What are the best practices for using MI to help clients with co-occurring disorders?
Co-occurring disorders, also known as dual diagnosis, refer to the presence of both a mental health and a substance use disorder in a person. This can pose many challenges for treatment, as both conditions need to be addressed simultaneously and effectively. Motivational interviewing (MI) is a client-centered, collaborative, and goal-oriented approach that can help clients with co-occurring disorders overcome ambivalence, enhance motivation, and make positive changes. In this article, we will discuss some of the best practices for using MI to help clients with co-occurring disorders.
One of the key principles of MI is to express empathy and respect for the client's perspective, without judging, confronting, or imposing solutions. This can help build rapport, trust, and engagement, as well as elicit the client's own reasons and values for change. To understand the client's perspective, you can use open-ended questions, reflective listening, affirmations, and summaries. For example, you can ask the client how they feel about their situation, what they want to achieve, what they see as the benefits and costs of their substance use and mental health symptoms, and what they are willing or ready to do.
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Mark H.
Counsellor, M.Couns., ACA Level 4| Member of the Supervision College
I think in order to have that empathy, open mindedness is the key, and for the clinician to do their own work on themselves, to be able to provide an authentically safe and grounded presence. Stepping out of the ‘expert’ role is also really important and viewing the client as the expert into their own experience. This can open it up to greater possibilities when we are not viewing things through the lens of our personal biases.
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George Nolan
Chief Disruptor Refine2Inspire/Trainer
Working with those who are incarcerated, autonomy is unknown and learned helplessness is the popular mindset. Allowing this population to discover their own strengths and ideas through MI is a wonderful way to watch "the light come on" inside individuals. I am so grateful to be a part of this process.
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Laurie Pham Swaringen, LCSW
HCA Service Chief I, Outpatient Mental Health Access Point Clinic-Santa Ana
Working with any vulnerable population, a non judgmental approach and establishing trust in the relationship is cliché yet often times a crucial component that is missed. Navigating through the stages of change with the person is effective when the focus is on empathy for the person's perceived situation and not rushing into getting the person to see their situation as problematic and therfore needing to change. The person has to trust the relationship to be safe...so the therapist can then proceed with open-ended style MI in order to elicit more genuine responses from the person.
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Dr. Joey (The Traveling Social Workers)™ Pagano, DSW, LSW, CRS, FPS, Life Coach
LinkedIn Top Voice 👐 | Transform Mental Health: From Challenge to Path 🧠 | Celebrated 2 X #1 Best-Seller & Pulitzer Contender 📚 | Renowned Addiction Intervention Expert 🛠️ | Pioneer in SUD Education 🌱
🌟 Recently, I worked with a client battling addiction and depression. Using MI, we focused on empathy, reframing their narrative from self-doubt to self-empowerment. 🔄🗣️ This approach helped them recognize their own ability to change, leading to significant progress in therapy. It's about finding that spark of hope and fanning it into a flame! 🔥
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May Edwards MBACP (Accred)
Integrative Therapist
I have had the opportunity to work with individuals in the early stages of their recovery journey, encompassing precontemplation, contemplation, preparation, and action. When it comes to assessing the needs of those who are utilizing harm reduction strategies, it is crucial to consider a holistic approach. It is not solely about their willingness or confidence, but also their ability and realistic beliefs. Various factors can influence a person's readiness, and there are diverse ways in which readiness can be achieved. As a clinician, our most valuable asset is our professional knowledge and understanding, which serves as a powerful tool in guiding and supporting our clients.
Another important aspect of MI is to assess and enhance the client's readiness for change, which can vary depending on the stage of change they are in. The stages of change are precontemplation, contemplation, preparation, action, and maintenance. Depending on the stage, you can use different MI strategies to help the client move forward. For example, if the client is in precontemplation, you can use the FRAMES technique, which stands for feedback, responsibility, advice, menu of options, empathy, and self-efficacy. If the client is in contemplation, you can use the decisional balance technique, which involves exploring the pros and cons of changing and not changing. If the client is in preparation or action, you can use the SMART goals technique, which involves setting specific, measurable, attainable, relevant, and time-bound goals.
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Mark H.
Counsellor, M.Couns., ACA Level 4| Member of the Supervision College
I think it’s really important to unpack where the client is at and meet them there. Something else to consider is that a client may be desiring change, but something like unresolved trauma can be holding them back, because trauma is something from the past that we experience in the present. MI is great in that it is easy to incorporate other therapies based on the clients needs, so we don’t have to feel tied to one approach. Ultimately, everyone wants to feel better, but may not have found the way to do that yet, or in the case of addiction, a way that will promote overall well-being rather than having the shame that can be tied to the use of substances or other unwanted/unhealthy behaviours.
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Catherine Raymond
Clinical Therapist and Wellness Expert
In terms of working with clients with co occurring disorders, it’s important to recognize that their readiness to change may fluctuate due to the multitude of contributing factors. It’s important to stay attuned to fluctuations of emotional states, which, in turn, influence readiness to change. Leading with compassion can help enhance the therapeutic relationship, thereby,moving the client along the stages of change. Self compassion enhances client efficacy and helps the them feel empowered.
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Lisa Cypers Kamen
Championing Equitable and Hospitable Healthcare for Better Patient Outcomes
Unconditional Positive Regard. Creation of connection allows the vital two-way channel of vulnerability where truths and solutions can be communicated. Demonstrating to the client that you respect and accept them regardless of what they do or don’t do. Think about the value of feeling seen, heard, and understood. It is medicine and the secret sauce to helping others.
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Michael Fuller
AOD Counselor II at Father Joe's Villages
In my particular population, I have worked with clients in the pre-recovery stages; a combination of precontemplation, contemplation, preparation, and action. How do you assess needs for those utilizing harm reduction stradegies? Balancing decisions need to be based not just on willingness or confidence, but also on ability, and realistic belief. There are many things that may play a part in a persons readiness, but there are also, different forms of how readiness may be attained. This is a clinicians most powerful tool, the tool of professional knowledge and understanding.
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Cristina Menegon
Gerente financeiro na ML Serviços BPO
Utilizar a entrevista motivacional no cliente é funcional e trará resultados a partir do momento que ele esteja disposto e aberto a modificaçoes. Caso contrário o trabalho será desperdicado
A common challenge for clients with co-occurring disorders is ambivalence, which means having mixed or conflicting feelings about changing. Ambivalence can lead to resistance, procrastination, or relapse. To address ambivalence, you can use the MI technique of evoking change talk, which is any statement that indicates the client's desire, ability, reason, or need for change. Change talk can increase the client's motivation and commitment to change. To elicit change talk, you can use the OARS technique, which stands for open-ended questions, affirmations, reflections, and summaries. You can also use the scaling questions technique, which involves asking the client to rate their importance and confidence for change on a scale of 0 to 10.
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Liz Smithson
Length of Service-Unknown
If I ever use MI again, I really want to focus on the motivation part. My question to the individual should be “why are you not these…” Not “so you are… Let’s get motivated.” The client should acknowledge an accurate diagnosis momentarily. Acknowledgment of one’s diagnosis does not promote recovery. acknowledgment, cripples, motivation. Acknowledgment, signals defeat. And agreeable client does not signal a recovering client. A client who is willing to tell me why they are not their diagnosis signals in motivated client. Our clients need to know that we hear their voice. our clients need to be able to tell us we are wrong. Not everyone who is treated for SUDS is truly a substance abuser who is labeled a failure for future moderate use.
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Lourdes Carson
Activity Therapist with a deep commitment to enhancing lives through personalized & engaging wellness programs. Specializing in the art of life transformation. My mission is to foster joy & positivity in every session.
One thing i have found helpful is: Explore Ambivalence: Co-occurring disorders often involve ambivalence about change. Use MI techniques to explore the client’s conflicting feelings and motivations related to both disorders. Understanding their readiness to change.
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Michael Fuller
AOD Counselor II at Father Joe's Villages
Participant ambivalence has since been referred to as a counselor issue of not being able to fully connect with a participant. Now, this may be half or so true. But the reality is, anyone that does not see eye to eye in terms of goals and personal motivations, will experience ambivalence. If I want my participant to stop harmful drug using behavior, but that is not really a first and foremost issue on their mind, well than what is an issue? How can I engage them within their own self-interests?
Another core principle of MI is to collaborate with the client, rather than direct or persuade them. This means that you respect the client's autonomy and choice, and work with them as a partner, rather than an expert or authority. This can help reduce resistance, increase engagement, and foster a sense of empowerment and self-determination. To collaborate with the client, you can use the MI technique of developing a discrepancy, which involves highlighting the gap between the client's current situation and their desired goals or values. You can also use the MI technique of rolling with resistance, which involves acknowledging and validating the client's concerns or objections, rather than arguing or correcting them.
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Megan Romano, M.S., LMFT
Trauma-Informed Licensed Marriage, Family and Child Therapist
Everything starts with a relationship. If you cannot build a rapport with a client, it doesn’t matter what else comes next. Really understanding what they are facing is key, and the only way to do that is by regulating and recognizing your own parameters.
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Michael Fuller
AOD Counselor II at Father Joe's Villages
When I think of interview between an interviewer and an interviewee, I don’t naturally take all the nuance that goes into both presenters participation. Much like a news interview, or celebrity interview, With MI , A counselor and participant both need to work collaboratively in effort to best utilize MI to it’s fullest. MI is not just a tool for the counselor, and not just a ‘do it all yourself’ method for the participant. It is a method in which both participant, and counselor equally, explore concepts of motivation.
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Cristina Menegon
Gerente financeiro na ML Serviços BPO
Conforme explanei anteriormente é necessário parceria e disposição por parte do cliente para uma adequação, implantação e melhor aproveitamento da entrevista motivacional com ferramenta.
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Alexa Vella, NBC-HWC, BCNC, CHN, CTRS, CDP
Integrative Health Coach
Fostering autonomy for clients is a crucial responsibility as a coach. It's important to allow the client to set the agenda, perhaps even more so when dealing with co-occurring disorders. I find great joy in moments when clients express thoughts or ideas I might have considered, without any direct prompting from me. Holding space and asking powerful questions allows them to reach their own conclusions. It is incredibly rewarding to create a harmonious alignment without any sense of imposition. This goes beyond building rapport, an important aspect of MI. I often consider myself as an accountability partner, guiding each client to discover the wealth of ideas and solutions within themselves.
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Christine James
Owner at Garden Path Counseling
While collaboration is a core principle of MI, I have witnessed poorly executed MI technique that ends of feeling like a schmoozey sales pitch for what the therapist thinks the client should be doing, vs. actually being collaborative and getting to the core of the client's values and why they may or may not want to make a change. As the therapist, keeping your own motives and values in awareness so that does not happen is key.
The final principle of MI is to support the client's change, by reinforcing their strengths, resources, and achievements. This can help boost the client's confidence, optimism, and self-efficacy, as well as prevent or cope with setbacks. To support the client's change, you can use the MI technique of affirming, which involves expressing appreciation, recognition, or encouragement for the client's efforts or progress. You can also use the MI technique of planning, which involves helping the client identify and implement specific and realistic steps to achieve their goals, as well as anticipate and overcome potential barriers or challenges.
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Michael Fuller
AOD Counselor II at Father Joe's Villages
Supporting a clients change builds upon strengths that the client already had, but has now chosen to fully evolve. This is strength based motivation! This emphasizes that the participant always had these skills, and now with the fully equipped skills being utilized, the participant gains such motivation by having this affirmed!
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Alexa Vella, NBC-HWC, BCNC, CHN, CTRS, CDP
Integrative Health Coach
Supporting client change in MI is crucial for fostering intrinsic motivation, reducing resistance, empowering clients, promoting sustainable change, strengthening the therapeutic alliance, and respecting the autonomy of individuals undergoing the change process. Confidence and self-efficacy serve as powerful catalysts for motivation, both playing pivotal roles in the cultivation and sustenance of healthy habits. It is incredibly rewarding to witness lasting behavior and lifestyle change in my clients.
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Diego Kiçula
CLO | General Counsel | DPO | Lecturer
Principalmente em processos de mudanças profundas que impactem na cultura e procedimentos da empresa, é necessário acompanhar o cliente suportando-o durante todo o processo.
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Aleksander Savija
Business Broker/ Aftersales Exports
What you learn is repeated several times in order to understand what results from it. At the moment you can't handle an AI like you would a Lego kit to present what has been built. Let's discuss deeper insights into the world of psyche, conversation and action. Only then can we determine the first characteristics. What do you think?
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