Enhancing Readiness-to-Change Substance Abuse in Persons with Schizophrenia: A Four-Session Motivation-Based Intervention

Kate B Carey; Daniel M Purnine; Stephen A Maisto; Michael P Carey

doi:10.1177/0145445501253001

. Author manuscript; available in PMC: 2008 Jun 23.

Published in final edited form as: Behav Modif. 2001 Jul;25(3):331–384. doi: 10.1177/0145445501253001

Enhancing Readiness-to-Change Substance Abuse in Persons with Schizophrenia

A Four-Session Motivation-Based Intervention

Kate B Carey ¹, Daniel M Purnine ¹, Stephen A Maisto ¹, Michael P Carey ¹

PMCID: PMC2435265 NIHMSID: NIHMS53470 PMID: 11428245

Abstract

This article describes a four-session intervention designed for persons with co-occurring substance abuse and schizophrenia-spectrum disorders, to be administered as an add-on module to supplement ongoing mental health treatment in an outpatient setting. The intervention targets those dually diagnosed individuals with low readiness-to-change as indicated by current use, and/or low level of engagement in treatment for substance abuse. The intervention is designed to increase problem recognition, to enhance motivation to change maladaptive patterns of substance use, and to facilitate engagement in substance abuse. To achieve these goals, we have adopted constructs from the Transtheoretical Model of Change and utilize principles of motivational and harm reduction interventions, and tailored them to the target population.

Persons with schizophrenia are at elevated risk for substance use disorders (Regier et al., 1990). Among the more common classes of Axis I disorders, the odds ratio of substance abuse or dependence is particularly high for schizophrenia (4.6); in comparison, the odds ratios are 2.6 for affective disorders and 1.7 for anxiety disorders (Mueser, Bellack, & Blanchard, 1992). Among all persons with a diagnosis of schizophrenia, nearly half meet lifetime criteria for a substance use disorder (Regier et al., 1990). Furthermore, use of multiple substances is common among persons with schizophrenia; Mueser et al. (1992) reported that 42% of schizophrenic inpatients met lifetime abuse/dependence criteria for two or more substances.

Substance abuse/dependence hinders mental health treatment. Symptom exacerbation and psychiatric admissions have both been linked to acute drug use in persons with schizophrenia (Shaner et al., 1995). Comorbidity of major psychiatric and substance use disorders is associated with more frequent inpatient hospitalizations (Haywood et al., 1995), poorer response to neuroleptic treatments (Bowers et al., 1990), and less consistent participation in aftercare (Solomon & Davis, 1986). With regard to outpatient treatment, the dually diagnosed exhibit poor medication compliance (Owen, Fisher, & Booth, 1996; Pristach & Smith, 1990), report more severe psychiatric symptoms (Carey et al., 1991), and become only minimally involved in structured treatment programs (Carey & Carey, 1990; Lehman, Herron, Schwartz, & Myers, 1993). Although treatment compliance is poor, schizophrenic patients with substance use disorders use more institutional and emergency services, with higher associated costs than do schizophrenic patients without substance use disorders (Bartels et al., 1993; Kivlahan et al., 1991).

The high prevalence of substance use disorders in this population, as well as adverse effects related to it, underscores the importance of effective treatment. However, most individuals with co-occurring schizophrenia and substance use disorders report little involvement in substance-related treatment (Ziedonis & Trudeau, 1997), and likely would benefit from interventions that enhance their level of motivation for change.

Specific Characteristics That Complicate Substance-Related Treatment

According to the DSM-IV (American Psychiatric Association, 1994), schizophrenia is characterized by “a range of cognitive and emotional dysfunctions that include perception, inferential thinking, language and communication, behavioral monitoring, affect, fluency and productivity of thought and speech, hedonic capacity, volition and drive, and attention” (p. 274). Symptoms have been described as falling into two broad categories. Positive symptoms involve excess or distortions of normal functions and include delusions and hallucinations. Negative symptoms involve deficits or restrictions of normal functions, such as decreased emotional expression, productivity of thought and speech, and goal-directed activity. Bellack and DiClemente (1999) identifies three areas in which individuals with schizophrenia may experience specific difficulties that inhibit the change process. These include cognitive impairment, social impairment, and obstacles to motivation.

Perhaps the most significant obstacle to change involves negative symptoms related to cognition. These may include memory problems, compromised ability to concentrate and sustain attention, difficulties in abstract thought, alogia (impoverished thinking), and thought blocking. Cognitive deficits limit a patient’s ability for self-reflection or evaluation of previous experiences in order to develop realistic self-efficacy appraisals. Persons with schizophrenia often exhibit impaired ability to develop realistic goals, or to appraise the consequences of substance use.

Many individuals with schizophrenia lack formal and informal social connections, involvement, and commitments. It is not uncommon for patients to report that they spend their time “smoking” or “watching TV.” Social skills deficits may result from specific cognitive and affective facets of the illness as well as unstimulating social environments; a downward spiral may also be created as poor social skills and impoverished social environs contribute to one another. Social skills influence a patient’s ability to engage in change-related efforts, such as initiating healthy social activities that do not involve substances, or negotiating health-provider networks, or establishing a relationship with a therapist. Bellack and DiClemente identify three aspects of social impairment relevant to treatment for substance use disorders: difficulty resisting social pressure to use, difficulty establishing new relationships with non-substance-abusing friends, and difficulty developing sufficient social support to abstain or reduce their use. Social deficits or withdrawal may also have a reciprocal relationship with motivational problems.

Developing a motivation-based intervention for those with schizophrenia is especially challenging because obstacles to motivation are characteristic of the illness. General avolition/anergia is a common feature that may inhibit a patient’s ability to engage in new and challenging behaviors required for abstinence. Low energy and drive may result from patients’ medications as well as the mental illness itself. Furthermore, anhedonia may limit a patient’s ability to experience and benefit from positive aspects of reduced use. Affective blunting or flattening may also contribute to difficulty engaging and participating in therapy and benefiting from it. These symptoms may be manifest by poor eye contact, affective non-responsiveness, and lack of modulation in vocal inflection and facial expression.

Interventions designed to reduce substance abuse in this population must accommodate to the cognitive, social, and motivational impairments inherent in the illness of schizophrenia. Lack of initiative in treatment seeking or poor follow-through on treatment recommendations offered by traditional substance abuse programs may not necessarily imply a lack of interest or ability to change. We suggest that specific attention should be provided to enhancing motivation for change and engaging dually diagnosed patients in initial steps towards substance-related treatment.

Influences on the Present Intervention

The clinical features of schizophrenia highlighted above require a flexible and population-sensitive approach to motivating patients for treatment. Guiding our efforts to tailor a motivation-enhancing intervention to patients with schizophrenia is a set of therapeutic influences that include the Transtheoretical Model of change, motivational interviewing strategies, and the harm reduction perspective to substance use treatment.

Transtheoretical Model (TTM)

The TTM has been influential in raising awareness of the need to consider a person’s readiness for change when developing interventions. According to this model, change occurs gradually, with different change processes associated with different stages of change. In earlier stages (i.e., precontemplation, contemplation, preparation), experiential and consciousness-raising techniques may be used to encourage self-reevaluation and changes in the way a person thinks and feels about a given problem. Use of these processes has been linked to positive behavior change in longitudinal studies (DiClemente, 1993; Prochaska et al., 1992). In later stages (i.e., action, maintenance), intervention strategies that are action-oriented (e.g., contingency management or stimulus control) may be more effective. The present intervention helps participants to consider the role of substances in their lives, effects of that use, and the prospects of reduced use.

Because this intervention is aimed toward people who are not yet ready for active change processes, many of the following techniques are incorporated into the design of the motivational intervention: sharing observations, interpretations and concerns regarding substance use behavior; comparisons with normative data; information regarding personal consequences of substances; values clarification; challenging beliefs/expectations; and expressing feelings about a problem and potential solutions (DiClemente, 1993).

The idea of “decisional balance” has been associated with the processes articulated in this TTM. Prochaska and colleagues (1994) found that later “stages of change” were correlated with significant shifts between the relative pros and cons of changing problematic behavior. Decisional balance activities, as well as formal assessment and feedback of decisional balance, are significant components of the current intervention.

Motivational interviewing (MI)

This intervention reflects the principles of MI (Miller & Rollnick, 1991): (a) express empathy, (b) avoid argumentation, (c) roll with resistance, (d) support self-efficacy, and (e) develop discrepancy. Expressing empathy, avoiding argumentation, and rolling with resistance aim to establish a supportive, collaborative therapeutic relationship. This is especially true in the context of a problem behavior that often engenders stigma and confrontation. Self-efficacy is key to many theories of health behavior change; enhancement of self-efficacy can be achieved by focusing on past or present successes in controlling substance use. By “developing discrepancy” between current experiences or behavior and more attractive possibilities, a person may become motivated to change in order to decrease the discrepancy. In other words, outcome expectancies for change come to be seen as preferable to the expectancies associated with continued use (e.g., “If I continue using, my health will deteriorate,” versus “If I cut down my use, my health will improve”).

MI assumes that the patient is ambivalent about change to some degree. Increasing patients’ awareness of their ambivalence is encouraged by helping patients speak about their ambivalence and the costs and benefits of their current behavior. Consistent with self-perception theory (Bem, 1970), it is helpful for the patient to be the one who makes the argument for change; this helps patients to change their perception of themselves and their position regarding substance use. Many activities described in this intervention are designed to elicit self-motivational statements.

Emphasis is also placed on a therapeutic stance of collaboration with the patient and avoiding statements that unduly challenge the patient or otherwise invite “resistance.” This emphasis on a collaborative relationship is similar, to some degree, to Rogers’ client-centered approach. Rather than being non-directive, however, motivational interviewing is client-centered and directive.

Although not developed for persons with schizophrenia, the motivational interviewing guidelines presented by Miller and Rollnick (1991) work well with this group for several reasons. First, nonconfrontational interactions are consistent with the way mental health treatment staff relate to their patients. For example, mental health professionals recognize that direct challenges to delusional thinking are usually ineffective. In addition, patients with schizophrenia often have difficulty dealing with expressed emotion (Hooley, 1985); their inability to benefit from confrontational methods may explain in part their lack of comfort with and success in traditional substance abuse treatment programs. Second, motivational interventions attempt to enhance self-esteem and self-efficacy, both of which tend to be undermined by the many social and developmental disappointments experienced by persons with schizophrenia (Pepper et al., 1981). Third, motivational interventions also avoid labeling patients as “addicts” or “alcoholics,” labels that can represent additional stigmatization to mentally ill individuals. Fourth, because motivation is viewed as a dynamic state rather than a static trait, readiness-to-change can be enhanced by both therapeutic intervention and naturally-occurring events. In this view, treatment providers play an active role in motivating the “unmotivated patient.” Fifth, this approach can take place at a very concrete level (e.g., you got high and you were arrested) or at more abstract levels (e.g., you want to have more options but you think that using drugs may close out some options for you).

Harm reduction

The current intervention also adopts the philosophy of harm reduction (Marlatt, 1999) as opposed to traditional abstinence-oriented treatment philosophies. This perspective pays particular attention to the harmful social, physical, and psychological consequences that characterize substance abuse. Such negative consequences may be expected to decrease in severity or frequency as a patient decreases the amount or frequency of substance abuse. Therefore, reduced use is seen as a significant positive outcome in itself, rather than a step toward the only positive outcome of abstinence.

Use of the harm reduction approach also has a significant advantage in treating patients with lesser degrees of readiness-to-change. It is more likely to engage those patients who cannot embrace the goal of abstinence. Reduced use is a more proximal, attainable goal that may seem more realistic to these individuals. For persons with schizophrenia, goal-setting must involve modest objectives, given (a) negative symptoms including avolition and anergia, (b) limitations regarding abstract cognitive functioning necessary for planning distant goals and intermediate steps to achieve them, (c) less personal experience with successful goal-setting and subsequent goal-attainment, and (d) limited social and other external supports. Therefore, change steps in the direction of reduced use, less risky use, or abstinence are encouraged and supported.

Conceptualizing Readiness-to-Change

We distinguish between “readiness-to-change” and “motivation-for-change.” As illustrated by Figure 1, readiness-to-change is the overarching construct. Motivation-for-change can be considered an internal cognitive/affective state, and can be considered necessary for behavior change (or maintenance of changes). Readiness-to-change, on the other hand, can be considered a broader construct, reflecting a number of factors that, combined, indicate the likelihood that someone will begin (or continue) to engage in behaviors associated with substance use reduction (e.g., including therapy, self-initiated quit attempts, or other behaviors in support of reduced use). Readiness-to-change, therefore, includes motivation-for-change as well as other factors, including relevant behavioral skills and supporting external factors. In addition, resources and barriers may be presumed to affect motivation as well as action itself, through various paths illustrated in Figure 1. For example, a patient may be more likely to engage in change-related behaviors if s/he feels ready and willing to change, and if s/he has acquired the skills that make success more likely and if s/he anticipates receiving support and reinforcement from change efforts. A person with low motivation and few resources may first benefit from a motivational intervention, followed by skills training (Carroll, 1998).

Readiness-to-change should be assessed in a manner consistent with its conceptualization as a multiply-determined phenomenon that may fluctuate in level over time. No single measure has been developed to assess readiness-to-change directly and comprehensively (Carey et al., 1999). Instead, it may be preferable to “triangulate” readiness-to-change, based on both cognitive-affective and behavioral measures. Cognitive and affective measures may include constructs such as outcome expectancies, decisional balance, and self-efficacy. Behavioral measures include general help-seeking as well as involvement in substance abuse treatment and/or self-help groups.

The model presented in Figure 1 serves as a heuristic for identifying goals of a motivation-enhancing intervention. Although other intervention targets are likely to have motivational implications, we chose to focus on the hypothesized precursors of motivation as the most suitable targets for a brief intervention.

Three Therapeutic Goals

This intervention is designed primarily to enhance motivation-for-change, and is organized around three main goals. As depicted in Figure 1, two psychological constructs are believed to contribute directly to motivation-for-change. Helping individuals to modify their outcome expectancies regarding quitting or continuing to use, and helping them to enhance their self-efficacy expectations to quit are two goals. To facilitate these changes, it is also necessary to develop a therapeutic alliance characterized by a trusting relationship, a sense of collaboration, and therapist actions that minimize resistance.

Table 1 describes the relationship between therapy activities and the three therapeutic goals. The first two sessions place special emphasis on process issues such as expressing accurate empathy and avoiding confrontation. Outcome expectancies are approached directly in Sessions 2 and 3. Self-efficacy expectations overlap with process; affirming the patient, citing past successes, and other therapist actions that support the therapeutic relationship may support self-efficacy as well. In addition, a gradual shift from emphasis on outcome expectancies to self-efficacy may take place throughout the intervention, as the former is the object of Session 2’s decisional balance exercise, both are addressed in Session 3’s strivings exercise, and self-efficacy expectations are emphasized in Session 4’s attention to developing goals and action plans that are realistic and likely to succeed. The gradual shift from therapeutic alliance to outcome expectancies to self-efficacy throughout sessions represents an ideal scenario; in most cases, the therapist makes adjustments according to the pertinent issues of the particular patient. Sometimes, emphasis must be placed on simply establishing an alliance throughout the four sessions. In some cases, it becomes clear (e.g., from the Expectancy Scales) that self-efficacy expectancies (confidence) should be emphasized across the sessions or, rather, that outcome expectancies (importance of change) should be the central focus.

Table 1.

Relationship Between Therapeutic Goals and Activities, across Sessions

	TA	OE	SE

Session 1 Activities
1. Introduction to the intervention.	X
2. Assess & discuss importance/ confidence regarding change.		X
3. Feedback of current substance use, consequences, risks.		X	X

Session 2 Activities
1. Review Session 1	X
2. Decisional Balance Exercise		X

Session 3 Activities
1. Review Session 2		X
2. Personal Goals Exercise		X
3. Assess & discuss importance/ confidence regarding change		X	X

Session 4 Activities
1. Review sessions, reinforce gains.			X
2. Elicit goals and develop an action plan.			X

Open in a new tab

“ TA = Therapeutic Alliance; OE = Outcome Expectancies; SE = Self-efficacy Expectancies.

Accommodating to the Target Population

Addressing varying degrees of readiness-to-change

This intervention is designed for persons who struggle with problematic substance use or those who have not yet firmly established a pattern of healthier behavior. The specific activities of each session need to be applicable to persons at various stages-of-change, with regard to both quitting or reducing use. The therapeutic activities described here are associated with gradually increasing levels of readiness-to-change. For instance, the “current use charts” used at Session 1 may be associated with “consciousness raising,” which is suitable for precontemplators. The “Next Steps” form (Session 4) presumes that some commitment to action has taken place before a plan is discussed.

We have combined strategies typically associated with different levels of readiness-to-change for several reasons. First, each patient may move forward (or backward) in the change-process within the duration of an intervention. Second, patients often do not fit neatly into a particular “stage” of change or level of motivation; as a result, specific stage matching of intervention techniques may not be possible. Third, our model of change holds that various mental/behavioral processes (e.g., raising consciousness, assessing relative pros/cons, forming goals, action) are pertinent throughout the change-process.

Finally, it is possible to exhibit different levels of readiness-to-change as a function of different change goals. To illustrate, consider a patient who has recently reduced his alcohol intake from 24 beers to 12 beers per day. On the one hand, he is taking deliberate and meaningful action. On the other hand, he may resemble a precontemplator, given his failure to quit, despite significant physical symptoms, and his consistent under-representation of the significance of his difficulties. Is it more productive to focus on raising consciousness (precontemplation) or on eliciting self-motivational statements to reinforce his recent behavioral change (action)? In our experience, both may help to achieve intervention goals.

The following points summarize the relationship of this intervention to the varying levels of readiness-to-change that may exist among patients with schizophrenia who continue to struggle with substance use:

It may be helpful to broaden the notion of readiness-to-change, to include readiness to a) initiate/enact changes, and b) maintain changes.
Consistent with harm-reduction principles and a client-centered approach, it is generally preferable to allow the patient to determine whether the sessions shall focus on making (further) changes or on maintaining changes that have already been made. “Developing discrepancy” remains the therapeutic objective throughout.
Positive outcome expectancies and self-efficacy for change are important throughout the stages of change.
Each therapeutic activity aims to enhancing the perceived importance of change and/or self-efficacy regarding the ability to change.

Addressing complicating factors related to schizophrenia

We revisit the three complicating factors characteristic of patients with schizophrenia, and discuss ways in which the present intervention accommodates them.

Existing motivational strategies are modified in order to account for cognitive difficulties. For example, verbal administration of all measures allows for greater control over assessments. Assessors may offer prompts and encouragement and can regulate the pace in order to maintain patients’ attention; they can also inquire about a patient’s comprehension and offer clarification where appropriate.

“Homework” exercises have been found to be helpful by some (e.g., Sobell & Sobell, 1996). Whereas these may save valuable session time and be beneficial for higher functioning patients, those with schizophrenia may be less likely to complete assignments independently and understand them fully. In this intervention, all structured exercises take place in session.

Use of in-session assessments and assessment feedback may have therapeutic value. Patients with schizophrenia may benefit from this type of feedback as they may be less inclined than other patients to engage in self-reflection regarding their patterns of use, attitudes about using, attitudes toward themselves, and connections among these. Also, feedback and exercises surrounding these measures provide structure to sessions.

Exercises such as decisional balance and goal-setting can be highly structured when necessary and are composed of easily understood components. Worksheets are used to guide and/or summarize activities in each session, and can serve as visual prompts to focus patients’ attention. Reviewing the work of previous sessions is also made easier by referring to specific worksheets. They are concrete reminders of specific activities and discussions.

With regard to decisional balance activities, our previous research indicates that persons with schizophrenia are capable of considering the pros and cons of their substance use in an open-ended format with prompting (Carey, Purnine, Maisto, Carey, & Barnes, 1999) and can reliably report this information with the use of standardized measures (Carey, Maisto, Carey, & Purnine, in press). Their ability to do so has been supported with regard to the pros and cons of quitting versus continuing to use; this suggests that, with appropriate guidance, individuals with schizophrenia are capable of considering hypothetical future events, despite limited capacities for cognitive abstraction. Our experiences with decisional balance, goal-setting, and other exercises is that they may be effective with sufficient structure, cues, encouragement, and therapist patience.

Problems posed by poor social skills (e.g., drink refusal skills) are understood largely as obstacles to actual change and change-related behavior (see Figure 1), rather than obstacles to change-related motivation. They are appropriate targets of social skills training, once a person in committed to therapy and the change-process. Figure 1 also includes an “external factors” component that includes extra-personal barriers to change; a lack of social-emotional support, and deficits in one’s social environment may be described as such. They may indirectly affect motivation-for-change, but are not central to the motivational focus of this intervention. As noted above, however, social skills deficits may affect a patient’s ability to establish a productive therapeutic relationship. Therapists, therefore, should be experienced and skilled in working with persons with schizophrenia, and express sufficient patience, empathy, and encouragement to successfully engage these patients.

The intervention also accommodates to one particular aspect of skills deficits: difficulties managing emotional arousal. Lower levels of stress tolerance and impaired ability to cope with negative emotional states are characteristic among persons with schizophrenia. Emotional arousal must be monitored carefully and controlled unless patients have sufficient tolerance for these states. As a result, the use of processes of change involving emotional arousal is not encouraged, even though these processes are often considered useful for motivating change in early stages of change (DiClemente, 1993).

Motivation is the target of this intervention and will be addressed, in large part, according to the principles of MI. Considering the specific obstacles to motivation posed by schizophrenia (e.g., avolition and anergia), two features of the intervention are worth noting. First, therapeutic use of “approach motivation,” is addressed in Session 3. This involves the identification, development, and support of patients’ goals, as well as the intermediate actions needed to secure such goals. The ways in which continued substance use may prevent the achievement of these goals will also be addressed. The reasoning is as follows. Research indicates that “approach motivation” is more powerful and effective than avoidance-motivation (Elliot & Harackiewicz, 1996). Also, particularly among this population, avoidance motivation may not be salient because, with fewer resources/ commitments, they have less to lose than other individuals as a result of substance use. For example, many do not have a job to lose or do not have close romantic or family ties that might be threatened. Therefore, the potential benefits of quitting may be more pronounced than the negative effects of continued use. Second, motivational deficits are likely to interfere with attendance at this or any other intervention. Efforts are made to remind patients of upcoming sessions and to contact them when appointments are missed. In the Next Steps exercise, the therapist encourages modest goals that appear to be within the patient’s behavioral repertoire, to enhance the likelihood of follow-through. The goal throughout this intervention is to assess the participant’s motivational state, and to encourage movement forward on the continuum of change.

In sum, we have identified the need to engage more patients dually-diagnosed with schizophrenia and substance use disorders in substance abuse treatment. Toward that end, we have developed a brief, four-session module designed to enhance motivation-for-change and treatment engagement. We have adapted principles from the Transtheoretical Model, motivational interviewing, and harm reduction interventions to accommodate the cognitive, social skills, and motivational deficits often seen in this population. The intervention aims to establish a positive therapeutic alliance as a context for exploring change, to enhance positive outcome expectancies, and to reinforce self-efficacy expectancies, consistent with our heuristic model of change.

Intervention Manual

This manual consists of three parts. First, we describe common therapeutic factors that are pertinent throughout the course of the intervention. These techniques are adopted from the tradition of MI (Miller & Rollnick, 1991) and are consistent with our three general therapeutic goals (a focus on therapeutic alliance, increasing change-related outcome expectancies, enhancing self-efficacy expectations). Second, clinical considerations in adapting a motivation-based approach to persons with schizophrenia are then addressed. Third, the structure and content of each of the four proposed sessions are described. The outline of each session describes General Goals and an Overview of the Therapeutic Activities for the session. A Therapeutic Stance for the session contains tips regarding the particular session, in order to help therapists stay true to principles of motivational interviewing. Specific Therapeutic Activities are then introduced, with their purpose or rationale, instructions for the therapist, and illustrative examples.

Motivational Interviewing Techniques

Therapeutic principles of MI, as described earlier, are followed throughout all sessions (expressing empathy, avoiding argumentation, rolling with resistance, supporting self-efficacy, and developing discrepancy). In addition, MI involves a number of therapist behaviors that may be useful to engage patients in discussion about their substance use and encourage the generation of self-motivational statements. These include the following types of therapist statements.

Reflective Listening

Simple reflection

Reflections generally paraphrase a patient’s statement with an emphasis on a particular aspect of the statement in order to make this aspect more salient. Often, it is the affective component that is underscored. Reflections are a form of hypothesis-testing; the patient may accept, reject, qualify, or expand on a reflection. In this way, reflections serve to clarify the patient’s thoughts and feelings for the therapist and for the patient him/herself.

Example:

P: Last weekend when I was with my parents, I didn’t drink at all. It went OK - pretty different.
T: You enjoyed your time together
P: It was better than usual, actually. We got along, I guess.
T: ...and not drinking - that was pretty different for you...
P: Yeah, that was unusual too...

Double-sided reflection

This statement clarifies a patient’s ambivalence by making explicit the tension between two competing statements or attitudes expressed by a patient. (e.g., “If I understand correctly, you know that you’d get along with your family a lot better if you weren’t drinking...but quitting feels like some of your freedom is taken away?”).

The disorganized cognitive style that is sometimes present among persons with schizophrenia presents a particular challenge in that completely contradictory statements may be expressed within a single session. In some cases, this may even occur within adjacent statements. Double-sided reflections may be useful in gently bringing this to a patient’s attention and facilitating resolution of the contradiction, as in the following example regarding quitting overall and abstinence on the weekends:

P: I know I can’t hang out with the same people or go to the same places... (later) I couldn’t do it without God or my daughter.
P: (a few minutes later) Oh, it’s easy, Dr. _______. I’m not tempted at all!
T: So, sometimes it seems pretty easy and you’re not even tempted, but overall, there’s no way you could do it without the support of family and God...”
P: Oh, it’s not easy, it’s not easy...

Amplified reflection

This reflection exaggerates a patient statement. By casting it in a more extreme form, the patient may re-examine the statement and consider the other side of his/her ambivalence. Subtle amplification is often all that is needed to change the direction of dialogue. For example:

P: I don’t think marijuana is really such a bad drug as people make it out to be.
T: You think it’s pretty benign - not harmful.
P: Right. The one harmful thing it does have is short-term memory. (Patient goes on to describe how impaired short-term memory has affected him.)

Affirmation

This can enhance a person’s sense of self-efficacy as well as contributing to the therapeutic alliance. Emphasis on affirmations are particularly warranted in cases where confidence to make changes is lower than perceived importance of changing.

Example:

P: I’m so hot and tired - walked from the other side of town to get here.
T: It is pretty hot out today; it’s great that you could make it here to work on these issues despite the weather and the long walk!

Reflections and affirmations may be blended:

T: So, even though you’ve felt a bit more anxious and had a kind of “pressure” in your head, you made efforts to smoke less pot; that doesn’t sound easy.
P: Not at all!

Emphasize Autonomy, Control, and Responsibility

This may be effective in preventing or resolving “resistance.” If the therapist does not take on the role of change-advocate or agent of change, then there is nobody to resist. The two positions of change and not-change are then more freely accessible to both the patient as well as the therapist.

Example: This exchange occurred at the end of Session 1, despite the therapist’s efforts to avoid taking on the voice of change and explicit emphasis on the patient’s autonomy at the outset:

T: Was this (session) helpful?
P: Yeah, it’s good to hear someone other than my therapist tell me I shouldn’t use it and why.
T: Oh, I hope I haven’t been telling you what to do - I don’t think I have...
P: (laughing) OK, yeah, I know, it’s up to me what I’m going to do...

Requesting Elaboration

In helping the patient give voice to change-related themes, the patient becomes the agent of change. When such themes arise (e.g., one’s successes, ambivalence, confidence, barriers), it is helpful to encourage the patient to stay with the theme and speak more about it. The following example involves elaboration of a barrier to change (fear):

P: There was a part of me that didn’t want to give up that drug life - scared of something - maybe scared I’d get off of drugs and be a normal person.
T: Why might that be scary?
P: (laughs).
T: Seriously, what might be scary about that?
P: Well I’ve been in the same ditch for years...
T: So if you get up and out of that ditch...(?)
P: I wouldn’t know how to act. I don’t know what kind of people I’d meet.

“Columbo” Technique

As with simple reflections and requests for elaboration, this method helps patients continue to “unpack” statements and further explore their thoughts and feelings. As the therapist feigns ignorance (or expresses it genuinely), a patient may feel empowered to “educate” the therapist. This may be useful for patients who feel a need to be in control. It can also be useful in elaborating statements that appear complete or obvious, but may have more to them.

P: I enjoy (the high) actually, and I don’t know why - I just enjoy it.
T: I’m not sure I understand...
P: It feels like you’re in a different land.
T: Tell me about that (requesting elaboration).

Summary Statements

Summarizing key points of a discussion can help reinforce it for the patient. Summaries are a form of reflection in that the therapist’s understanding of important points made by the patient are fed back to him or her, providing the opportunity for the patient to accept, reject, or qualify the summary (e.g., “does that sound about right?”). Like other facets of reflective listening, this may lead to clarification or elaboration as well as the reinforcement of change-related themes expressed by the patient. Miller and Rollnick (1991) note that summaries offer a good opportunity to underscore ambivalence, as with double-sided reflections. Also in keeping with these authors’ recommendations, the first session of this intervention should close with a summary that establishes a common ground of understanding and reinforces a collaborative approach by soliciting the patients’ feedback. Summaries should be used liberally with individuals affected by poor memory, attention, or cognitive organization. Each therapeutic activity described in the following sections should close with a summary.

Clinical Considerations

Levels of Therapist Activity/Assistance

Each session contains specific activities with associated “worksheets” on which insights generated by these activities are recorded. These include pros and cons of substance use, costs and benefits of quitting, personal strivings, substance-related goals, and an action plan. Ideas in each of these areas may flow freely with some individuals, but may be hard for others to produce. Alogia, amotivation, poor attention and memory may serve as barriers. Spontaneous insights are preferable when they are forthcoming. When spontaneous verbal behavior is not forthcoming, however, increasingly active assistance is warranted. Four types of therapist activity are described below; these represent increasing levels of assistance with this process. For illustrative purposes, the following examples refer to “cons of using.” As can be seen from the increasingly lengthy therapist statements, higher levels are less conducive to patients taking an active role and voicing change-related statements on their own.

Spontaneous material. No assistance is required in generating insights.
- P: “Oh, drinking usually makes me more depressed. Then I isolate even more. And sometimes I get kind of wild when I drink - do things I wish I didn’t later.
Prompts. As with a menu, the therapist probes particular areas that might be affected.
- T: How does drinking affect your emotions? ... What have you noticed in terms of how it affects your relationships?...(physical health, etc.)
Reference prior statements. The therapist refers to previous patient -generated material.
- T: You know, something you mentioned last time stuck with me. I think you said you might drink when you feel kind of down, but then you end up feeling even more depressed. Is that right?
- P: Oh, I just feel worse, yeah.
Use of formal assessment. An assessment battery prior to the intervention itself provides a wealth of information that is useful when lower levels of assistance remain under-productive. Items that were endorsed strongly may be used as stimuli for discussion.
- T: Do you remember those questionnaires you completed? One of them included statements about the effects of drinking and asked how much you agreed it was true for you. Would it be alright if I picked out things you agreed with most and asked you if they’re still accurate?...OK, you seemed to agree that drinking can make you feel more depressed. Is that still true for you?

Use of Activity Worksheets

In contrast to under-productive patients, persons whose verbal/cognitive associations are disorganized or those who are impulsive present a different challenge. At these times, the therapist’s task is one of structuring and sometimes constraining conversation. Responses to various therapeutic activities may be overly vague, idiosyncratic or otherwise difficult to interpret. In these cases, it is helpful to maintain physical control of the worksheet (and/or pen). In this way, only those responses that have been discussed and clarified are recorded. This may help to structure a patient’s thought processes. It also makes things easier when, in later sessions, earlier activities are reviewed.

For some patients, viewing the entire worksheet may be confusing and remain distracting throughout the course of a conversation. At these times, it is helpful to keep most of the worksheet covered, revealing only that portion that is immediately under discussion. Therapists must also decide whether a particular worksheet is helpful in structuring a discussion or if it serves as a distraction. In many instances, it may be more helpful to fill out worksheets after the discussion has taken place. Instead of being a distraction, the worksheet then helps structure a summary of key points in an activity.

Therapeutic Flexibility

Flexibility on the part of the therapist is paramount when working with persons that suffer severe symptoms. Session-specific instructions, as described in the next session, are guidelines only. They may be followed in a different order or modified depending on the needs of a particular patient on a given day.

Psychiatric decompensation, crises, and supplemental sessions

Psychiatric symptoms (e.g., delusions, hallucinations, depression) may exacerbate to the point where it is difficult or impossible to engage in a specified therapeutic activity. It may be possible but not productive to do so. It also may strain the therapeutic alliance if, for instance, a patient is emotionally and cognitively preoccupied with a distressing personal event and the therapist persists in the pursuing activities specific to the intervention. At such times, it may be necessary to abandon a given session’s agenda. Supplemental sessions may simply be added later.

Additional sessions may also be warranted after an extended lapse between sessions. This may occur for a number of reasons, including hospitalization, periods of heavy drinking, or being jailed. In these cases, an extra session may need to focus primarily on re-establishing the therapeutic alliance, reviewing intervening events, and re-orienting the patient to the intervention.

Pacing

Some patients (e.g., hypomanic) may wish to speed through activities at a fast clip and others (e.g., depressed) may proceed slowly. The therapist must be persistent in pacing those who would speed through an activity, to facilitate adequate processing of meaning and affect. Some patients appear to move too fast motivationally; they may voice or endorse more change-related themes, but in a vague or superficial manner. Gentle confrontation may be helpful in these cases (e.g., “I’m impressed by how important you feel change is for you now; what barriers to change are you most concerned about?). The verbal pace of some patients may be especially slow for various reasons. Coordinating the tempo of the session with a patient’s slower pace is important, if the issue has to do with cognitive deficits or depression. The therapist must gently press on, however, if progress is slow due to obsessive tendencies that make it difficult for the patient to change topics. On the other hand, much redirection may be necessary in working with tangential patients.

Intensity of affect

Effective motivational interviewing is generally believed to involve the elicitation of emotion, positive and/or negative. In general, patients who express little emotion throughout a session may not be motivationally engaged. However, this population may be more prone to excessively intense affect that can lead to cognitive disorganization, delusional thinking, hostility, or other symptoms that disrupt the therapeutic process. Therefore, therapists must be judicious in eliciting affect and be prepared to diffuse situations through distraction (e.g., changing topics) or other means.

Session 1 (Introduction, Assessment, Information Feedback)

GENERAL GOALS

To establish a therapeutic alliance and collaborative approach.
To begin to develop discrepancy (raise awareness of the extent of one’s use and its negative consequences).

In this session, a common ground of understanding should begin to take shape. Both therapist and patient should get a clear picture of the patient’s initial perception of the intervention, his reason(s) for coming, his feelings about his current patterns of use, about the prospect of different forms of change, and his reactions to the therapist’s clarifications. Both therapist and patient should come to an understanding of the purpose of the intervention and each person’s role.

OVERVIEW of THERAPEUTIC ACTIVITIES

Introduction to the Intervention.
Assess and Discuss Readiness to Change.
Feedback of Current Use, Consequences, and Risks.

THERAPEUTIC STANCE

Maintaining a non-judgmental stance requires that the therapist remain open to the question of whether or not there is a problem regarding substance use. Premature suggestion that there is a problem may only invite the patient to take the opposite position that there is no problem.

Avoid using words and phrases that are likely to be off-putting to patients, such as those that imply pressure to change (e.g., “quitting”), or have negative connotations (e.g., “drug abuse,” “dependence”). Especially in the early stages, a therapist’s stance should be matter-of-fact and upbeat. Feelings of self-blame and shame are easily evoked and are counterproductive to the change process.

Frame substance use in the context of larger life concerns (to avoid the impression that quitting is an end in itself). If substance use and related consequences are not currently a central concern in the person’s life, acting as if they are (or should be) represents a failure in empathy that can interfere with relationship-building.

THERAPEUTIC ACTIVITIES

#1. Introduction to the Intervention

Purpose

(a) to elicit the patient’s reasons and motivations for coming and (b) to establish understanding of the nature and purpose of the intervention.

Instructions for (a)

Elicit the patient’s reasons for coming. Are they being paid? Is it mandatory? Do they think that talking with a therapist might be helpful to them? How do they feel about being here and participating? It is important to understand the patient’s reasons for participating and level of motivation for doing so. Only then can a therapist express accurate empathy -- understanding the person’s position as well as accepting it.

Example: Welcome! I’m glad you could make it today. By now, I’m sure you’ve been told a little bit about this project and what these meetings will be about, but I’d like to hear from you. What made you decide you’d like to take part in this?

Note. Discussing reasons for participating may or may not lead directly into a discussion of attitudes toward substance use and the prospect of changing it. Although the latter is described below as a separate activity, linking reasons for coming and desire for change may be appropriate.

Instructions (b)

Clarifying the nature and purpose of the Substance Use Discussion sessions is usually necessary, even though they may be conducted within an ongoing therapeutic relationship. Especially if someone else referred the person, the therapist should explain his/her role.

Example: In these sessions I’ll meet with you to explore the role that substance use may play in your life. We will use some of the questionnaires you filled out to help you learn as much as you can about yourself and your use of _____________. What you do with this information is completely up to you -- my role is to help you look at this and provide you with some information you may not be aware of. People generally find this enjoyable and useful in making decisions that feel right for them.

#2. Assess and Discuss Readiness to Change

Purpose

To establish mutual understanding of the patient’s attitudes toward his/her substance use and the prospect of making any changes. To convey respect for the patient’s attitudes. To evaluate using (a) open-ended techniques and (b) structured techniques.

Materials

Expectancy Scales (see Figure 2)

Instructions for (a)

Initiate open-ended discussion of the patient’s current attitudes toward his or her patterns of use and toward change (e.g., “How do you feel about your use of _______ now?”). Reflective listening here can help develop discrepancy, but empathic understanding is the primary concern at the outset of the intervention. This discussion may not only clarify the patient’s position, but may also provide the therapist with a sense of how receptive the patient is to new perspectives and how tolerant s/he is of making explicit the level of discrepancy that exists. In addition, the open-ended nature of this discussion can elicit evidence of how cognitively organized or loose a patient may be, how emotionally reactive, and content areas that are salient (or a source of preoccupation). This helps the therapist adapt his or her actions accordingly.

Example. The following sample dialogue illustrates this first discussion about a patient’s feelings toward his drinking. Several simple reflections and requests for elaboration are used to facilitate self-exploration.

P: I’m sick of it...sick and tired of feeling sick and tired.
T: It makes you feel sick and tired...how so?
P: Both mentally and physically...not clear thinking.
T: Hard to keep your mind on track.
P: Yeah, concentration.
T: Does that involve getting disoriented sometimes?
P: Not really. I don’t drink that much or get that bad.
T: Just feeling less alert or on top of things(?)
P: Yeah (nods).
T: And you said “sick” as well as tired. Does it make you feel sick sometimes?
P: Yeah, nauseous the next morning.
T: So if you have a 40 ouncer, you might not feel so good the next morning.
P: Headache, hangover...

Instructions (b)

After the open-ended discussion, administer (or re-administer) the Expectancy Scales, which consist of ratings of Importance and Confidence with regard to a substance-related goal. Two versions of the scales are generally administered -- expectancies for “cutting down” and for “quitting.” For persons who have recently quit using or who perceive themselves as having made significant changes, a scale is available that assesses expectancies for “maintaining the changes” one has made.

Example. Now, after talking about your feelings on this, I’d like to ask you to use these scales to record where you are in your thinking about (substance) _________. You may recognize these from last time, but sometimes people can feel differently from week to week. The instructions say...(Patient completes rating scales).

This activity can aid the discussion by highlighting differences between (i) attitudes toward cutting down vs. quitting, (ii) importance of changing vs. confidence that change can happen, and (iii) one’s attitudes today vs. last time (if this was previously administered). Some of these differences may have been discussed before introducing the scales. In this case, they may be considered a visual aid to reinforce the discussion and help people process the information more deeply.

Some patients may respond more favorably to “cutting down” their use than quitting completely. Others may feel that quitting is the best approach, perhaps because any use will be problematic or that it will inevitably lead to excessive use. A therapist should strive to understand the patient’s perspective as well as possible. In many cases, a preference between the two goals will not emerge. This affords an opportunity to explore both and help the patient think them through. In-depth discussion of these approaches may be contra-indicated, however, if the patient is not showing an interest in any form of change. This situation can be handled matter-of-factly, with the expectation that reasons for change may emerge in later discussion.
Some patients may express high confidence that they could make changes, but place little importance on such change. In contrast, some may describe a strong wish to change, but little confidence that change is possible. These require the therapist to take different approaches. A therapist may also take one approach with patients who express high importance and confidence, and another approach with those who express low levels of both expectancies. We recommend that the scales be used as a stimulus for discussion rather than an objective measure. An initial response may differ from a view that evolves through a thoughtful discussion.
Discuss current ratings on Expectancy Scales, vis-a-vis pre-test ratings, including why there are discrepancies or why there are no changes.

Example. Compared to the first time you rated these, you seem to think it’s more important to cut down now...but it looks like you’re not any more confident you can do it. Is that about right? Why do you think it’s more important to you now? What would need to happen in order to feel more confident you could cut down, say, from a confidence of here to about here ...?

As noted in Part I of this manual, this intervention may target persons who have recently begun to make changes in their substance use as well as those in earlier stages of change-readiness. Therefore, discussion may focus on attributed importance and confidence regarding the maintenance of changes, when cutting down or quitting has recently taken place. The following sample dialogue begins with the patient responding to the scale of confidence in maintaining his recent reductions in drinking.

Example:

P: It’s really unknown to me. Trying to predict the future...
T: How confident you are is kind of a mystery to you...
P: Yeah. Today, I don’t know.
T: That’s pretty honest. You’re saying, “I’m not entirely certain how able I’ll be to maintain these changes...” (pause, as Patient marks the scale). It looks like, from where you marked your X that you have some confidence but you’re not really sure.
P: Yeah.
T: Do you have ideas about what kind of things might get in the way of your plans?
P: Well, if I met a woman, she may be a drinker and I’d probably start drinking with her...

#3. Feedback of Current Use, Consequences, and Risks

Purpose

To foster the patient’s awareness of the extent of use, comparison to norms, negative consequences, and risks associated with this pattern of use. The “give-and-take” of feedback-reaction may help the patient “own” or accept the information, and starting the process of “developing discrepancy.” For some individuals, this may be the first time they have fully considered the extent of their use, across substances and across time. Eliciting discrepancy between a patient’s self-perception and the facts of recent use may help motivate a reduction in use in order to resolve the discrepancy. Feedback of current use also offers an opportunity to refine our understanding of the patient by asking him/her directly how accurate our information is, and observing reactions to potentially novel information.

Materials

Current Use Worksheets, based on Timeline Follow-back data (see Figure 3)

Instructions

Using the forms appropriate to the patient’s gender and substances used, review recent use. Proceed from topics that are less emotionally charged to those that may be more threatening. Use patterns of a less problematic substance may be reviewed before discussing the “primary problem substance,” and frequency is generally discussed before quantity. Where possible, compare use with population norms. Explore the financial consequences and health consequences of using. Elicit effects across a range of dimensions (e.g., physical, emotional, relational, financial, effects on psychiatric symptoms, etc.). Accept both positive and negative effects. Review increased risks associated with higher rates of use.

Example:

T: Do you remember going over the calendars? We took the information about the last 3 months and simplified it on some summary sheets. This shows how many days in the last 3 months you had some beer or other alcohol. You had 143 drinks during that time. On average, then, you have about 11 drinks each week. Does that sound about right?...So, let’s compare that with the overall population of American women. How much do you think you drink compared to others?
P: About average. Maybe a little less than others.
T: Let’s see...it looks like you’re part of this group. Seven percent of women may drink between 7 and 16 drinks. Six percent may drink more.
P: You mean everyone else drinks less than that -- 7 in a week? No way, not the people I know.
T: The people you know drink more...
P: More than me, yeah.
T: Do you think this information isn’t quite accurate?
P: I don’t know... maybe I’m just used to hanging around people who drink.
T: And so you tend to think that’s how things are (?)
P: Yeah, maybe other people don’t drink as much...

Note: Some patients may report patterns of use that are not excessive, relative to population norms. Due to the nature of schizophrenia and use of psychotropic medications, however, even modest use may cause significant difficulties, including relapses and interactions with medications. Psychoeducation around these issues may be helpful for these patients.

In addition, binge-patterns of use may be obscured by weekly averaging. It is helpful to distinguish between use patterns that are more and less risky. For example, the health consequences are more serious for a patient who drinks a 12 pack at one sitting, compared to another who drinks the same amount spread over the course of a week (1 - 2 drinks per day). In these cases, focus on peak use days and their associated consequences rather than weekly averages.

Additional Examples:

Now we’ve talked a little about your use of __________. These days, what are some of the effects it has on you?...Any other effects? How does it affect your mood? (and probe other dimensions).
You mentioned that it is an issue with your family. Could you give me an example of that? ...Could you tell me more about that? What other difficulties have you had in regard to using __________? (requesting elaboration).
So you like the feeling that it takes you away from some of your problems for a while, but you really don’t like that you eventually have to face those problems and that using may make them worse. (double-sided reflection).
It sounds like using ______ is kind of important to you, since you use it even though you mentioned you’d like to have that money to get your car fixed.

Example of summarizing this activity: So maybe we can review a little. You drink about 11 drinks a week, which is similar to 13% of women in the U.S. Eighty-seven percent of women drink less than that, which was pretty surprising to you. We figured that if you spend about a dollar on each drink, that comes to about $520 each year. We also took a look at Americans’ use of marijuana, seeing that 5% of people have used it in the last month. You thought that was a bit low. Have I got that right?

Summary of Session (and patient response)

Summarize the information elicited by each activity. You may offer the patient the Current Use Sheets to take home and refer to later, but they should be photocopied first, lest they be lost and the content forgotten. In your summary, include the patient ’s reactions to your feedback; in particular, reinforce self-motivational statements, as evoking such statements is a principal purpose of providing feedback. Double-sided reflections may heighten a patient ’s awareness of ambivalence about current use patterns. Also, the summary may set the stage to briefly describe the activities of next session.

Example: So, maybe we can summarize a little. Let me know if I’ve got things right and what isn’t quite accurate, OK? So, you came here because your therapist thought it would be a good idea, but you’re somewhat interested in these issues and don’t really mind talking about them (?) You’re a little bit more interested in cutting down these days, partly because your girlfriend doesn’t want you to use it - and I gather that she’s someone you really care a lot about. You’re not completely confident that you could cut down, but on the other hand you told me about some successes you’ve had, despite the fact that it was tough - like feeling strong urges, and “pressure in your head.” Then, we took a look at how much you smoke and the patterns of Americans overall - you were pretty surprised that it was less than you’d thought - and we talked about why that might be. Is that about right? Have I forgotten anything? OK, next time we’ll do an activity that most people find enjoyable, called “decisional balance.”

A good way to begin summarizing a session is to ask patients what information they recall. This will give you a sense of what the patient found meaningful or memorable.

Example:

T: We’ve talked about a lot of things today. I wonder, what sticks in your memory? What was most significant to you - did anything surprise you or make an impression?
P: I thought that a lot more people smoked pot than they really do. Maybe it’s just the people I hang out with. Finding friends who don’t use it probably wouldn’t be so hard as I thought. Oh, and I’m realizing that I have made some changes - done some things I haven’t really given myself credit for. That’s a pattern with me...