Reading H

Iarussi., M. (2020). Integrating Motivational Interviewing and Cognitive Behavior Therapy in Clinical Practice. Routledge.

Overview of the Integration

Many clients present for substance use or addiction treatment due to the influence of a third party, including being judicially mandated to treatment or referred by employers, family members, or social service agencies (e.g., child protection agencies). Consequences are typically incurred when mandated clients do not follow through with treatment, such as incarceration or other consequences related to the criminal justice system, loss of employment, child custody restrictions, and other effects on family and friend relationships. Challenges involving motivation are common among these populations, and discord can be inherently present within the therapeutic relationship given the unique combination of extrinsic forces into treatment and high stakes for the client related to treatment outcomes. Even after clients acknowledge that there is a problem with the substance use or addictive behavior, ambivalence is a common barrier to embracing change.

People often continue to have reasons why they should not change, including costs involved with change (e.g., “I can’t give up my friends; they’re my friends!” “If I’m in treatment, then I’m not working and my PO says I have to keep this job.”) and perceived inability to change or need for the substance (e.g., “I can’t fall asleep if I don’t use.” “I need to relax, and this works for me.”). Therefore, the majority of clients will present in the earlier stages of change, including precontemplation and contemplation. MI is a natural fit for this population given it was initially developed to enhance readiness to change and to address ambivalence. MI differs from CBT in that it is a process-oriented method that is not focused on teaching new skills but rather on enhancing motivation. Through MI spirit and core skills, MI counselors seek to engage clients in conversations about potential change, collaborate with clients on what changes are of focus (including negotiating the goals of third-party referral sources with the clients’ goals), evoking clients’ own personal motivations for change, and then planning for change, all while moving at the client’s pace. In addition to concerns related to motivation and discord in the therapeutic relationship, substance use and addiction are typically accompanied by cognitions which lead to using or addictive behaviors. For instance, Wright, Beck, Newman, and Liese (1993) described three basic addictive beliefs:

1. Anticipatory beliefs. Expectations of use (e.g., “I will finally be able to relax.” “I will have so much more fun than when I’m sober.”)
2. Relief-oriented beliefs. Expecting the substance to remove discomfort (e.g., “This craving will not go away unless I use.”)
3. Permissive beliefs. Justify substance use despite consequences (e.g., “I work really hard; I deserve this.” “No one will know; it will be ok.”)

Clients who are experiencing substance use or addictive disorders can benefit from learning the cognitive model, including how these common beliefs can lead to perpetuating substance use and addictive behaviors. MI+CBT treatment can involve increasing clients’ awareness of current cognitions, evaluating them, and then working to revise them. These skills are learned in individual or group counseling sessions and then applied in between sessions. Further, addictive behaviors are often reinforced through repeated associations over the course of the addiction. For example, consider a client who drinks alcohol in social situations and over time, as he feels more confident and less inhibited, he associates social activity with drinking (let alone that many cultures associate social activity with drinking, such as happy hour or tailgating).

A client uses opioid medication because she learned it is the only thing that sufficiently relieves her physical and emotional pain. Therefore, counterconditioning can be utilized as a behavioral tool to assist a client in diminishing the effects of a conditioned stimulus. Using the functional analysis in CBT can help bring these associations to light and bring them into the focus of treatment. Behaviors are also a focus in CBT work in which clients learn new or strengthen healthy coping skills, such as relaxation techniques, assertive communication, and refusal skills. MI evokes and strengthens client motivation and addresses any discord in the therapeutic relationship, as well as offers clients cognitive and behavioral tools to enable changes in substance use and addictive behaviors. The case of Josie, a 14-year-old Latina girl who was brought to counseling by her mother for marijuana use, will be threaded as an example in this section to illustrate how MI can be applied appropriately and successfully.

Assessment and Establishing the Therapeutic Relationship

For most substance use and addiction treatment, the first in-person contact with a client is the intake assessment, in which the focus is on gathering information in order to inform treatment, including diagnosis, and to make recommendations for an appropriate level of care. While the content of the session is on gathering information, the process of the intake assessment is a ripe opportunity for the intake counselor to begin a relationship with the client. In many agencies, the intake counselor may not serve as the client’s treatment provider, in which case it might be easy to focus solely on the content of the intake and dismiss the process. However, regardless of whether the intake provider will serve as the treatment provider, the experiences clients have during the intake assessment influence their impressions of help-seeking and their expectations of what is to come. Further, the counsellor’s approach to gathering necessary information can enhance or harm the client’s engagement, including levels of resistance/reactance. MI+CBT can be applied during the intake assessment to achieve both objectives of developing a productive therapeutic relationship with the client and gathering necessary information to inform treatment.

Developing the Therapeutic Relationship

Given that many clients present for treatment due to some level of coercion (e.g., court mandate, family member, employer), it is not uncommon for discord to be present at the onset of the counseling relationship. Discord (formerly known as resistance) through the lens of MI describes conflict in the therapeutic relationship that can manifest in defensiveness, argumentative behaviors, or the client making negative comments directed to the counselor and/or about the services provided. When counselors recognize discord in the therapeutic relationship, as the trained professional, it is a signal for the counselor to approach the client differently. It is not uncommon for clients in substance use treatment to be disengaged, defensive, or argumentative at the onset—in these cases, it is important to not take this personally and to keep in mind that the client is likely lumping you in with the other components of the systems he or she has encountered, such as the judge, probation officer, the family member, or the employer who referred them, and the client expects you to meet him or her with similar judgment and directiveness that he or she experienced in these other relationships.

And there lies the challenge and the opportunity to create a different environment for and relationship with the client—one that is grounded in empathy and compassion and focused on understanding clients’ perceptions within their current contexts. Why? Because resistance has been shown to lead to poor outcomes in substance use treatment. In essence, the more resistant a client is in treatment, the more likely he or she is to continue or increase substance use. That leaves the question, “How do we establish a productive therapeutic relationship with clients?” By applying MI, we first embark on the process of engaging. This process guides MI+CBT practitioners to execute strategies to diminish discord starting with maintaining the spirit of MI, or the humanistic, interpersonal “way of being” with clients. Clients who experience substance use disorders often have experiences that result in a “me against them” dynamic. Implementing the MI spirit can offset this dynamic by emphasizing partnership, acceptance, compassion, and evocation. The table below presents the components and descriptions of the spirit as well as antitheses that clients with substance use and addictive disorders commonly experience.

Finally, examples of the spirit are illustrated through a counsellor’s dialogue with Josie.

Table 1. Spirit of MI applied to engaging with clients with substance use and addictive disorders

In addition to maintaining the spirit of MI, counselors using MI can recognize discord and respond in a timely manner to diminish discord. MI counselors can recognize discord as client defensiveness, argumentation, or other negative comments made about the counselor or services (Miller & Rollnick, 2013). Discord is conceptualized as an interpersonal dynamic, and therefore, it is a signal for the counselor to respond differently. The first-line response includes listening and expressing empathy. When done well, this alone is often enough for discord to diminish. Once the client realizes you are not going to argue with him or her and you do not become defensive yourself, but instead you are consistent in your genuine striving to understand the client’s experiences and ideas, there is no longer a need for “resistance,” and discord in the relationship will diminish. Reflections are the most used skill to express empathy, and therefore, reflections are heavily relied upon when diminishing discord. However, there are opportunities to use open questions, affirmations, and summaries as well. Open questions let the client know that you want him or her to share, and when open questions are followed by reflections, this skill combination lets the client know you are listening and interested in hearing more. Summaries can be used to collect larger quantities of information to demonstrate listening and understanding, as well as to help organize or link information. When the discussion seems to hit a dead end or becomes non-productive, counselors can summarize the previous content and then ask an open question to shift the focus to a more productive topic of conversation

Affirmations can be especially meaningful for clients with substance use or addictive disorders due to the clients often hearing about all the things they do wrong and all the negatives about themselves and their behaviors from others. By highlighting the positives, clients can begin to see themselves in a more positive way, which can assist in further developing self-efficacy and strengthening a more positive self-image, as well as diminish discord. Finally, counselors can emphasize client autonomy by reinforcing personal choice and control (e.g., “As much as your parole office might want you to be in treatment, only you can decide how much effort you’re going to put into this.”), ensuring that the client is the primary resource in finding answers and solutions to his or her problems (e.g., “You’ve been in treatment before, and you’ve dealt with this issue for a while now. What have you found that works for you? What have you learned does not work?”), and asking for permission prior to giving information or making suggestions (“I have some assessments here that we use with all new clients. Would it be ok if I shared some information about them with you?”).

Implementing strategies to diminish discord in the therapeutic relationship requires the counselor to practice with responsivity and intentionality. As with all MI+CBT practice, there is no single way to respond but rather a menu of options from which the practitioner can choose. Such decisions should be made intentionally, with consideration to the client’s context, including social, cultural, and clinical considerations. Each decision is made based on a hypothesis about what might be effective in cultivating a relationship with this individual. If it does not result in the desired outcome (e.g., the client maintains defensiveness), then the practitioner listens and learns from the client’s response to reformulate the hypothesis and try another strategy or revise his or her style to better match the needs of the client. The skills of responsivity and intentionality culminate in the art of the engaging process as well as in the remaining components of treatment. The extract below provides an opportunity for you to consider how you might develop a therapeutic relationship with an adolescent client, Josie, during the initial intake assessment session.

Case Study

Intake Assessment with Josie

Josie is a 14-year-old girl who was brought to counseling by her mother for marijuana use. Josie and her mother attend an intake assessment, and you are the assigned counselor. You have several pages of questions to ask from the agency’s intake form that you must complete, as well as some formal assessments (Substance Abuse Subtle Screening Inventory-Adolescent Version; SASSI-A) the client must complete. You meet with Josie’s mother first and then with Josie alone. It quickly becomes apparent that Josie does not want to talk with you. She makes little to no eye contact and mutters “I don’t know” or shrugs when you ask a question. What do you do? What strategies can you draw on to proceed with Josie

^{(Iarussi, 2020)}

Summary

As separate approaches, MI has strong empirical support in the realm of substance use and addiction treatment. MI provides clinicians with strategies to address discord and motivational issues in the earlier stages of change and cognitive and behavioral interventions for clients who are ready for active changes. The foundation of a strong therapeutic alliance is fostered through the continuing the spirit of MI. Practice considerations include the need for comprehensive treatment that addresses concerns that interplay with substance use and addiction, such as mental health disorders, criminal records, and employment concerns, as well as the duty to provide culturally responsive treatment.