ready are you to make a change in your alcohol/drug use?”

If readiness is greater than a 2: “Why that number and not a _____ (lower one)?”

-  If the patient is somewhat open to referral, use the readiness ruler: “On a scale of 0-10 how ready are you to consider seeing someone to talk more about your alcohol/drug use?” If readiness is greater than 2: “Why that number and not a _____ (lower one)?”

- Ask pros/cons of seeing someone for an assessment for treatment (ask about cons first, then pros).

Step 4 – Negotiate Plan

-  If not motivated for referral or to change substance use, stop, thank patient, offer patient education materials, negotiate follow-up visit.

- If not motivated for referral but motivated to change substance use:

• Summarize the conversation (zone, pros/cons, readiness); ask question: “What steps would you be willing to take?”

• Explore patient’s goal for change (offer options if needed); write down steps to achieve goal; assess confidence

• Negotiate follow-up visit; thank patient

 - If interested in accepting the referral:

• Explore the patient’s understanding of what “treatment” is, provide feedback to explain types of treatment and support, and most importantly that treatment takes many forms.

• Elicit reactions: “Sounds like you are open to considering getting some help. I’m wondering what you know about the different types of treatment options?”

• Use a warm handoff and plan how to get help or support: “Would it be okay if we called right now to make you an appointment?” or “Can I call in my colleague to talk to you for a few minutes?”

• If needed, assess for withdrawal risks and management.