Brief Motivational Interventions
Engaging the Double Troubled
Presenter: Bronwyn Jones, Tutor, Social Services, Weltec
Introduction
• How prevalent co-existing disorders?
• Barriers to change
• Adapting the traditional & developing new
approaches
• Motivational Interviewing process & the
Stage of Change Model
• Development of brief Interventions
• Sample Models of Brief Intervention
• Sample Socratic questions
What does the term mean?
• Dual diagnosis is a medicalised term & focuses on the diagnosis
• Co-morbidity focuses on the “morbid” process & diagnosis
• Co-existing disorders focuses on the disorder
• Co-existing mental health & substance misuse problems wordy
but correct
• Co-existing problems preferred name no allegiance to medical or
social methods of treatment - allows clinicians to focus on
working with the client to alleviate these problems
It is estimated that 75% of those entering an alcohol
& other drug service are likely to have a diagnosable
mental health disorder
Co-existing psychiatric & addiction
disorders is the rule
not the exception
It is estimated that 95% of those entering a
psychiatric facility are likely to have a diagnosable
alcohol & other drug disorder
Barriers
The historical, artificial separation of specialist
treatment for addiction & mental health problems
resulted in the placement of clients in either one
system or the other (often in neither)
Treatment that looks only at either substance
abuse or mental illness will leave a client
vulnerable to relapse due to the untreated
disorder
 Factors related to attitudes & knowledge were a barrier
to the adoption of integrated interventions
Adaption of traditional models
Development of new approaches
Concept of dual diagnosis = late 1980s focus on substance use
among clients with severe mental illness in the community
It became apparent that new approaches were needed
Working with dual disorder clients who deny substance abuse,
who are unmotivated for substance abuse treatment & who are
unable to tolerate intense confrontation, required a new model,
a non-confrontational approach to the engagement &
treatment of this special population
The Flow of Motivational Interviewing
Spirit
Express Empathy
Develop Discrepancy
Roll with resistance
Support Self-Efficacy
Autonomy
Collaboration
Evocation
Principles
Micro Skills
Desire
Change Talk
Ability
Reason
Need
Confidence
Open ended questions
Affirm
Reflection
Summary
Commitment Talk
Behaviour Change
I will…
Stages of Change Model
Around since
1979
Prochaska & DeClemente
DEFINITIONS:
Brief interventions
• Brief interventions are “practices that aim to investigate
a potential problem & motivate a client to begin to do
something about his/her substance abuse, either by
natural, client-directed means or by seeking additional
substance abuse treatment
• A brief intervention is not a substitute for
individuals Brief interventions are “practices that
aim to investigate a potential with
addiction/mental health disorder but can be used
to engage clients to seek further help.
Status Quo or Change?
Skills Training before Eliciting
Commitment to change
•
•
•
•
Because of variety of cognitive neurobiological social
deficits particularly executive functioning in clients - adapt
the traditional models to
Brief sessions
Slower question pace
Pauses for questions
Some argue that client’s serious mental disorders cannot
sustain intentional behaviour (following through with
commitment) before they have the skills to do so
Suggestion that skill training with client’s can enhance
goal attainment = before any commitment to not using is
reached
Bellack & Di Climente (1999)
BRIEF INTERVENTION
How it works
• The phase-by-phase interventions from
"denial" to "abstinence" or harm
minimisation begin by assessing the
client's readiness to engage &
contemplate change
Readiness levels are accepted as
starting points for treatment, rather
than points of confrontation or
criteria for elimination
Brief Intervention-Principles
• The objective in the engagement phase - develop
comfortable & trusting relationships
• Information about aetiology & processes of illness
in an empathic & educational manner
• The interaction effects between symptoms of
mental illness & substance disorders, included in
this exploration
Clients are not required to disclose personal
experiences or to admit they use or abuse
substances until they are comfortable doing so
•
Can I get through this?
A BI Model
‘FRAMES’
Feedback is given to the individual about
personal risk or impairment
Responsibility for change is placed on the client
Advice to change is given by the provider
Menu of alternative self-help or treatment
options is offered to the client
Empathic style is used in counselling
Self-efficacy or optimistic empowerment is
engendered in the client
Source: Miller & Sanchez, 1993
The Brief Negotiation Interview
4 MAJOR STEPS
1) Raise The Subject
• Establish rapport
• Raise the subject of alcohol/other drug use
2) Provide Feedback
• Review client’s drink/drug amounts & patterns
• Make connection between drink/drug & amount of
hospital, or doctor’s visit, or trouble with mental
health (if applicable)
• Compare client’s level of drink/drug with national
norms
The Brief Negotiation Interview
4 MAJOR STEPS cont……..
3) Enhance Motivation
• Assess readiness to change
• Develop discrepancy between patient’s drink/drug
& problems or potential problems related to
alcohol/drugs
4) Negotiate & Advise
• Negotiate goal
• Give advice
• Summarise & complete drink/drug agreement
A Brief Intervention…
1. Introducing the issue in the context of the client's
health
2. Screening, evaluating, & assessing
3. Providing feedback
4. ‘Change Talk’ Talking about change & setting
goals
5. Summarising & reaching closure
 Providers may not use all five of these components in every
session- reflect the needs of the client.
 Must be good reason to eliminate steps in the brief
intervention process
Socratic Enquiry: Introducing the Issue
• Would you be willing to talk to me briefly about how
alcohol/drug fits into your life? Whatever we talk about will
remain confidential."
• Or, "This must be tough for you. Would it be OK with you if
we take a few minutes to talk about your drug/drinking?"
• "Would it be OK with you if we discuss some of the
difficulties you may have because of your drinking/drug use
meetings
• May be we can work together to help you take
advantage of getting the balance back in your
life through a supportive treatment process?"
Exaggeration Question
• ‘Would you have drunk 6 bottles of whisky (or
50 joints) this week?’
• “Because of your drinking did you stop taking
your medication for ten days?”
Sampling Sobriety
• “a 2-week trial when you don't drink alcohol at all
would be helpful in determining whether or not
drinking makes things worse and if stopping use
works for you. What do you think?"
Summary
• Clear evidence high incidence of co-existing disorders
• Recent focus on co-existing disorders generated the need for new
approaches to engage and treat client’s
• Considering the limitations of mental illnesses i.e. the variety of
cognitive neurobiological social deficits -Teaching skills prior to
commitment to change considered valuable
• Frames model and Brief motivational methods can elicit client
motivation and change in co-existing clients
• Understanding attitudes and empathic approaches of enquiry
• With adequate training, brief intervention can be delivered in both the
addiction & mental health care settings
Resources & Bibliography
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knowledge and beliefs regarding brief intervention for heavy drinkers; Addiction, Vol
96, N0. 2, Feb. 2001 , pp. 305-311(7): Carfax Publishing.
Adamson S. J, Todd, F.C., Sellman, J.D, Huriwai, T, Porter, J. (2006). Co-existing psychiatric
disorders in a New Zealand Outpatient Alcohol and other drug clinical population
Australian and New Zealand Journal of Psychiatry; 40:164-170.
Lock, C. A. Kaner, Lamont, E., Bond, S. A qualitative study of nurses' attitudes and practices
regarding brief alcohol intervention in primary health care Research Associate, School of
Health Sciences, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
Miller, W.R. & Rollnick, ,S. (2002). Motivational Interviewing: Preparing people for change (2nd Ed.)
New York: Guilford Press.
Saunders, B., & Herrington, J. (1995). Exploring options: Motivational counselling and addiction
behaviour. Perth: William Montgomery, Pty., Ltd.
Sciacca, K. 1997. Removing barriers: dual diagnosis and motivational interviewing.
Professional Counsellor 12(1): 41-6.
Sobell, L.C. Toneatto, T. & Sobell, M.B. (1994). Behavioural assessment and treatment planning
for alcohol, tobacco, and other drug problems: Current status with an emphasis on clinical applications.
Behaviour Therapy, 25, 33-0.
Wells, E., Baxter, J., & Schaaf, D. (2006, November). Substance use disorders in Te Rau Hinengaro:
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Uni-services Ltd.
Vellman, Richard & Baker 2008 Moving away from medicalised & partisan terminology: a contribution
to the debate, Mental Health and Substance Use: Dual Diagnosis, 1:1 2-9