7.7 Treatment

In the past, treatment for people with severe mental illness and substance use problems tended to concentrate on the limits and impairments associated with mental health problems, while overlooking the strengths that people can often harness to achieve their personal goals. We have found that treatment is more effective when it focuses on identifying people's personal goals and abilities, and the personal and community resources and opportunities available to help them achieve their goals.

Motivational approaches to treatment

Motivational approaches can be more effective than conventional methods of working with people with concurrent disorders. Motivational approaches are also useful in encouraging people to identify their goals, and in building hope and commitment to change and recovery.

Some people enter therapy determined to change and are ready to talk about their reasons for wanting to change. However, many people are not motivated to change. There are many justifiable reasons for this:

• Some people may not even acknowledge that they have problems.
• People with concurrent disorders are more likely than others to have had previous unsuccessful attempts to change.
• The interaction of their substance use and mental health problems may have made it harder to follow treatment plans.
• They are more likely than other clients to feel discouraged about the prospects of improving their situation.
• They may also feel that substance use gives them relief from other symptoms and from their distress.

Being ambivalent (being of two minds) about a particular behaviour is normal. How people balance the costs and benefits of a behaviour affects whether they'll continue or change the behaviour.

Motivational approaches use the client's perspective on his or her mental health and substance use problems as the starting point for treatment. It requires that therapists get in touch with how the client sees things. This approach often opens a pathway to working on practical issues of concern to the client. This can include issues of health and safety—for example, finding housing—even when the client isn't ready to change behaviours that may actually contribute to the problem. Acknowledging the client's perception and lifestyle doesn't necessarily mean that the therapist agrees with that perception. The long-term objective is to help the client set goals and recognize that his or her current lifestyle interferes with achieving these goals. However, in the short-term, the family—or others, such as an employer—may not understand why the client and the therapist are not working directly on the substance use and mental health problems.

Click the link below to print/view the following PDF:

• Activity 7-1: Exploring ambivalence about change (PDF)

Motivation and substance use goals

When people have concurrent disorders, abstinence is often the best long-term substance use goal. Continued use of alcohol and/or other drugs may worsen emotional and mental health problems and threaten a person's overall physical and psychological well-being. However, many people may, at least at first, lack the confidence and skills to decrease or stop their substance use. So, when clinicians work with someone who is struggling with both major substance use and mental health problems, the short-term goal is often to reduce the most harmful effects of substance use while developing a strong working alliance with the client. This trusting relationship can help clients understand the negative effects of their substance use and develop the motivation to address it. This approach—not requiring the person to commit to abstinence as a condition for help—is called harm reduction.

Stages of change

Changes in behaviour occur over a series of stages (Pruchaska et al., 1992). Recognizing what stage a particular a client is at can help clinicians decide which interventions are more likely to be successful at a particular point in treatment and recovery.

The stages of change model outlines five basic stages:

• precontemplation
• contemplation
• preparation
• action
• maintenance.

Some people move steadily through the stages toward recovery. Others move rapidly and then slow down or stop for a while. People often relapse (return to problematic behaviours), move backward through the stages and then move forward again.

Table 7-1: Stages of change

Stages of treatment

The stages of change model describes the process of behavioural change. Treatment strategies should be adapted to a person's motivation to change. Researchers have developed a complementary step-wise model of stages of treatment. The model describes four major stages:

• engagement
• persuasion
• active treatment
• relapse prevention.

Table 7-2: Stages of treatment

Click the link below to print/view the following PDF:

• Activity 7-2: The family concurrent disorders (PDF)