This Web site is a component of the SAMHSA Health Information Network
|
This Web site is a component of the SAMHSA Health Information Network |
 |
| | | | | | ||||||||||
 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
This Web site is a component of the SAMHSA Health Information Network. |
|
Evidence-Based Practices: Shaping Mental Health Services Toward RecoveryCo-Occurring Disorders:
|
| Pros | Cons |
| Privacy | Trouble managing his money |
| Nothing gets stolen | Isolation and loneliness |
| Control of when to sleep, eat etc. | Drinks more |
| Something that is his | Friends want to move in |
| No money for furnishings | |
| Not eligible for housing supplement |
After looking over the list, Kevin began to talk more about his use of substances and how much he has lost because of drinking. When he was taking medication, he was able to concentrate better and felt more hopeful about life. Kevin's case manager said that Kevin was presenting an interesting picture and wondered if Kevin would like feedback on his impressions, noting that the feedback could be taken or thrown out. Kevin agreed to hear the feedback. The case manager suggested that there could be a connection between Kevin's use of substances, taking medication, and his capacity to live on his own. The case manager also wondered if Kevin's desire to be in control has actually left him out of control in most areas of his life. He then asked for Kevin's reaction to the feedback. Kevin agreed he wanted control of his life and that until recently he believed he was in control.
Kevin's case manager asked him what he wanted to do next. Kevin decided to begin working on a plan that included reducing his drinking to every other day, attending a money management group once, and thinking about opening a bank account to work on saving money for housing.
After four months, Kevin was taking medication. After two more months, he decided to apply for and got into a residential treatment setting where he was able to stop substance use, take some classes, and become involved in Alcoholics Anonymous. He stayed there for two years and then transitioned into his own apartment. He had reconnected with one of his children, and was proud to be involved with her family.
WHAT IS MOTIVATIONAL INTERVIEWING?
Motivational interviewing is an approach to counseling that helps clients to enhance their motivation to reduce substance use or to become abstinent in order to reach their personal goals. These techniques can also be used to help clients to become motivated for mental health treatment, or to make other changes in their lives. This client-centered counseling approach aims to help clients who aren't yet ready to change. In the past, these clients were seen as "resistant" or "in denial" of their substance abuse or of their need for mental health treatment. Motivational interviewing, on the other hand, assumes that clinicians can help clients to increase their readiness to change behavior by helping them to focus on their own goals.
Using stage-wise integrated dual disorders treatment that includes the techniques described in this chapter results in remission of substance abuse for the majority of clients who receive the treatment. Even clients such as Kevin, who are often seen as difficult to treat because of severe symptoms, threatening behavior, or difficulties processing information, tend to respond well to this approach.
STAGE OF TREATMENT
Motivational interviewing techniques are important to use when working with clients in the engagement and persuasion stages of treatment. For example, Kevin is initially in the engagement stage for substance abuse and mental health treatment. Therefore, his counselor concentrates on developing trust and building motivation. The counselor explores Kevin's mixed feelings about his substance use and about treatment for his mental illness without passing judgment, giving advice, or being coercive in any sense. He helps Kevin to set goals and to recognize that using substances gets in the way of reaching his goals.
PRINCIPLES OF MOTIVATIONAL INTERVIEWING
Motivational interviewing uses five principles, which are listed in Table 1. Counselors should keep these principles in mind during interactions with their clients during the persuasion stage.
Table 1. Principles of Motivation Interviewing
|
EXPRESSING EMPATHY
To express empathy, the counselor begins by actively listening to the client without offering judgment, criticism, or advice. The goal is to understand fully the client's situation and perspective. This requires active listening, where the counselor uses body language to show the client he is interested. He faces the client and uses frequent eye contact. He reflects back what he hears the client say. He asks for more information and more details to clarify the client's view of the world. He does not to give advice, reframe the client's views, make interpretations, or attempt to persuade the client of anything. The goals of reflective listening are to understand the world through he client's eyes and to build trust by being a good listener and demonstrating that understanding.
Early in treatment, the client is often not interested in treatment. Pushing for change at this time only turns the client off and increases resistance to change. Thus, initially the focus is on building trust and supporting the client instead of suggesting change. In Kevin's vignette, the case manager wisely attempts to form a relationship, to listen carefully, and to assure Kevin that change is up to him.
DEVELOPING DISCREPANCY
One of the goals of motivational interviewing is to identify and amplify discrepancy between behavior and goals in the client's mind. This is done in two steps. First, the clinician helps the client to clarify what her goals are. It is critical to identify the client's goals, not the family's, the clinician's, or anyone else's. The clinician does, however, help the client to focus on goals that are feasible and healthy. Together they look carefully at steps needed to reach the goals. Second, when the topic of substance use arises, the clinician helps the client to explore the pros and cons of continued use, especially how the substance use impacts the steps she wants to take towards reaching her goals. This approach assumes that almost everyone who abuses substances is ambivalent about continuing to use. When the client lists pros and cons of substance use and considers them in depth, she will often make her own argument for changing. The clinician then highlights the discrepancy between the goal and the substance use by repeating back to the client her recognition that substance use interferes with her goals. In this process the client may make a statement about concern over her drinking or wanting to change. When this happens, the clinician reflects the statement back.
In Kevin's case, the case manager helped him with what is called a decisional balance exercise. This exercise is often useful for clients with mental illness. They can be done on simple, structured worksheets that can be used to guide the discussion. The worksheets also serve as visual prompts to focus attention.
In doing this exercise, Kevin identified the "good things" in his life as well as the "not so good" things. The clinician learned that Kevin wished to have his own home rather than live in the shelter, and that he strongly wished to reconnect with his children. He explores in the decision balance some of the steps necessary to getting housing. It might be helpful for the clinician to point out, using Kevin's own words, the discrepancy between Kevin's current behavior and his goals. The clinician should emphasize the ways in which Kevin's use of alcohol and marijuana may be preventing him from living the way he desires. In addition to discussing housing, the counselor might ask Kevin if his use of substances has affected his relationship with his children. Repairing relationships with family can be an important motivator to reduce substance use. However, take care not to overwhelm clients with early discussions of too many areas of behavior change.
Where do you start? When clinicians work with persons with dual disorders, the multitude of problems may seem overwhelming. Some clinicians prefer to focus on the area in which the client is most ready to change; others begin by targeting behaviors that pose the greatest threat to the client's well-being. In either case, remember that the client is ambivalent. Decisional balance statements should reflect that genuine ambivalence: for example, "I hear you saying that you really enjoy drinking, but that it also keeps you broke and apart from your children."
AVOIDING ARGUMENTS
Many people reject being labeled with a mental illness or addiction diagnosis. Motivational interviewing differs from other approaches to treating substance abuse in that it avoids confrontation, especially around diagnostic labels. The principle is to avoid arguments in general, with the assumption that arguments simply strengthen people's beliefs, rather than helping them change their beliefs. While making a diagnosis is necessary to help clinicians target treatment to mental illness, it may not be helpful to the client. As a general rule, the counselor emphasizes the clients' perceptions of the consequences of their behaviors rather than the clinician's model of its causes.
In motivational interviewing, whenever the clinician senses disagreement, it is time to change strategies rather than getting into an argument. The focus should be on discrepancy, or ambivalence, within the client's thinking, not on discrepancy between the client and the counselor. This is an important principle behind the success of these techniques. Most people do not want to change if they feel they have to defend themselves and that the clinician is unsupportive. The clinician working with Kevin has appropriately focused on Kevin's life context (homelessness) and behavior (drinking) rather than labeling Kevin as alcoholic or mentally ill. Also of note, Kevin's case manger did not argue with him about the judge's pronouncement; rather he offered an empathetic ear to his concerns and an acceptable way for them to meet on Kevin's own turf.
ROLLING WITH RESISTANCE
If a client doesn't want to go in a certain direction ("resistance"), it is important to let him express his opinions, or to "roll with it" instead of trying to fight it. It is helpful for the counselor to encourage the client to explore all the possible answers to his own questions and concerns. By doing this, the client becomes the source of answers, does not feel defeated in sharing his concerns, and is able to risk expressing true feelings. For example, helping Kevin to develop a pros and cons list about having his own place to live helped him think about the impact of his drinking on housing.
Clinicians also need to be ready to roll with unusual behavior, such as clients' restlessness, disorganized behavior, and inappropriate speech. The clinician can handle this behavior in a matter-of-fact way, rather than interpreting it as a sign that the client is unmotivated or too ill to participate. In Kevin's case, since he refuses to go to the mental health center, the case manager has begun meeting with him at the homeless shelter. This is a good example of "rolling with resistance." It is likely that as Kevin develops further trust in his counselor, they can explore together Kevin's concerns about going to the mental health center.
The principle of rolling with resistance is simple if one thinks back to the treatment plan. There are always several possible areas to work on, and rather than getting into a struggle, it's always better to find an area where the client is ready to do some work. For example, if the client begins to express resistance related to discussing medications or drinking, the counselor can move quickly to ask about finances, housing, family, work, or other areas of concern that the client has previously identified.
SUPPORT SELF-EFFICACY
Self-efficacy is the belief that one can succeed at change. The final principle in motivational interviewing is to support the client's self-efficacy. This is particularly critical for people who are demoralized, depressed, or hopeless. Dually diagnosed clients are often reluctant to attempt to change because they have a long history of failing to achieve their goals. The clinician demonstrates optimism and belief in the client's ability to change by interest, attitude, comments, and behavior.
Self-efficacy can be enhanced by achieving success on small, realistic goals and undermined if the client focuses on unrealistic goals. For dually diagnosed clients, a reduction in dangerous behavior or substance use may be a more realistic early goal than complete abstinence. Remember that success breeds greater self-efficacy and further success.
One strategy for increasing self-efficacy is to discuss examples of positive changes the client accomplished in the past. In Kevin's case, his former job as a heavy equipment operator seems to be a particular source of pride. The counselor may wish to raise the issue of this past success and explore a time in Kevin's life when things were going well for him as a way of rekindling optimism, self-efficacy, and remembrance of important goals.
HOMELESSNESS AND DUAL DIAGNOSIS TREATMENT
Many clients with dual disorders become homeless over the course of their lives because substance abuse consistently worsens life problems as well as mental illness. When people with mental illness use substances, they often behave in ways that cause problems with relationships, finances, housing, and self-care. They often lose their housing as a result of those problems. Many dual disorder clients therefore end up in shelters. Offering treatment for clients in these settings that includes motivational interviewing is critical to helping them to attain stable housing as well as sobriety.
RECOVERY-GETTING BACK TO LIFE
People with mental illness, substance abuse, or dual disorders are usually motivated by a desire to pursue recovery, which means attaining personally satisfying and meaningful life goals. They have often become discouraged, lost hope, and given up on their goals. The crux of motivational interviewing is to help the client to identify those goals, to break them down into realistic steps, and to figure out that managing one's illnesses is part of achieving one's goals.
People with dual disorders have the same goals as everyone else. They want to have meaningful activities, friendships, and family members in their lives. For example, most people with dual disorders are parents. Many have had problems in their role as parents, and they may have lost custody of their children, but they still strongly wish to be good parents and to have contact with their children. Similarly, most people with dual disorders, even those who are homeless and unemployed for many years, want to work. These normal wishes for normal adult roles can be strong motivators to become engaged in treatment to attain sobriety and control of mental illness symptoms. Kevin exemplifies these issues.
The treatment team can instill new hope that life will get better by providing practical and intensive supports, by helping the client recognize the costs they are incurring through their substance use, and by helping to identify small steps toward large goals. This support can help clients achieve some success and thereby to find optimism, confidence, and meaning in their lives. This is what recovery is all about.
Recommended reading
There are now many good books, treatment manuals, and articles on motivational counseling. We strongly recommend Principles of Motivational Interviewing by William Miller and Stephen Rollnick (New York, Guilford Press, 1991). It is an excellent introduction to the principles and techniques, and it offers a wealth of practical examples.
|
| Home | Contact Us | About Us | Awards | Accessibility | Privacy and Disclaimer Statement | Site Map |
