Precontemplation Contemplation Preparation Action
A“simultaneousapproach” thataddressesthe “how to do it” elementsconcurrentlywith the systemicguidelines, ismosteffective in implement-ing integrated servicesforco-occurring mental illnessand addictiondisorders. Thisapproachhelpsparticipation branch outbeyond smallpilotgroupsinto broadercommunitiesand statewide arenas.The simultaneousapproach isquite differentfrom the traditionalsequential approach, which focuseson systemsorinfrastructure elementswhile program implementation, staffdevelopment, and serviceprovisionelementsare hardlyaddressed. Service implementation frequentlygetscouched in discussionsofchartersand guidelinesand isoftenexperienced ascomplex, laborious, and abstract. Thisapproach can betime-consuming, wasteful, and delaytreatmentand services. Itisusuallylimited to a small numberofparticipants.
Implementing a SimultaneousApproach
To successfullyimplementa co-occurring program track, the following elementsare necessary• Ascreening tool.• An empathicengagementstrategythatrecognizesclient’sreadiness.• Interventionsthatare stage and phase specific.• Aco-occurring clinical assessment.• Outcome measure.• Program implementation tracking.
• Staffdevelopmentand training thatresultsin participant’slearning “how to” provide servicesand intervention.
The materialsand protocolsforimplementing integrated, co-occurring servicesare readilyavailable and include effective approachessuch asbestpracticesdual diagnosistreatmentand evidence-based motiva-tional interviewing interventionsthatare clear, learnable, and have beenpracticed formore than 20 years.An outstanding example isthe State ofGeorgia, which, forthe pastfiveyears, hasimplemented dual diagnosisprogramsacrosssystemsin aclear, concise waywhile continuing to refine itsinfrastructure.
The state’sgoal isto make everystate-affiliated program capable ofaddressing co-occurring disorders. Everyyear, a seriesoftraining seminarsandintensive program implementation groupsare offered atnumeroustimesformanagersand directcare providers. Each intensive training and tech-nical supportgroup focuseson program implementation acrosssystemsand programs, includesdual diagnosistreatmentand motivational inter-viewing, and yieldsatleast16 new dual diagnosisprograms.
Dual Diagnosisand Motivational Interviewing Interventions
The dual diagnosismodel described here originated in 1984 in the mentalhealth field
and setprecedentsforinterventionsthatfollowed.Motivational interviewing also evolved in the 1980s, butfrom theaddictionsfield.
Both modelsemploysimilarapproachesyetofferseparate setsofskills.Dual diagnosisand motivational interviewing
employacceptance,nonconfrontation, and recognition ofclient’sreadinesslevels, andassesschange incrementally. Building rapport, respect, trust, and safetyin groupsand individual interactionsisparamount. In contrastto thesymptom-focused medical model, these modelsemployinterventionsthatconnectto individualsand strive to understand theirthoughts,feelings, struggles, aspirations, and disappointments. Providersserve asempathicallieswhile working toward facilitating thorough exploration of an issue.These modelsdepartfrom traditional mental health and addictionsprogramsthatview clientswho enterservicesas“action” readyandquicklyforge an action plan. Dual diagnosisand motivational interview-ing engage clientsattheirvariouslevelsofreadinessto change. Eachmodel initiallyemployed a wayto determine clients’ level ofreadinesstochange. Motivational interviewing cited the StagesofChange
asanincremental processofchange. Dual diagnosisdeveloped a ReadinessScale,
which isdescriptive, numerical, and a phase-by-phase treatmentmodel thatdefinesa client’smovementalong the continuum ofchange.The stages, phases, and numerical descriptorscorrelate and provide acrosscheckwhen theyare used in combination. These stage and phasemodelsare recommended asbestpracticesforco-occurring disordersbythe Substance Abuse and Mental Health ServicesAdministration.
Combined InterventionsAlong the Continuum ofChange
Clients’ readinesslevel providesthe explanation fortheirattitudetoward change and ridsprovidersofnegative interpretationssuch asthe“uncooperative” or“resistant” client. Interventionsconcurwith theclient’sreadinesslevel. Dual diagnosisand motivational interviewing modelsare empathic, collaborative, and strategic. Providersremainconnected and follow along with the client(client-centered) whilesimultaneouslyemploying directive strategiesto facilitate clients’movementalong the continuum ofchange. The processofmovementthrough stagesand phasesisnonlinear; clientsmaymove backtoearlierstagesand stagesmayoverlap.
Dual DiagnosisTreatmentand Motivational Interviewing forCo-occurring Disorders
Kathleen Sciacca, MA, Consultant, Executive Director, Sciacca Comprehensive Service DevelopmentforMental Illness, Drug Addiction and Alcoholism
Dual diagnosisand motivational interviewing interventionsmatch stagesin the client’sreadiness
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