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Article Type: Editorial From: Advances in Dual Diagnosis, Volume 6, Issue 3.
The utility of motivational interviewing in dual diagnosis
Welcome to this issue of Advances in Dual Diagnosis. I have been an editor since its inception and have seen this journal go through many changes and evolutions. I am delighted to observe that we have moved from being very UK-centric, to a publication that has an international editorial board, readership and contributing authors. This latest issue has a diverse range of papers focusing on approaches informed by Motivational Interviewing (MI) (Glassman et al. and Green et al.), facilitating multi-agency working (Anderson et al.) and good practice in prescribing (Hamilton and Pringle).
The first two papers in this issue are connected by the use of therapeutic approaches associated with MI (Miller and Rollnick, 2012). This approach emerged in the 1980s from alcohol treatment and has gained centre ground as an evidence-based therapeutic approach within addictions. However, it has utility beyond just the addictions field. The recognition that much of healthcare was now dedicated to self-management of long-term conditions (diabetes, hypertension, arthritis) and life-style-related health problems (smoking, obesity, alcohol), MI has been applied in a range of healthcare settings with some encouraging results.
What do we mean by MI?
It is a collaborative conversation style for strengthening a person's own motivation and commitment to change (Miller and Rollnick, 2012, p. 12).
MI is a collaborative approach that seeks to work with a person's own reasons and needs to change rather than impose it from the treatment service agenda. It seeks to adopt a “guiding style” which is somewhere between directive, i.e. telling people what to do and “following” which offers no guidance or focus at all. In the latest version of the Motivational Interviewing book, Miller and Rollnick (2012) promote the importance of the underlying “spirit”. This comprises of four overlapping concepts: Partnership, Acceptance, Compassion and Evocation.
Partnership – it is not something that is DONE TO but rather something that is DONE WITH. Each party brings their own expertise to the table. This also requires self-awareness and self-monitoring of our own aims and aspirations (as clinicians) and how these may be leading us to a certain focus or questioning strategy.
Acceptance – this is in terms of acceptance of what the person brings with them; but this does n’t mean that we need to accept that things are not able to change or that the situation is acceptable (i.e. in situations where someone is harmed or at risk of harming others). Acceptance has roots in person-centred approach of Carl Rogers and includes:
1. Absolute Worth: the inherent worth and potential of every human being. This is also referred to as unconditional positive regard.
2. Accurate Empathy: an active interest in and ability to see the world through the person's own eyes.
3. Autonomy Support: respecting the right of the person to decide their own direction, choices and lifestyle. The opposite is coercion and control to make someone do something. Telling someone they can’t do something usually provokes a reaction in the opposite direction and can be counter-productive for engagement.
4. Affirmation: to seek and acknowledge a person's strengths and effort.
Compassion – is the deliberate commitment to pursue the welfare and best interests of others.
Evocation – is to be able to extract through questioning the reasons, needs, desires for change from the person themselves (adapted from Miller and Rollnick, 2012).
Utility in dual diagnosis
Health and social care workers are in the business of working with change and it's a common frustration that despite (what we consider) our best efforts, that people don’t make the changes we plan for. However, clinicians are not equipped with special powers to “make” people change. In order to do our jobs well, we must ensure that we have created the optimum environment in which people feel safe to explore their options and choices without being judged or nagged. This is where the spirit of MI comes in. A true MI practitioner must be prepared to drop the trap of being “expert” and also become humble about their own limits and skills.
MI has been adapted and evaluated with people with dual diagnosis, and there is strong consensus for its use in dual diagnosis. In the UK it is recommended in the National Institute for Care Excellence (NICE) national guidance on best practice for psychosis and co-existing substance misuse (NICE, 2011). In fact, some of the earlier research into dual diagnosis incorporated the concept of a model of change (Osher and Kofoed, 1989 – Four-Stage Model) into the Integrated Treatment Approach (Drake et al., 2001) and treatment approaches utilised in stages 1 (engagement) and 2 (persuasion) rely on an using MI approach and its philosophy.
In terms of using MI in dual diagnosis of mental health and substance misuse, there have been several randomised trials of interventions using MI with people who have serious mental health problems and co-morbid substance misuse (see Cochrane Review by Cleary et al., 2008). These have varied in target groups, setting, dose and some have been MI alone, and others have been integrated with other approaches, most notably cognitive behaviour therapy. A major criticism of intervention trials is that it is often difficult to know that the intervention was in fact MI. This is very important as if a study showed a good effect, then the ingredients of the intervention should be transparent in order to allow for replication, and/or implementation into routine care. There are ways of ensuring optimum fidelity to the intervention but these are additionally burdensome to the therapists as well as the research team. Good practice would involve a treatment manual, initial training and skills assessment for the therapists, a schedule of supervision by someone with expertise in MI and some fidelity checks of sessions. These would be audio-taped and independently scored using an instrument designed to assess MI skills in practice such as the MITI. One of the other issues of MI for dual diagnosis is whether the approach is suitable for people with complex needs, who often experience cognitive impairments as a result of their drinking, psychosis and medications.
The findings of these studies so far have provided little definitive evidence that MI can have a significant impact on primary outcomes such as substance misuse or psychiatric symptoms. However a common theme to emerge is that those exposed to MI are more likely to remain engaged with services. Engagement is a really important outcome in a group who often struggle to stay in contact with treatment and we know from the National Confidential Enquiry (2013) that suicide risk is associated with treatment drop-out. It also allows opportunities to work with a whole range of other issues if someone is engaged.
Given the emphasis on choice, control and autonomy, it is often challenging for mental health workers to consider how an MI approach would work in their field. This is mainly due to some of the situations where choice and control are taken away from the service user during times of acute mental illness or vulnerability (such as use of Mental Health legislation). However this doesn’t mean that an MI approach is not compatible with mental health work. In fact the collaborative and empowering style has much in common with the Recovery movement and principles.
This issue contains two papers that describe studies that have attempted to use an MI-informed approach with people with multiple needs, dual diagnosis.
Scott Glassman and colleagues undertook a pilot study of MI with a small group of service users with dual diagnosis in the states. His aim was to see if the addition of an MI intervention could improve treatment retention and improve optimism and hope in the participants. Despite the small sample, Glassman and colleagues were able to demonstrate that this approach was acceptable to the client group and improved retention in services.
Anita Green and colleagues have undertaken a small project in a psychiatric intensive care unit in the UK where cannabis is a common co-morbidity. There is limited work focusing on interventions in PICUs and this is a useful step in understanding the nature of the issues as well as testing out some new ways of working. From identifying urine screening as a potential point of conflict, Green and colleagues decided to train the ward staff in a new way of having conversations about the urine test result. This involved teaching the staff about principles of MI (especially about being non-confrontational and being more eliciting). They found that the service users found this approach acceptable. There were also some challenges to implementing such an evaluation in a unit where by its definition, service users are quite unwell, and there is a rapid turnover. However, small projects such as this can generate useful data to work towards more robust research evaluations that have been informed from the grass roots of service provision.
One of the issues that arises over and over again in dual diagnosis discourse is the importance of collaborative and joined up working across all stakeholders in a local area. Sarah Anderson and colleagues have written about their Communities of Practice Pilot Project to enable local service representatives to come together and work on the issues related to service provision for people with complex needs. Whilst not a formal research evaluation, Anderson reports on what defines a CoP, how it has been used in the pilot sites, and what has worked well. Considerations are made for the development of such a model in the future and how to sustain joint working, especially in the current climate of economic austerity.
An issue that is often raised by clinicians, service users and carers is the safety of taking prescribed medication with illicit substances. It is often an area where people are unsure of the safety and potential for adverse effects. In order to address some of the main concerns, Ian Hamilton and Rose Pringle discuss prescribing issues in relation to psychotropic drugs and dual diagnosis. In this discussion paper they highlight some of the risks and adverse reactions as a result of illicit substance use and alcohol, as well as good practice and principals in prescribing in mental health.
Cleary, M., Hunt, G.E., Matheson, S.L., Siegfried, N. and Walter, G. (2008), “Psychosocial interventions for people with both severe mental illness and substance misuse”, Cochrane Database of Systematic Reviews, No 1, doi10.1002/14651858.CD001088.pub2
Drake, R.E., Essock, S.M., Shaner, A., Carey, K.B., Minkof, K., Kola, L., Lynde, D., Osher, F.C., Clark, R.E. and Rickards, L. (2001), “Implementing dual diagnosis services for clients with severe mental illness”, Psychiatric Services, Vol. 52, pp. 469-76
Miller, W.R. and Rollnick, S. (2012), Motivational Interviewing, Helping People Change (Applications of Motivational Interviewing), 3rd ed., Guildford Press, New York, NY, London
National Institute for Health and Clinical Excellence (2011), “Psychosis with co-existing substance misuse assessment and management in adults and young people”, National Clinical Guideline 120, available at: http://guidance.nice.org.uk/CG120/Guidance/pdf/English (accessed 9 September 2013)
Osher, F.C. and Kofoed, L.L. (1989), “Treatment of patients with psychiatric and psychoactive substance abuse disorders”, Hospital and Community Psychiatry, Vol. 40, pp. 1025-30
University of Manchester (2013), “National confidential enquiry into suicides and homicides by people with mental illness”, Annual Report, July, available at: www.bbmh.manchester.ac.uk/cmhr/centreforsuicideprevention/nci/reports/AnnualReport2013_UK.pdf (accessed 9 September 2013)