Presenter: Bronwyn Jones, Tutor, Social Services, Weltec

1. Brief Motivational Interventions Engaging the Double Troubled Presenter: Bronwyn Jones, Tutor, Social Services, Weltec

2. 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

3. What does the term mean? • Dual diagnosisis a medicalised term & focuses on the diagnosis • Co-morbidityfocuses on the “morbid” process & diagnosis • Co-existing disordersfocuses on the disorder • Co-existing mental health & substance misuse problemswordy but correct • Co-existing problemspreferred name no allegiance to medical or social methods of treatment - allows clinicians to focus on working with the client to alleviate these problems

4. 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 drugdisorder

5. 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

6. Adaption of traditional models Development of new approaches Concept of dual diagnosis = late1980s focus on substance use among clients with severe mental illness inthe 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 Be Nice!

7. The Flow of Motivational Interviewing Spirit Autonomy Collaboration Evocation Express Empathy Develop Discrepancy Roll with resistance Support Self-Efficacy Principles Open ended questions Affirm Reflection Summary Micro Skills Change Talk Commitment Talk Desire Ability Reason Need Confidence I will… BehaviourChange

8. Stages of Change Model Around since 1979 Prochaska & DeClemente

9. 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 nota 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?

10. 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)

11. BRIEF INTERVENTION • How it works • The phase-by-phase interventions from "denial" to "abstinence" or harm minimisation begin by assessing the client's readinessto engage & contemplate change • Readiness levels are accepted as starting points for treatment, rather than points of confrontation or criteria for elimination Ambivalence

12. 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?

13. 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

14. The Brief Negotiation Interview4 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

15. The Brief Negotiation Interview4 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

16. A Brief Intervention… • Introducing the issue in the context of the client's health • Screening, evaluating, & assessing • Providing feedback • ‘Change Talk’ Talking about change & setting goals • 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

17. 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?" Agreement with a twist

18. 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?"

19. 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

20. Resources & Bibliography Aalto M.; Pekuri P., Seppä, K. (2001).Primary health care nurses' and physicians' attitudes, 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: • the New Zealand mental health survey : final report. Prepared for ALAC. Auckland: Auckland • 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