Integrating Motivational Interviewing and Cognitive Behavior Therapy in Clinical Practice

Melanie M. Iarussi

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351203210
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Integrating Motivational Interviewing and Cognitive Behavior Therapy in Clinical Practice shows counseling and other mental health professionals how the theoretical bases and evidence-based practices of motivational interviewing (MI) and cognitive behavior therapy (CBT) can be used together to maximize client outcomes.

Chapters outline effective methods for integrating MI and CBT and show how these can be applied to clients in a diverse range of mental health, substance use and addiction, and correctional settings. Written in a clear and applicable style, the text features case studies, resources for skill development, and "Voices From the Field" sections, as well as chapters devoted to specific topics such as depression, anxiety, and more.

Building on foundational frameworks for integrative practice, this is a valuable resource for counseling and psychotherapy practitioners looking to incorporate MI and CBT into their clinical practices.

SECTION III
Clinical Applications

CHAPTER 10
Substance Use and Addictive Disorders

MI and CBT are both popular and effective treatments for substance use and addictive disorders (Pilkey, Steinberg, & Martino, 2015). Meta-analyses have found CBT to be largely efficacious for treating substance use disorders with the strongest support for cannabis use disorders, followed by cocaine and opioid use, and with smaller effect sizes for multiple use substance use disorders (Magill & Ray, 2009; McHugh, Hearon, & Otto, 2010). MI was initially developed to assist people who had problems related to alcohol use and who were required to attend treatment (Miller, 1983). Lundahl, Kunz, Brownell, Tollefson, and Burke’s (2010) meta-analysis found that MI was effective in addressing substance use as well as gambling behaviors. When compared to other treatments, MI’s efficacy is on par with CBT and 12-step facilitation therapy but typically requires fewer sessions (Lundahl et al., 2010; Pilkey et al., 2015). In addition to these approaches being empirically supported separately, research has also supported the use of a combination of MI and CBT to further enhance outcomes related to substance use and addictive behaviors. For instance, the COMBINE study found that MI+CBT and medical management were found to be as efficacious as naltrexone and medical management in reducing drinking among clients with alcohol use disorder (Anton et al., 2006). A study conducted by Stea, Yakovenko, and Hodgins (2015) found that clients who implemented motivational, cognitive, and behavioral strategies were successful in altering cannabis use behaviors. The Cannabis Youth Treatment (CYT) series offers manualized approaches for five treatment protocols of varying length and foci, two of which incorporated MI and CBT (Sampl & Kadden, 2001; Webb Scudder, Kaminer, Kadden, & Tawfik, 2002). Research on the CYT found that clients who received motivational enhancement therapy (MET)+CBT had a 20% advantage for better outcomes at follow-up compared to those who did not receive a combination of MI+CBT (Donovan et al., 2008).

In this chapter, we explore MI+CBT applied to the treatment of substance use and addictive disorders, including during intake and assessment, goal development, making recommendations for treatment, treatment, and maintenance. In MI+CBT, we pay particular attention to the process of delivering the interventions as well as the content of the interventions and methods. Case examples are provided throughout the chapter to illustrate MI+CBT applied to specific client cases.

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 (Bright & Martire, 2013; Tiger, 2011) 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 (Norcross, Krebs, & Prochaska, 2011). MI is a natural fit for this population given it was initially developed to enhance readiness to change and to address ambivalence. As Beck, Liese, and Najavits (2005) noted, 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 (Velasquez, Maurer, Crouch, & DiClemente, 2001). 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. As both MI and CBT as separate approaches have a lot to offer clients who are seeking treatment for substance use and addictive disorders, the outcomes of MI+CBT can be synergistic. MI+CBT 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 throughout this chapter to illustrate how MI+CBT can be applied.

Voices From the Field 10.1

Integrating MI and CBT in DUI Drug Court

Written by
M. Scott Smith, M.S., LPC, CAADC
Doctoral Student, Clinical Psychology
Mercer University

As director of the DUI/Drug Court treatment program in Troup County, Georgia, I organized a two-day MI training not only for the clinicians on our team but also for the probation officers, staff members, and judge. I was particularly interested in how the MI training might affect the judge’s relationships with participants since research suggests that this relationship is a mechanism that significantly affects treatment outcomes (MacKenzie, 2015; Rossman et al., 2011).

To evaluate the effect of the training, we recorded audio of court hearings before and after the training. We found that the judge asked more open-ended questions and used more reflections after the training. The judge’s interactions with participants became much more of a dialogue than a one-sided conversation. Most significantly, the average hearing time increased from 1:43 before the MI training to 3:08 after the training. That may not seem like much of a change, but research shows that drug court programs where the judge spent at least three minutes on average with each participant during court hearings had 153% greater reductions in recidivism (Carey, Mackin, & Finigan, 2012). In the year following the MI training for our team, our program’s retention rate increased from 73% to 80%.

Having our whole team complete the MI training changed the way we interacted with each other as well as with participants. We started to talk less about sanctions and more about affirmations. During every staffing, we brainstormed new open-ended questions to evoke change talk in the courtroom. The presiding judge commented, “The open-ended questions give us a focal point and help me to encourage reticent participants to talk more.” A lead counselor observed, “When clients come to court, there’s often a barrier between them and the judge. The MI approach takes down that barrier and allows the clients to build a relationship with the judge.”

When the members of our drug court treatment team started to practice not only in the skills but also the spirit of MI, that laid the groundwork for the CBT interventions delivered in the substance use treatment groups. Strategies for changing thoughts and behaviors were more easily assimilated by participants when they were presented as part of a cohesive system that affirmed their efforts and empowered them with their own motivation rather than blaming, shaming, and shackling.

References

Carey, S. M., Mackin, J. R., & Finigan, M. W. (2012). What works? The ten key components of drug court: Research-based best practices. Drug Court Review, 8, 29. National Drug Court Institute. Retrieved from www.ndci.org/sites/default/files/nadcp/DCR_best-practices-in-drug-courts.pdf

MacKenzie, B. (2015). The judge is the key component: The importance of procedural fairness in drug treatment courts. American Judges Association. Retrieved from www.amjudges.org/pdfs/judge-key-component.pdf

Rossman, S. B., Roman, J. K., Zweig, J. M., Rempel, M., & Lindquist, C. H. (2011). The multi-site adult drug court evaluation: Executive summary. Urban Institute Justice Policy Center. Retr...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgments
• Section I: The Foundations
• Section II: Methods of Integration
• Section III: Clinical Applications
• Section IV: Clinical Practice Issues
• Index