Phase 2 - Motivational Interviewing

Excerpted from Structured Relapse Prevention: An Outpatient Counselling Approach.

Recent research has examined the application of Motivational Interviewing tools and techniques to people with concurrent disorders (Martino et al., 2002; Graeber et al., 2003; Steinberg et al., 2004). (See references.) Particularly noteworthy are the adaptations to Motivational Interviewing for people with severe mental illness suggested by Martino and his colleagues (2002). Referred to as Dual Diagnosis Motivational Interviewing, or DDMI, this modified approach is designed to respond to cognitive impairments and disordered thinking. (“Dual diagnosis” is a term commonly used in the United States for concurrent disorders.) The table below presents an overview of the standard practices of Motivational Interviewing alongside the recommended DDMI modifications.

With clients who have concurrent disorders, therapists should expect to work at a slower pace, focusing on engagement and encouragement. Clients may be at the precontemplative stage for a long time (e.g., two years).With this client population, the quality of the relationship between the client and the therapist is crucial, as it can help to motivate change.

Standard Motivational Interviewing Practices and Dual Diagnosis Adaptations
Standard MI Practices	DDMI Modifications
Targets substance use.	Targets concurrent substance use and mental health issues (e.g., substance use, medication compliance, barriers to treatment).
Presumes clients are cognitively intact and logically organized.	Uses repetition, simple and direct verbal and visual materials and breaks within sessions. Therapist guides conversation to promote logical organization and improved reality testing. Group sessions meet for only 60 to 90 minutes.
Uses open-ended questions.	Avoids compound open-ended questions; poses queries in clear and concise terms.
Uses reflective listening.	Reflects in clear and concise terms; reduces use of reflections on disturbing life experiences; uses metaphors to anchor concepts in reality; provides plenty of time for clients to respond to reflective statements.
Uses statements of affirmation (strengths, change efforts and accomplishments).	Places heightened emphasis on affirmations.
Provides personalized feedback from objective substance use–related assessment results.	Contrasts client and therapist ratings of severity (developing discrepancy). Uses images, simple rating scales, analogies and metaphors.
Uses 2 x 2 decisional balance matrix to weigh the costs and benefits of changing substance use, and the costs and benefits of staying the same.	Uses simple decisional balance to explore client ambivalence about getting CD treatment, taking psychiatric medication and changing substance use. Focuses only on the costs and benefits of behaviour change.
Adapted from Martino et al. (2002), p. 301.

Because SRP incorporates a Motivational Interviewing style throughout all treatment phases, the guidelines in the right-hand column above should be kept in mind throughout the CD-adapted SRP treatment.

NOTE: For a more detailed discussion of the application of Motivational Interviewing techniques and principles with clients with concurrent disorders, see the article “Dual Diagnosis Motivational Interviewing,” by Martino et al. (2002), in Appendix B.

Description

Clinical Tools

The client receives feedback on assessment findings, with a focus on exploring the client’s: reasons for change in alcohol or other drug use pros and cons of change strength of commitment to change coping strengths triggers for use (exploration of IDTS-8 profile, if undifferentiated. Clients must reach an explicit decision. In other words, they must state their definite intent to try to work toward change in alcohol and/or other drug use before proceeding to SRP counselling.

Client’s completed Assessment Summary Form—CD Adapted Client’s completed IDTS-8 Feedback about Goal Setting and Commitment to Change—CD Adapted Personalized Alcohol Use Feedback Online Tool (optional) Decisional Balance Assignment—CD Adapted

NOTE: Tools that have been altered for clients with concurrent disorders are labelled “CD Adapted.” Tools that do not have adapted versions can be found in Part II of this manual.

Return to the index of excerpts from Structured Relapse Prevention: An Outpatient Counselling Approach.

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