Sciacca, K. 1997.

Removing barriers: dual diagnosis and motivational

interviewing. Professional Counselor 12(1): 41-6. Reprinted with
permission from Health Communications, publisher of Counselor (formerly
Professional Counselor), www.counselormagazine.com. All rights reserved.

"Removing Barriers: Dual Diagnosis Treatment and Motivational

Interviewing"

In the past, traditional treatment methods for drug addiction and alcoholism have been
characteristically intense and confrontational. They are designed to break down a client’s denial,
defenses, and/or resistance to his or her addictive disorders, as they are perceived by the
provider. Admissions criteria to substance abuse treatment programs usually require abstinence
from all illicit substances. Potential clients are expected to have some awareness of the problems
caused by substance abuse and be motivated to receive treatment.
In contrast, traditional treatment methods for mental illness have been supportive, benign
and non-threatening. They are designed to maintain the client's already-fragile defenses. Clients
entering the mental health system are generally not seeking treatment for their substance abuse
problems. Frequently clients within the mental health system who actively abuse drugs and
alcohol are not formally identified. If they are, they do not admit to such substance use.
As some attention began to focus on clients with both substance abuse problems and
mental illnesses, it quickly became apparent that new methods and interventions were necessary.
Working with dual disorder clients who deny substance abuse, who are unmotivated for
substance abuse treatment, and who are unable to tolerate intense confrontation, required a new
model, a non-confrontational approach to the engagement and treatment of this special
population. I first developed such a treatment model in 1984, with the goal of providing
nonjudgmental acceptance of all symptoms and experiences related to both mental illness and
substance disorders.

A brief history
Such treatment interventions and integrated programs -- which truly adapted to the needs
of severely mentally ill chemical abusers -- had their genesis in 1984 at a New York state
outpatient psychiatric facility. In 1985, these integrated treatment programs were implemented
across multiple program sites. Concurrently, treatment and program elements were taught
through training seminars in New York as well as nationally.
In September 1986, the New York State Commission on Quality of Care (CQC) released
the findings of 18 months of research. In their report, they described the detachment and
downward spiral of dually diagnosed consumers, who were bounced among different systems
with "no definitive locus of responsibility." As a result, New York’s governor designated the
state Office of Mental Health as the lead agency responsible for coordinating collective efforts
for this population. The commission visited the dual diagnosis programs developed in 1984, and
declared the treatment interventions, the training, and integrated programs to be positive
solutions to the dilemma.
 When a 1987 Time magazine investigation of these programs revealed that at least 50
percent of the 1.5 million to 2 million Americans with severe mental illness abuse illicit drugs or
alcohol -- as compared to 15 percent of the general population -- the "doubly troubled" were
brought to the attention of the general public.
A gubernatorial task force declared its vision for statewide program development and a
training site for program and staff development in the treatment of mentally ill chemical abusers
was created to attain that vision. Short-term and on-going training and program development was
provided to hundreds of New York’s treatment providers at both state and local mental health
and substance abuse agencies. Consumer-led and family-support programs were also developed.
The state produced a training video that demonstrated the integrated treatment model, however,
the training site closed in 1990 due to budgetary considerations. Programs and groups that grew
out of this model continue to be an important nucleus of current services in New York and
nationally.
These treatment interventions evolved in adaptation to the needs of the dual diagnosis
clients. Methods and philosophies clearly differed from traditional substance abuse treatment.
Consumers who were actively abusing substances, physically addicted, unstable, and
unmotivated, were engaged through a "non-confrontational" approach to denial and resistance,
and acceptance of all symptoms. Consumers participated in treatment groups without pressure to
self-disclose, and explored topics from their own perspectives. Subsequent providers either
learned from this model, or came upon similar processes through their own experimentation.

How it works
The phase-by-phase interventions from "denial" to "abstinence" begin by assessing the
client's readiness to engage in treatment. Readiness levels are accepted as starting points for
treatment, rather than points of confrontation or criteria for elimination. Mental health and
substance abuse programs who integrate these programs, implement screening forms to identify
clients who have dual disorders.
Identified clients are followed up for engagement and assessment of readiness. Clients
are encouraged to participate in dual diagnosis treatment even if they do not accept or agree to
the presence of a substance disorder. Clients may participate on the basis of their interest in
learning more about mental health and substance disorders, or with the belief that they may be
able to lend support to others who are seeking help, among other reasons. The process then
proceeds from identification to the engagement phase.
The objective in the engagement phase is to develop comfortable and trusting
relationships and, if possible, to expose the client to information about the etiology and processes
of these illnesses in an empathic and educational manner. The client is given the opportunity to
critique the information presented, rather than being told about any particular fact. Interaction
effects between symptoms of mental illness and substance disorders are also included in this
exploration. Clients at this phase are not required to disclose personal experiences or to admit
they use or abuse substances until they are comfortable doing so.
The inclusion of educational materials and discussion topics allows for discussion of the
issues and impersonal participation. Clients are encouraged to move along a continuum from
“exploration” to “acknowledgment” of their symptoms. This includes:
* attaining a level of trust necessary to discuss their own use of substances and/or
symptoms of mental illness;
* the exploration and subsequent discovery of any problems or interaction affects that
result from substance use and mental health symptoms;
* considerations and motivation for addressing these problems;
* active engagement in a process of treatment that seeks to eliminate symptoms;
* attainment of partial or full remission;
* and participation in an individualized maintenance regime for relapse prevention.
These programs are implemented as components of existing mental health, and substance
abuse programs, and thereby provide integrated treatment.
Materials developed for the implementation of this treatment process include
screening instruments, with separate instruments used for detecting substance abuse among
persons who are known to have a mental illness, and detecting mental illness among those
persons who are known to have substance abuse/dependence.
The pre-group interview provides engagement strategies and a scale to indicate the
client's level of readiness or motivation to participate in treatment. The comprehensive
assessment reviews past and present mental illness, substance abuse, and interaction effects.
Forms for progress reviews and updates include criteria necessary to measure change throughout
the phases of movement toward readiness for treatment, active treatment, and relapse prevention.
Forms for data collection include programmatic information regarding statistics, client
participation, and outcome. See Figure one.

Figure 1: Sciacca Treatment Model for Dual Diagnosis*

Program Form/Intervention Process and Outcome

1. Screening: Mental health, Identification of potential

dual disorders, DD CAGE, dual diagnosis clients.
substance abuse, MISF.

2. Pre-group interview and a. Engagement into group

readiness scale. Engagement. treatment;
b. Assessment of readiness
level (1-5).

3. Continuation of engagement Client requires engagement

(when applicable). beyond pre-group interview.

4. Provide group treatment. Phase 1: Client does not

disclose personal situation,
participates in discussions or
educational materials/topics,
develops trust.

5. Complete monthly data form

for each group.

6. Administer comprehensive Phase 2:

assessment (phase two): a. Client discusses own
 a. Integrate information into substance abuse/mental health.
treatment plan;
b. Make diagnosis.

7. Client progress review Continuation of Phase 2:

updated periodically, includes b. Client identifies adverse
readiness scale. effects, and/or interaction
between dual disorders

8. Client continues in Continuation of Phase 2:

treatment and/or relapse c. Client recognizes impact of
prevention. symptoms upon well being.

Phase 3:
a. Client becomes motivated
for treatment.
b. Client actively engages in
treatment and symptom
management until stability
and/or remission is achieved.
c. Client participates in
relapse prevention.
*from Journal of Mental Health Administration, Vol.23,No.3 Summer 1996, SAGE
Publications "Program Developmnet Across Systems for Dual Diagnosis: Mental Illness
Drug Addiction and Alcoholism, MIDAA" by: Sciacca, K. & Thompson, C.. pp. 288-297.

Motivational interviewing
As the dual diagnosis treatment model for substance abuse treatment evolved within the
mental health system, motivational interviewing evolved within the field of alcoholism
treatment. Some striking similarities can be found -- in both philosophy and methodology -- in
comparison to dual diagnosis treatment, including the points of departure from traditional
substance abuse treatment:
Dual disorder treatment and motivational interviewing:
* forego traditional treatment-readiness criteria and begin at the client's stage of
readiness/motivation and degree of symptomatology.
* do not utilize intense, confrontational interventions in response to denial or resistance.
* advocate the need for the development of trust as essential to the treatment process.
* advocate acceptance, empathy and respect for the client's perceptions, beliefs and
opinions. They tolerate disagreement and dispel moral and judgmental beliefs.
* do not interpret relapse as treatment failure, or employ punitive consequences.
* convey and/or provide a hopeful vision, a belief in the possibility of change, and
support self-efficacy.
The authors of motivational interviewing (Miller and Rollnick, 1991) detailed the
underlying beliefs that form the foundation for intense confrontational traditional substance
abuse treatment. They have conducted literature searches and research around the principles of
this foundation and have found no supporting evidence for these widely held beliefs.
One main example is the belief that motivation is a personality problem. This assumption
is that alcoholics, addicts, offenders, etc., possess extremely potent defense mechanisms that are
deeply ingrained in their personality and character. These defenses are considered to be non-
responsive to ordinary means of therapy and thereby justify aggressive confrontational
interventions.
In view of their findings Miller and Rollnick assert that "...there is not, and never has
been, a scientific basis for the assertion that alcoholics (let alone people suffering from all
addictive behaviors) manifest a common consistent personality pattern characterized by
excessive ego-defense mechanisms."
Within motivational interviewing, confrontation is recognized as a treatment "goal" not a
style. It is part of the change process that includes "awareness raising." It is likened to Carl
Rogers’ client-centered philosophy, which sought to provide a safe atmosphere for the
examination of self and change. Like dual diagnosis treatment, confrontation is not used in
response to client's denial or resistance.

A state of readiness
Motivational interviewing strategies correlate to client readiness based upon the stages of
change theory (Prochaska and DiClemente, 1984). Stages of change are represented in the form
of the "wheel of change," which indicates that one can go around the wheel several times. (See
Figure 2 for stages, motivational interviewing and dual diagnosis correlates.) The five principles
of motivational interviewing that entail a therapist's style as well as strategy also correlate to dual
diagnosis treatment interventions. (See Figure 3 below.)

Figure 2: Stages of Change and Accompanying Tasks

Stages of Motivation Dual Dual Diagnosis
Change al Diagnois Intervention
Prochaska Interviewi Phase Task
and
DiClemente ng Task Sciacca Sciacca
Miller and
Rollnick

1. Raise doubt; Identification Engage client to participate in

Precontem- increase and a treatment process that
plation client's Engagement: includes exposure and discus-
stage: perception of Client sion of numerous elements of
Person does risks and identifica- addictive disorders, recovery,
not con- problems with tion; engage- mental illness and interactions
sider the current ment process; effects. Client participation
possibility behavior. assessment of does not require acknowledgment
for change. readiness of substance abuse problem.
level.

2. Tip the Phase One: Provide information about

Contempla- balance, Client is not discrete disorders and dual
tion stage: evoke reasons required to disorders; express empathy
Marked by to change, disclose regarding the real properties
am- risks of not personal of these disorders, including
bivalence; changing, situation; physiology and the process of
person both strengthen participates recovery; dispel moral beliefs
considers self- in discussions and judgements; allow client to
change and efficacy. of educational participate as critic of
rejects it. topics and information; respect client's
materials; knowledge and opinions.
develops
 trust.

3. Help client Phase Two: Assist client to identify and

Preparation determine Client understand adverse effects of
-Deter- best course discusses own symptoms and behavior; provide
mination of action. substance use information and discussion of
stage: and mental strategies and treatment ap-
Person health; iden- proaches that have potential to
considers tifies adverse bring symptoms into remission;
various effects and/or administer comprehensive as-
strategies interactions sessment and convey findings to
for change. between dual client.
disorders; re-
cognizes
impact of
symptoms upon
well being.

4. Action Help client Phase Three: Support client’s efforts toward

stage: to take steps Client becomes change, including self-
Person toward motivated for efficacy; assist client to make
engages in change. treatment; ac- necessary adjustments to
particular tively engages utilization of strategies
actions de- in treatment and/or adjunct services or
signed or symptom interventions; assist client to
to bring management recognize or acknowledge
about until positive effects of change as
change. stability it occurs; assist client to
and/or recognize need for continued
remission is supports for sustained change.
achieved.

5. Help client Phase Three: Assist client to develop

Maintenance identify and Client network of supports; utilize
stage: use strat- participates and adjust to each of these
Person egies to in supports; gain a working
strives to prevent relapse understanding of client's
sustain relapse; prevention. motivation for change; explore
changes client may and understand client’s use of
made in exit wheel, deterrents from previous
action into behaviors; explore and avoid
phase. permanent potential relapse pitfalls.
maintenance.

6. Relapse Help client Relapse: Assist client to renew

stage: renew process Client has motivation and efforts; explore
Person has of contem- minor slip or utilization of, or failure to,
minor slips plation, major relapse. utilize previous deterrents to
or major determination relapse; explore and discover
relapses; and action, possible pitfalls; help client
seen as without to learn from relapse; relapse
normal part becoming is not considered to be a
of change stuck or failure of treatment; client
process. demoralized does not suffer treatment-
due to model-imposed consequences;
relapse. empathy, support and
encouragement are provided
until client moves beyond
relapse.
Removing barriers
Dual diagnosis treatment approaches and motivational interviewing interventions
represent far-reaching changes for substance abuse treatment and comprehensive services, within
both the mental health and substance abuse systems. The removal of the long-standing barriers of
traditional substance abuse treatment readiness criteria opens the way for persons with various
profiles of singular, dual and multiple disorders, including the homeless, the incarcerated, and
others who have been disengaged. These people will be provided an opportunity to develop the
trust necessary to participate in an exploration of their situation, and thereby to make informed
decisions regarding change
These non-confrontational, non-threatening approaches that are necessary for those who
have a severe mental illness will also embrace others who might never have the opportunity to
participate in substance abuse treatment due to their inability to acknowledge substance abuse as
a problem, become motivated, or tolerate intense confrontational interactions.

Figure 3: Motivational Interviewing Principles And Dual Diagnosis

Correlates

Motivational Interviewing Dual Diagnosis Correlate

Technique

1. Express empathy. This is seen Acceptance of all symptoms in

as the corner-stone of the all phases is essential. The
intervention process and relates development of trust is a part
to all and any experiences of the treatment process.
conveyed by the client. It is Understanding and pro-viding
marked by the underlying information about the real
attitude of "acceptance." It properties of each disorder, and
includes warmth and reflective dispelling moral beliefs, stigma
listening in an effort to and judgments is a formative
understand the client's feelings goal.
and perspectives without
judging, criticizing or blaming.
It conveys respect. Ambivalence
is accepted as a normal part of
human experience not as
psychopathology.

2. Develop discrepancy. Provide atmosphere that is

Awareness of consequences is conducive for client to move
important. A discrepancy between toward self disclosure through
present behavior and important trust. Assist client to
goals will motivate change. The recognize adverse effects and
client should present the consequences of singular/dual
arguments for change. disorders and interaction
effects through an integral
understanding of information and
personal experience. Acknowledge
and actualize client's con-
siderations for change through
discussion.
 3. Avoid Argumentation. Client's opinions and beliefs
Arguments are counter are respected. Therapist and
productive. Defending breeds peers may hold different views
defensiveness. Resistance is a but they are not expressed in
signal to change strategies. rebuttal to client's beliefs.
Labeling is unnecessary. Defending is unnecessary. A
"non-confrontational" approach
to resistance or denial is
utilized. Client explores
effects or symptoms of various
disorders and does not have to
accept labels.

4. Roll with resistance. New Topic areas are explored from

perspectives are invited by not many different perspectives,
imposed. The client is a with client as critic versus
valuable resource in finding student. The client is a
solutions to problems. valuable resource in finding
solutions to problems. In group
treatment all clients
participate in finding solutions
for themselves and one another.

5. Support self-efficacy. Belief Support, encouragement and the

in the possibility of change is belief in the possibility of
an important motivator. The change is essential. For clients
client is responsible for who have severe mental health
choosing and carrying out symptoms that may impair a
personal change. There is hope vision for the future, the
in the range of therapist must envision the
alternative approaches outcome of change and pre-sent
available. such possibilities to the
client. The client participates
in the course of action for
change.

As the number of mental health and other providers who find the new non-
confrontational approaches to be comfortable and in keeping with their therapeutic style
increases, the total number of substance abuse treatment providers will rise correspondingly.
This will greatly increase the availability of substance abuse services. Most important, the
quality of care will proceed in the direction of the development of trust, respect, empathy,
empowerment, and will measure success along a multitude of criteria.
The systemic changes will yield both mental health and substance abuse agencies more
comprehensive in scope. This will change the course of history that has eliminated dually
diagnosed clients and other client profiles who have been deemed "unmotivated" or "not ready"
for treatment. Agencies may readily include services that employ an "exploratory" versus
"expert" approach. This will provide many opportunities to provide education within all models
of service. For some substance abuse practitioners dual diagnosis treatment and motivational
interviewing interventions may represent a dramatic departure from their current practice and
techniques. Miller and Rollnick suggest that motivational interviewing techniques be included in
one's "tool box" of interventions and be utilized when traditional approaches fail.
It is clear that these new interventions and efforts to accomplish comprehensive care will
carry forward into the new millennium. Each of these changes represents models of "inclusion"
and will replace the "exclusionary" models that have resulted in serious casualties among
persons who suffer with singular, dual or multiple disorders.

Kathleen Sciacca is founding executive director of Sciacca Comprehensive Service Development

for Mental Illness, Drug Addiction and Alcoholism (MIDAA) in New York City. She is a
nationally and internationally known consultant, program developer, lecturer, and seminar leader
for dual diagnosis and a trainer of motivational interviewing. Sciacca is author of the MIDAA
Service Manual: A Step by Step Guide to Program Implementation and Integrated Treatment for
Dual Disorders, and producer of the education and training video, Integrated Treatment for
MIDAA: The Alaska Example. Dual Diagnosis Website: http://pobox.com/~dualdiagnosis