Motivational Interviewing

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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,...
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