SBIRT (screening, brief intervention and referral)

1. Introduction

Version followed: the SAMHSA service model as set out in TAP 33 (2013) for the overall S-BI-BT-RT continuum; the WHO ASSIST-linked brief intervention (Humeniuk et al., WHO 2010) as the main brief-intervention procedure for alcohol and drugs; the Brief Negotiated Interview (BNI; D'Onofrio, Bernstein, Bernstein and Rollnick, as taught in US SBIRT curricula) as the alternative BI script; the NIAAA clinician's guide Helping Patients Who Drink Too Much (2005) for alcohol-specific limits, assessment and follow-up; the WHO AUDIT manual (Babor et al., 2001) for alcohol risk zones; and the AAP clinical report (Levy & Williams, 2016) for adolescents. Where these differ, the version is named inline.

SBIRT is a public-health service model, not a single therapy: a standard way of finding people whose alcohol or drug use puts them at risk (screening), responding in proportion to that risk (no action, brief advice, brief intervention, brief treatment), and connecting the small high-risk group to specialist care (referral to treatment). It was designed for non-specialist settings (primary care, emergency departments, schools) and staff such as nurses, social workers and health educators, but it transfers directly to a psychotherapy intake and caseload. [source: TAP 33]

Core idea of change: most people who drink or use drugs riskily are not dependent and never reach specialist services; a short, personalised, non-judgemental conversation that feeds back their own screening result, links it to harms they care about, leaves the choice with them, and elicits their own reasons and plan can tip ambivalence toward cutting down. Brief intervention is built on motivational interviewing (Miller & Rollnick) and the FRAMES elements (Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy). Those with likely dependence need more than a brief conversation, so the same conversation is used to motivate them toward assessment and treatment. [source: TAP 33; WHO ASSIST-linked BI manual]

2. Framework

SBIRT is a stepped-care pathway. Each person enters at screening and is routed by risk level; they can move up or down levels as their use changes, and screening is repeated over time. [source: TAP 33; AUDIT manual]

Phase 0: Set up universal screening

Goal: screen everyone, not only those who "look" like they have a problem, as a routine part of intake. [source: TAP 33]
Format: decide who administers (self-report on paper or tablet, or interview), where results are recorded, which tools you use, your referral list and who does follow-up. [source: TAP 33; Iowa SBIRT Module 4]
For a psychotherapist [synthesis]: build a prescreen into every intake form and re-screen at least annually and when presentation changes; keep a current, checked list of local specialist services, withdrawal management, mutual-help groups and harm-reduction services.

Phase 1: Prescreen (about 1 minute)

Goal: rule out the majority with no risky use quickly.
Options: the NIAAA single heavy-drinking-days question (any day in the past year with 5+ drinks for men or 4+ for women); AUDIT-C (the three AUDIT consumption items); a single-question drug prescreen; the NIDA drug-use screening tool. [source: TAP 33; NIAAA 2005]
Move on when: any prescreen is positive → full screen.

Phase 2: Full screen and risk stratification (5–10 minutes)

Goal: estimate risk level (not diagnosis or severity); decide the response. [source: TAP 33]
Tools: AUDIT (alcohol), ASSIST (alcohol, tobacco and other drug classes), DAST-10 (drugs other than alcohol and tobacco), S2BI / CRAFFT (adolescents). [source: TAP 33; AAP 2016]

Risk cut-offs as the tool authors publish them

Tool	Lower / no risk	Moderate	High / likely dependence
AUDIT (WHO 2001)	Zone I 0–7: alcohol education	Zone II 8–15: simple advice; Zone III 16–19: simple advice + brief counselling + monitoring	Zone IV 20–40: referral for diagnostic evaluation and treatment
ASSIST v3.0 (WHO 2010)	Alcohol 0–10; other substances 0–3	Alcohol 11–26; others 4–26: brief intervention	27+: brief intervention aimed at assessment and specialist treatment
DAST-10 (Skinner 1982)	0: none; 1–2: low, monitor and reassess	3–5: further investigation	6–8 substantial, 9–10 severe: intensive assessment
NIAAA 2005	No heavy days and within limits	1+ heavy drinking day, or AUDIT 8+ men / 4+ women, without AUD: at-risk pathway	Meets AUD criteria: AUD pathway
S2BI (adolescents)	Never: positive reinforcement; once or twice: brief advice	Monthly: brief motivational intervention, consider referral	Weekly or more: BI focused on referral

[source: AUDIT manual Box 6; ASSIST manual; DAST-10 scoring sheet; NIAAA 2005; AAP 2016 via S2BI sheet]

AUDIT cut-off adjustments (WHO 2001): 8 is the standard threshold; 10 raises specificity; 7 for women and for men over 65. Score 2+ on the dependence items (4–6) or 4 on the harm items (9–10) → give the next higher level of intervention regardless of total. [source: AUDIT manual]
ASSIST exception: a currently abstinent person scoring only because of past (not past-3-month) answers is congratulated and given feedback, usually without a full BI. [source: ASSIST manual]
Any injecting in the past 3 months triggers additional steps (see 4.15); injecting more than about 4 times a month suggests dependence needing specialist assessment. [source: ASSIST manuals]

Phase 3: Respond by level

Level	Response	Dose
No / low risk	Positive reinforcement or alcohol education; feedback if time allows	Under 1–2 minutes
Moderate	Brief intervention (BI) at the screening site	1–5 sessions, about 5 minutes to 1 hour; ASSIST BI 3–5 min (steps 1–5) or 10–15 min (steps 1–10); BNI 5–15 min
Moderate–high	Brief treatment (BT), onsite or by referral	Typically 6–20 structured sessions (e.g. CBT, motivational enhancement, solution-focused)
High / dependent	BI used to motivate referral; referral to treatment (RT) with active hand-off	At least 15 min for the motivating conversation; then specialist care

[source: TAP 33; ASSIST-linked BI manual; Vermont/SAMHSA brief interviewing guide]

Multiple contacts are more effective than a single contact (TAP 33), so plan a return visit or follow-up call even for moderate risk.
In AUDIT stepped care, a person who does not respond to one level moves to the next. [source: AUDIT manual]

Phase 4: Follow-up and rescreening

At follow-up: goal met → reinforce and renegotiate; goal not met → explore barriers, renegotiate, consider a trial of abstinence, and if still unable to change, reassess for a use disorder. [source: NIAAA 2005]
After referral: confirm attendance, ask about the experience, keep in contact with the provider under a signed release. [source: TAP 33; Iowa Module 4]
Rescreen at least annually; re-administering the AUDIT can be used as an outcome measure. [source: NIAAA 2005; AUDIT manual]

3. Guiding principles

[source for this section: TAP 33; ASSIST-linked BI manual; NIAAA 2005; Iowa SBIRT Modules 3–4; AAP 2016, unless marked]

Universal, routine screening. Screen everyone as standard intake; it removes the sense of being singled out.
Screening is not diagnosis. A score sets the level of response; diagnosis and severity need further assessment.
Proportionate, stepped response. Match intensity to risk and step up when a lower step fails.
Brevity by design. Keep the BI short and focused on one behaviour; do not let it turn into a full assessment.
Ask permission. Ask before discussing use, before giving feedback, and before giving advice or information; accept a "no" gracefully and leave the door open.
Personalised, objective feedback. Use the client's own scores and consequences, stated neutrally, not general warnings.
Responsibility stays with the client. Say explicitly that what they do with the information is their choice; this lowers resistance.
Clear advice, without judgement. State that cutting down or stopping lowers risk; avoid directive phrasing such as "you really need to".
Empathy and no labels. Avoid terms like "alcoholic" or "addict" and avoid confrontation.
Evoke rather than install. Draw out the client's own concerns, reasons and plans (change talk) rather than arguing for change; arguing invites the client to argue against it.
Ambivalence is normal. Treat "good things" about use as legitimate and explore them first.
Menu, not prescription. Offer several options and let the client choose; negotiate goals rather than set them.
Self-efficacy. Build the client's belief they can change, ideally from their own statements and past successes.
Seamless continuum. Screening, BI, BT and RT should hand on to each other without gaps; a referral is "warm", active and followed up.
Chronic-condition stance. Lapses and relapse are expected; return to the plan rather than dismiss the client.
Confidentiality, with stated limits. Explain who sees results; for adolescents, see them alone and explain the safety limits up front. [source: AAP 2016; Illinois AAP deck]
Abstinence where use is unsafe at any level. Pregnancy, contraindicated medications, conditions worsened by alcohol, and an alcohol use disorder → recommend abstinence. [source: NIAAA 2005]
Harm reduction for those still using. For injecting or high-risk use, give safer-use and testing information alongside change work. [source: ASSIST-linked BI manual]
Training and fidelity. Staff delivering SBIRT need training and fidelity monitoring. [source: TAP 33]

4. Intervention inventory

Instruments are named and scored here but their items are not reproduced; use the official free versions from WHO, NIDA, NIAAA, the AAP/Boston Children's or the copyright holder. Example language is illustrative wording unless shown in quotation marks with a source.

4.1 Introducing screening and raising the subject

Purpose / when: at intake or any session where screening is due; gets consent and frames the questions as routine. [source: AUDIT manual; Iowa Module 3; BNI]
Steps:
1. Start with general conversation and rapport.
2. Say why you ask (routine for everyone; use affects health, mood, sleep, medications and therapy), that honest answers help, and how results are kept confidential.
3. Ask permission to talk about alcohol and other drugs.
4. If declined: accept it, say it is their choice, state briefly that you ask because of health risks, and say you are open to talking later.
Example language (illustrative): "I ask everyone I work with a few questions about alcohol and other drugs, because they can affect sleep, mood and how therapy goes. Would that be OK?" If declined: "That's completely your call. If it ever feels relevant, I'm happy to talk about it."
Watch for: defensiveness when the request sounds targeted; reduce it by stressing that everyone is asked.

4.2 Prescreening

Purpose / when: every client, at intake and at least annually. [source: TAP 33; NIAAA 2005]
Steps:
1. Alcohol: ask whether they sometimes drink; if yes, ask the NIAAA heavy-drinking-days question (past-year days with 5+ drinks for men, 4+ for women; NIAAA allows 4+ for everyone for sensitivity) or give the AUDIT-C.
2. Drugs: ask a single question about past-year use of illegal drugs or prescription medicines for non-medical reasons (or the NIDA tool).
3. Any positive answer → full screen (4.3).
Example language (illustrative): "In the past year, how many times have you had [4 / 5] or more drinks in a day?"
Watch for: under-reporting when drink sizes are vague; show a standard-drink chart.

4.3 Full screening with a validated instrument

Purpose / when: positive prescreen, or as a single combined step if time allows. [source: TAP 33; AUDIT manual; ASSIST manual]
Steps:
1. Choose the tool: AUDIT (alcohol, 10 items, past year), ASSIST (all substance classes, 8 questions, lifetime and past 3 months, scored per substance), DAST-10 (drugs other than alcohol and tobacco, past 12 months), S2BI or CRAFFT for ages 12–17/21.
2. Choose the mode. Self-report is faster and may give more honest answers but needs literacy. Interview allows clarification and immediate feedback; read questions as written and in order. [source: AUDIT manual]
3. Calibrate drinks. The AUDIT assumes a standard drink of about 10 g of ethanol; national definitions differ (e.g. 14 g in the USA). Adjust to local drink sizes. [source: AUDIT manual]
4. Use the skip rules for interview or electronic versions (not paper).
5. Score per the manual and record the score (for the ASSIST, on the front of the feedback report card for each substance).
Example language: "Now I am going to ask you some questions about your use of alcoholic beverages during the past year." [source: AUDIT manual, quoted]
Watch for: a score is a risk estimate, not a diagnosis; for a person with a history of dependence, use clinical judgement over the cut-off. [source: AUDIT manual; TAP 33]

4.4 Risk stratification and item-level flags

Purpose / when: immediately after scoring, to choose the response (see tables in Section 2).
Steps:
1. Place the client in a zone for each substance; act on the highest.
2. Check item flags: AUDIT dependence items 4–6 at 2+ or harm items 9–10 at 4 → move up a level; AUDIT items 2–3 at 1+ → hazardous consumption; harm items answered "yes, but not in the past year" → discuss vigilance. [source: AUDIT manual]
3. ASSIST: any injecting in the past 3 months → add the injecting steps (4.15). [source: ASSIST manuals]
4. Adolescents: overlay acute-risk screening (suicidal or homicidal ideation, injecting, withdrawal, mixing sedatives, heavy binge drinking, driving after use) before routine tiering. [source: AAP 2016]
Watch for: suicidal ideation or intoxication during the session; these take priority over the SBIRT script [synthesis].

4.5 Positive reinforcement and alcohol education (no or low risk)

Purpose / when: AUDIT zone I, ASSIST lower risk, S2BI "never". [source: AUDIT manual; ASSIST manual; AAP 2016]
Steps: give the result briefly; affirm the healthy choice; for adults, give low-risk limits; for younger adolescents add a normative statement that most peers do not use, so screening does not imply use is expected. [source: AAP 2016]
Example language (illustrative): "Your answers put you in the lowest-risk group. Whatever you're doing to keep it that way is working."
Watch for: abstinent people in recovery: congratulate and keep vigilance in view. [source: ASSIST manual]

4.6 Simple / brief advice

Purpose / when: AUDIT zone II; NIAAA at-risk drinking; S2BI "once or twice" (advice to abstain). About 5 minutes. [source: AUDIT manual; NIAAA 2005; AAP 2016]
Steps (NIAAA "Advise and Assist", at-risk pathway):
1. State your conclusion clearly and link it to their health or concerns.
2. Recommend cutting down to within limits (or quitting where abstinence is indicated, 4.13).
3. Gauge readiness: are they willing to consider a change?
4. If ready: set a goal, agree a plan, give written material (4.11). If not ready: go to 4.12 (stage-matched responses).
Example language: "You are drinking more than is medically safe." and "I strongly recommend that you cut down (or quit)." [source: NIAAA 2005, quoted]. A softer therapy-room alternative (illustrative): "Based on these answers, my advice would be to bring this down to within the low-risk limits. What do you make of that?"
Limits named in the sources: NIAAA 2005: men up to 65 no more than 4 drinks on any day and 14 a week; women and anyone over 65 no more than 3 a day and 7 a week. WHO AUDIT manual: no more than 20 g a day on 5 days a week. [source: NIAAA 2005; AUDIT manual] [uncertain] national guidelines have been revised in several countries since these documents; use your country's current guidance.
Watch for: advice that sounds like a lecture; keep it to one or two sentences and return to the client's view.

4.7 ASSIST-linked brief intervention (10 steps, FRAMES)

Purpose / when: ASSIST moderate risk for any substance; the core of the BI for high risk too. Steps 1–5 take about 3–5 minutes; all 10 steps about 10–15 minutes. [source: ASSIST-linked BI manual]
Steps:
1. Ask whether they would like to see their results. "Are you interested in seeing how you scored on the questionnaire you just completed?" [quoted, WHO]
2. Feedback: read each substance score and its risk level from the report card; describe the harms listed for the main substance objectively.
3. Advice: say that cutting down or stopping lowers the risk of harm, without judgemental phrasing.
4. Responsibility: "What you do with this information is up to you." [quoted, WHO]
5. Concern about scores: "How concerned are you by your score for [drug]?" [quoted, WHO]
6. Good things: ask what they like about using.
7. Less good things: ask about downsides; prompt by domain (health, relationships, legal, money, work or study, spiritual) if needed.
8. Summarise and reflect both sides, ending on the less good things.
9. Concern about less good things: "Do the less good things concern you? How?" [quoted, WHO]
10. Take-home materials: report card, substance information, self-help booklet, and the injecting card if relevant (4.11).
FRAMES mapping: Feedback (step 2), Responsibility (4), Advice (3), Menu of options (in longer sessions, 4.14), Empathy (throughout), Self-efficacy (elicit the client's own confidence statements). [source: ASSIST-linked BI manual]
Example language for steps 6–8 (illustrative): "What do you get out of using cannabis?" ... "And what's the less good side for you?" ... "So it helps you switch off after work and you enjoy it with friends, and at the same time you've noticed you're more anxious the next day and money's tight. Have I got that right?"
Watch for: working signs are the client voicing concern, asking questions, or naming a change; if they reject the feedback, go back to good and less good things rather than repeat the warning.

4.8 Brief Negotiated Interview (BNI)

Purpose / when: alternative semi-structured BI (5–15 minutes), developed for emergency departments (Project ED Health, D'Onofrio, Pantalon et al.) and widely used in US SBIRT training. Use it when you prefer a readiness-ruler-centred script. [source: BNI handout; Vermont/SAMHSA guide; Iowa Module 3]
Steps (four-step version):
1. Raise the subject / build rapport: ask permission; explore good and not-so-good things about use; summarise both sides (decisional balance, 4.9).
2. Provide feedback: ask permission; review the screen; link use to any known consequence; show the low-risk guidelines; ask for their reaction. Where the visit has a reason (an injury, a panic attack, a sleep complaint), ask what connection they see between it and their use; if they see none, offer the factual link.
3. Enhance motivation / build readiness: readiness ruler (4.10); reflect; ask "What's the next step?" [quoted, BNI handout]
4. Negotiate and advise: negotiate a goal; advise; summarise; give a written change plan or "drinking agreement" (an agreement with themselves, client keeps a copy); suggest follow-up; thank them.
Example language (illustrative): "Help me understand, through your eyes, what you like about drinking." (the phrase "Help me understand through your eyes" is from the Vermont/SAMHSA guide) ... "What are some steps that would work for you?"
Watch for: versions differ: some curricula put pros and cons before feedback (Iowa, Vermont), others put feedback first (Project ED Health handout). Either order is acceptable [uncertain: no single authoritative manual].

4.9 Decisional balance ("good things and less good things")

Purpose / when: inside any BI, for ambivalent clients; also when feedback is rejected. [source: ASSIST-linked BI manual; Iowa Module 3]
Steps:
1. Ask about the good things first (shows you understand why they use).
2. Ask about the less good things; prompt by life domain.
3. Use a double-sided reflection, ending on the less good things.
4. Ask how concerned they are about the less good things.
5. For longer sessions, a written grid (costs and benefits of changing and of staying the same, short and long term) can be completed together. [source: ASSIST-linked BI manual]
Example language (illustrative): "On one hand, drinking helps you relax and fit in; on the other, you've missed two Monday mornings this month and your partner is worried."
Watch for: accept every answer without arguing; do not "correct" the good things.

4.10 Readiness, importance and confidence rulers

Purpose / when: to gauge and build readiness inside a BI. [source: Iowa Module 3; ASSIST-linked BI manual; BNI handout]
Steps:
1. Ask permission to talk about change.
2. Ask for a rating on a 1–10 line (BNI/Iowa use readiness; the WHO manual uses separate importance and confidence rulers).
3. Affirm whatever number is given.
4. Ask why it is not lower; this draws out their reasons for change.
5. Optionally ask what would move it up (WHO version: "What would it take for you to go from a 3 to a 6?"). The Iowa curriculum advises against asking why it is not higher, because that elicits barriers. [uncertain: sources differ; if you ask about moving higher, frame it as "what would help", not "why not".]
6. Very low ratings (1–2): do not push; go to 4.12 (precontemplation response).
Example language (illustrative): "You said 4. Why a 4 and not a 1 or 2?"
Watch for: reasons given in the client's own words (desire, ability, reasons, need) are the change talk to reflect and summarise. [source: Iowa Module 3]

4.11 Take-home materials

Purpose / when: end of every BI; also the low-pressure option for someone who declines discussion. [source: ASSIST-linked BI manual; BNI handout; Iowa Module 3]
Steps:
1. Give the client's own result (the ASSIST feedback report card, or a written note of their score and risk level).
2. Give factual information on the substance(s) involved.
3. Give a self-help booklet on cutting down or stopping (WHO publishes one for the ASSIST).
4. If they injected in the past 3 months, give the risks-of-injecting card (4.15).
5. Give a copy of any written change plan or agreement (4.14).
6. Explain each item neutrally and only hand out what you have discussed.
Example language: (illustrative, modelled on the neutral framing the WHO manual recommends) "Some people find this booklet handy if they're weighing up whether to cut down."
Watch for: leaflets handed over without discussion add little; check whether they have questions.

4.12 Stage-matched responses (including "not ready")

Purpose / when: after you have gauged readiness (4.6 step 3 or 4.10). [source: ASSIST-linked BI manual; NIAAA 2005; Iowa Module 3]
Steps by stage:
- Precontemplation (most screen-positive people; ruler 1–2): give risk information and gentle, non-directive questions; do not push; restate that the choice is theirs; express continued concern; plan to revisit.
- Contemplation (ambivalent): the full 10-step BI or BNI; rulers; decisional balance.
- Preparation: help set a date and choose strategies.
- Action: negotiate goals, offer the menu (4.14), identify high-risk situations, make a plan.
- Maintenance: affirm progress; plan for high-risk situations and small lapses.
- Relapse: treat as expected and a learning point; review the plan; return to the earlier stage's work.
NIAAA "not ready" steps: acknowledge ambivalence is common and that the advice may already be shifting their thinking; invite them to reflect on what they like about use versus reasons to cut down and on barriers; reaffirm willingness to help when ready; reassess at future visits.
Example language (illustrative): "It sounds like now isn't the time to change this, and that's your decision. I'll still be here if that shifts. Would it be OK if I checked in about it in a few weeks?"
Watch for: pushing a precontemplative client generates counter-argument; success at this stage is that the topic stays open.

4.13 Advising abstinence when it is indicated

Purpose / when: when any level of use is unsafe. [source: NIAAA 2005]
Steps:
1. Check for: pregnancy or possible pregnancy; a medicine that interacts with alcohol; a medical or psychiatric condition caused or worsened by drinking; an alcohol use disorder.
2. If present, advise abstinence rather than limits, giving the specific reason.
3. For heavy drinkers without a disorder, consider recommending abstinence if there is a family history of alcohol problems, older age, drinking-related injury, or sleep or sexual problems.
4. If the client cannot keep to moderation goals, suggest a time-limited trial of abstinence.
Example language (illustrative): "With the medication you're on and how much the drinking is feeding your low mood, the safest advice I can give is a break from alcohol altogether. How would a trial month sound?"
Watch for: in a psychotherapy caseload, depression, anxiety, insomnia and psychotropic medication make this pathway common [synthesis]. If the client may be physically dependent on alcohol or sedatives, see 5.9 before advising them to stop.

4.14 Negotiating a goal and change plan (menu of options)

Purpose / when: once a client is willing to change; the "negotiate a plan" step of the BNI and the Action-stage work of the WHO manual. [source: ASSIST-linked BI manual; NIAAA 2005; Iowa Module 3; BNI handout]
Steps:
1. Ask what they are willing and able to do; negotiate a goal (within limits, cut down a specific substance, or abstain for a set period) rather than set it.
2. Ask permission, then offer a menu: a use diary or calendar; personal rules (days off, maximum per occasion); identifying high-risk situations and planning for them; alternative activities; supportive people; self-help materials.
3. Ask for specific actions and how each reduces risk; identify strengths and what has helped before.
4. Agree how progress will be tracked and when you will review.
5. Write the plan in the client's words; keep it simple and measurable; give them a copy.
6. Summarise and thank them.
Example language (illustrative): "What would be a realistic first step for you this week?" ... "Would it help if I mentioned a few things others have tried? You can see what fits."
Watch for: a plan that is really your plan; set realistic expectations and a review date.

4.15 Injecting drug use: risk discussion and harm reduction

Purpose / when: any injecting in the past 3 months. [source: ASSIST manual; ASSIST-linked BI manual]
Steps:
1. Ask about injecting frequency and practices without judgement; more than about 4 times a month on average suggests dependence needing specialist assessment.
2. Give the risks-of-injecting card and go through the risks (dependence, overdose, stimulant psychosis, infections, abscesses, vein damage, blood-borne viruses).
3. Give harm-reduction information: never share equipment; hygiene; avoid combining with alcohol or sedatives; do not use alone; know first aid; where to get sterile equipment and dispose of it safely.
4. Recommend testing for HIV and hepatitis B and C and refer to a testing service.
5. Plan at least 15 minutes and include the BI.
Example language (illustrative): "Whatever you decide about using, I'd like you to be as safe as possible. Can we go through a few things that lower the risks?"
Watch for: opioid users: the adolescent guidance also lists keeping naloxone available and using fentanyl test strips (Illinois AAP deck); applying these to adults is [synthesis] in line with local harm-reduction services.

4.16 Core MI skills inside the BI (OARS and change talk)

Purpose / when: throughout any BI, BT or referral conversation. [source: ASSIST-linked BI manual; Iowa Module 3]
Steps:
- Open questions that invite elaboration.
- Affirmations of strengths, efforts and honesty.
- Reflections of meaning and feeling, not just words, to highlight ambivalence.
- Summaries that collect concerns and change talk.
- Eliciting change talk: listen for and reflect statements of Desire, Ability, Reasons and Need.
- Rolling with resistance: reflect or reframe rather than oppose; do not argue for change.
Example language (illustrative): "I appreciate you being so open about this." ... "Part of you wants a break from it, and part of you wonders who you'd be at parties without it."
Watch for: for a trained psychotherapist, the main risk is drifting into a long exploratory session; keep the BI focused on one behaviour [synthesis].

4.17 Assessing for a use disorder after a positive screen

Purpose / when: NIAAA Step 2, after a positive alcohol screen; also when the client cannot meet goals. [source: NIAAA 2005]
Steps:
1. Ask about the past 12 months across the diagnostic criteria (role failure, hazardous use, legal and relationship problems; tolerance, withdrawal, loss of control, using more or longer than intended, giving up activities, time spent, continued use despite problems).
2. No disorder → at-risk pathway (4.6, 4.14). Disorder present → AUD pathway (4.18, 4.20).
Version note: the 2005 guide uses DSM-IV abuse and dependence criteria; current practice uses DSM-5 or ICD-11 criteria for substance use disorder [synthesis: apply the current criteria set you are trained in].
Example language (illustrative): "To get a fuller picture, I'd like to ask a few more questions about the past year. Have you found you need more to get the same effect?"
Watch for: this is assessment, not intervention; keep it non-judgemental and return to feedback.

4.18 Brief intervention for high-risk or dependent clients (motivating toward treatment)

Purpose / when: ASSIST 27+, AUDIT zone IV, DAST-10 6+, S2BI weekly, or a diagnosed disorder. [source: ASSIST-linked BI manual; NIAAA 2005; AAP 2016]
Steps:
1. Deliver the full BI (4.7 or 4.8), allowing at least 15 minutes.
2. State your conclusion and recommendation. NIAAA 2005 models a direct statement that the person has an alcohol use disorder, followed by a strong recommendation to stop drinking (paraphrased); therapists may soften the delivery but keep the recommendation clear.
3. Negotiate a goal: abstinence is safest for most; some with milder disorders who refuse abstinence may succeed by cutting down.
4. Encourage hope about treatment and explain what treatment involves.
5. Discuss past attempts to cut down (ASSIST question 7).
6. Explore underlying issues (pain, mental health, relationships, work, housing).
7. Recommend further assessment and specialist care (4.20); suggest mutual-help groups; for possible physical dependence, recommend medical assessment for managed withdrawal; mention that medication options exist for alcohol use disorder (NIAAA names disulfiram, naltrexone and acamprosate) to be discussed with a prescriber.
8. Arrange physical health checks through the client's doctor.
Example language (illustrative): "From what you've told me, this has moved beyond something you can manage on your own, and specialist help works for many people. Can I tell you what that might look like?"
Watch for: denial is common in severe disorders; use MI to encourage acceptance and stay engaged rather than discharge. [source: AAP 2016]

4.19 Brief treatment (BT)

Purpose / when: moderate-to-high risk, or people who did not respond to BI, who do not need or will not accept specialist treatment. [source: TAP 33]
What the source specifies: a specialty outpatient modality ("brief intensive intervention"), typically 6–20 structured, evidence-based sessions such as solution-focused therapy, cognitive-behavioural therapy or motivational enhancement; a systematic sequence of assessment, engagement, then change strategies; targets both current use and longer-standing problems; delivered onsite or through an outside programme. TAP 33 does not prescribe session content. [source: TAP 33]
Steps (suggested structure for a psychotherapist) [synthesis]:
1. Sessions 1–2: full substance and mental-health assessment; personalised feedback; agree goals.
2. Sessions 2–4: motivational enhancement (rulers, decisional balance, values); write the change plan.
3. Middle sessions: CBT skills such as tracking use, identifying triggers and high-risk situations, coping and refusal skills, alternative activities, addressing co-occurring anxiety, low mood or sleep problems.
4. Final sessions: lapse and relapse planning; review with rescreening; decide on step-down, follow-up or referral.
Example language (illustrative): "We've agreed on about eight sessions focused on your drinking. Let's start by mapping when it happens and what it does for you."
Watch for: if use is not reducing after a fair trial, or dependence features emerge, step up to referral (4.20). TAP 33 notes clinicians trained in long-term approaches may resist structured brief methods.

4.20 Referral to treatment and warm handoff

Purpose / when: high-risk or dependent clients, adolescents with weekly or more use, and those not responding to BI or BT; in primary care about 5% of those screened. [source: Iowa Module 4; TAP 33; AAP 2016]
Steps:
1. Confirm readiness and interest; use MI for ambivalence about treatment; do not rush someone who is not ready.
2. Present the referral as you would any specialist referral; tone and importance matter.
3. Choose the service with the client using a checklist: insurance or funding and prior authorisation; sliding fees; language and cultural fit; family services; accessibility and transport; whether it updates referrers; whether it provides discharge planning. Start with the least restrictive level of care that is enough. [source: Iowa Module 4; Illinois AAP deck]
4. Make the contact actively, ideally phoning together with the client present (speakerphone) and booking the first appointment before they leave. "The warmer the handoff, the better the outcome." [quoted, Iowa Module 4]
5. Complete paperwork and a signed release of information.
6. Help with practical barriers (transport, childcare, timing).
7. Agree how you and the provider will communicate and set a follow-up date with the client.
Example language (illustrative): "Would it be OK if we called them together now, so you can hear what they say?"
Watch for: working signs are a booked appointment and the client knowing exactly when and where; more than one referral is often needed. Use national treatment locators (e.g. SAMHSA's locator in the US) to keep the list current. [source: Iowa Module 4; NIAAA 2005]

4.21 Follow-up after a brief intervention

Purpose / when: at the next session or a scheduled review. [source: NIAAA 2005; ASSIST-linked BI manual; AAP 2016]
Steps:
1. Ask about use since last time and check against the plan (diary review if used).
2. Goal met: reinforce and support; discuss the benefits they have noticed; renegotiate goals if needed.
3. Goal not met: acknowledge that change is hard; explore barriers; renegotiate goal and plan; consider a trial of abstinence; if still unable to change, reassess for a use disorder (4.17) and consider BT or referral.
4. Involve significant others where appropriate (4.24).
5. Document use and goals at every contact; rescreen at least annually.
Example language (illustrative): "Last time you planned two alcohol-free days a week. How has that gone?"
Watch for: for adolescents with monthly use, the AAP suggests a follow-up after a few weeks of attempted change to see whether risk has fallen, stayed the same or escalated.

4.22 Follow-up after referral and ongoing monitoring

Purpose / when: after any referral. [source: TAP 33; Iowa Module 4; NIAAA 2005]
Steps: confirm attendance; ask about the experience and any concerns; obtain updates from the provider under the release (consider another service if none arrive); coordinate care; if the client declined referral, keep offering it and keep alcohol- or drug-focused visits going, since repeated focused visits can still bring improvement; track referrals systematically.
Example language (illustrative): "How did the first appointment go? What was it like for you?"
Watch for: drop-out after the first appointment; see 5.7.

4.23 Adolescent SBIRT

Purpose / when: clients aged about 12–21. [source: AAP 2016 via S2BI sheet; Illinois AAP deck]
Steps:
1. Set the confidentiality policy with teen and parent at the start, including its limits (safety; billing where relevant); remind the teen periodically.
2. See the teen alone for part of every visit.
3. Screen with a validated tool (S2BI, BSTAD, CRAFFT 2.1+N, or the NIAAA youth alcohol screen); ask about nicotine broadly, including vapes and pouches.
4. Check acute-risk features first: suicidal or homicidal ideation, injecting, withdrawal, mixing sedatives, frequent or heavy binge drinking, driving after use.
5. Respond by frequency tier: never → praise (plus a normative statement for younger teens); once or twice → clear advice to stop with brief health reasons and praise for strengths; monthly → brief motivational intervention, close follow-up, consider referral and whether confidentiality must be broken; weekly or more → referral for specialist evaluation, check for co-occurring mental-health problems, involve parents in planning, use MI to encourage acceptance.
6. If acute risk is present: use the BI to get a commitment to stop, and generally involve parents in a safety plan.
7. Before breaking confidentiality: explain to the teen why, what will be shared, who will share it and how it will help; acknowledge strengths; ask how they would prefer it to be shared.
Example language (illustrative): "Thanks for being honest with me. Because mixing those pills can be really dangerous, I need to bring your parents in on a safety plan. How would you like us to do that?"
Watch for: minors' consent rights for substance-use treatment vary by jurisdiction; check local law. [source: Illinois AAP deck; synthesis]

4.24 Involving significant others

Purpose / when: at follow-up or referral, when the client agrees. [source: NIAAA 2005 (brief mention only); AAP 2016 for parents]
Steps [synthesis beyond the source mention]: ask the client whether someone close could support the plan; with consent, invite them to a session to hear the plan and agree how they can help (e.g. alcohol-free activities, not offering drinks); give family-support group information.
Example language (illustrative): "Is there someone who'd be on your side with this? Would you like them to come to a session?"
Watch for: coercive or controlling partners; family involvement should support autonomy, not police it.

5. Handling problems

Sourced guidance is tagged; everything tagged [synthesis] is my own clinical guidance consistent with the SBIRT and MI sources, not taken from them.

5.1 Client declines screening or the conversation

Accept the refusal, say it is their choice, state your concern briefly, and leave the door open. [source: Iowa Module 3; ASSIST-linked BI manual]
Offer the take-home materials as a low-pressure alternative. [source: ASSIST-linked BI manual]
Re-offer at a later session, framed again as routine. [synthesis]

5.2 Minimising, under-reporting or denial

Clients may underestimate risk or be unwilling to admit dependence; objective data (medical examination, blood tests such as liver enzymes, obtained through their doctor) can help feedback. [source: AUDIT manual; ASSIST-linked BI manual]
Use a standard-drink chart and ask about typical and heaviest days to reduce vague reporting. [synthesis]
Do not argue about labels or numbers; reflect the discrepancy and ask what they make of it. [source: ASSIST-linked BI manual on avoiding labels and argument; wording is synthesis]

5.3 Resistance and negative reactions to feedback

Treat ambivalence as normal; reflect or reframe the resistance; do not argue for change. [source: ASSIST-linked BI manual]
If feedback is rejected, go back to the good and less good things (decisional balance). [source: Iowa Module 3; Vermont/SAMHSA guide]
Restate responsibility: the decision is theirs. [source: ASSIST-linked BI manual]
Check your own phrasing for judgemental or directive language ("you really need to"). [source: ASSIST-linked BI manual]
Example (illustrative): "It sounds like the score doesn't fit how you see it. What would you say is closer to the truth?"

5.4 Stuck: low readiness across several contacts

Keep the topic open, keep expressing concern, plan to revisit; success at precontemplation is continued engagement. [source: Iowa Module 3; NIAAA 2005]
Shift focus to the client's own goals (sleep, mood, relationship, work) and explore how use fits them. [synthesis]
Offer harm-reduction steps they are willing to take even without a reduction goal. [synthesis; for injecting, source: ASSIST-linked BI manual]

5.5 Non-adherence: goal not met

Acknowledge that change is difficult; explore barriers; renegotiate goal and plan; consider a trial of abstinence; reassess for a disorder if change still fails. [source: NIAAA 2005]
Treat lapse as a learning point and revisit high-risk situations. [source: ASSIST-linked BI manual]
Step up in stepped care: BI → BT → referral. [source: AUDIT manual; TAP 33]

5.6 Cannot moderate

Suggest a time-limited abstinence trial; if the client still cannot keep to limits, this is evidence for a use disorder and for referral. [source: NIAAA 2005]

5.7 Declines referral or drops out of treatment

Do not rush or label the client as resistant; keep the relationship; revisit when ready. [source: Iowa Module 4]
Keep offering referral and continue substance-focused sessions; address co-occurring depression or anxiety (treat if it persists 2–4 weeks after abstinence), triggers such as stress, conflict, insomnia and pain, and suggest mutual-help groups. [source: NIAAA 2005]
Remove practical barriers (funding, waitlist, transport, language); check capacity before referring; expect that more than one referral may be needed. [source: Iowa Module 4]
After drop-out, ask without blame what did not fit and look for a different service or level of care. [synthesis]

5.8 Overwhelm, shame or distress during the BI

Slow down, reflect the feeling, affirm their honesty, and drop to the shorter steps (1–5) or stop and return to it later. [synthesis]
If distress reveals suicidal thoughts, pause SBIRT and complete a standard suicide risk assessment and safety plan; include lethal-means counselling (e.g. reducing alcohol and stockpiled medicines at home and safer storage) because intoxication raises risk. [synthesis, following current standard risk practice] The AAP report lists suicidal ideation as an acute-risk overlay for adolescents. [source: AAP 2016]

5.9 Possible physical dependence and withdrawal

For dependent clients, NIAAA advises considering medically managed withdrawal. [source: NIAAA 2005]
Advise clients who may be physically dependent on alcohol, benzodiazepines or other sedatives not to stop abruptly without medical assessment, because withdrawal from these can be medically dangerous; liaise with their doctor before setting an abstinence goal. [synthesis]
Opioid dependence: refer for assessment for medication treatment; the Iowa module notes that medications for alcohol and opioid dependence are often overlooked. [source: Iowa Module 4] No prescribing guidance is given here.

5.10 Client attends intoxicated

Do not deliver the BI; check immediate safety (how they are getting home, whether they are alone), and reschedule; note the event as clinical information to discuss later. [synthesis]

5.11 Ruptures when SBIRT is added to ongoing psychotherapy

Introducing screening into an established therapy can feel like a judgement or a change in role. Explain that you now ask everyone, ask permission, and invite the client's reaction. [synthesis]
If the client feels judged after feedback, name it, apologise for anything that came across as a lecture, and return to their perspective (MI-consistent repair). [synthesis]
Keep substance work linked to the client's own therapy goals rather than a separate agenda. [synthesis]

5.12 Adolescent confidentiality conflicts

Set the policy and its limits at the start; when you must disclose, explain why, what, who and how to the teen first, and ask their preference about how it is shared. [source: Illinois AAP deck; AAP 2016]
Behaviours that may justify disclosure include injecting, withdrawal, continued use after a drug-related emergency visit, mixing sedatives, frequent heavy binge drinking and driving while intoxicated. [source: Illinois AAP deck]

5.13 Pregnancy and medical conditions

Advise abstinence from alcohol in pregnancy or possible pregnancy, with contraindicated medications, and with conditions worsened by alcohol; coordinate with the client's medical provider. [source: NIAAA 2005]

5.14 Polysubstance use, injecting and overdose risk

Act on the highest-risk substance; add the injecting steps and blood-borne virus testing; give harm-reduction information (not using alone, not mixing with alcohol or sedatives). [source: ASSIST-linked BI manual]
Link to local harm-reduction services, including naloxone where opioids are involved. [synthesis for adults; listed for adolescents in the Illinois AAP deck]

5.15 Impaired driving and safety to others

Ask directly about driving after use; for adolescents this is an acute-risk feature that may justify involving parents. [source: AAP 2016; Illinois AAP deck]
For adults, give clear advice and plan alternatives; know your jurisdiction's rules on reporting and duty to warn. [synthesis]

5.16 Co-occurring mental-health problems

Address co-occurring psychiatric disorders and nicotine use; treat concurrently. [source: NIAAA 2005; Illinois AAP deck]
In therapy, track whether anxiety, low mood or sleep improve as use falls; use this as personalised feedback. [synthesis]

5.17 Literacy, language and culture

Use interview administration for clients with poor reading skills; use validated translations; adjust drink-size questions to local drinks. [source: AUDIT manual]
Check whether a service offers language and cultural fit before referring. [source: Iowa Module 4]

5.18 Clinician frustration and drift

Remember the condition is chronic and relapsing; frustration is a known barrier. [source: Iowa Module 4]
Use training and fidelity checks (e.g. recorded role-plays rated against the steps) to keep BIs brief and MI-consistent. [source: TAP 33 on training and fidelity; method is synthesis]

Sources

Sources: