> 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  |
| dual disorders, DD CAGE,          | 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 beyond |
| (when applicable).                | 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    |                                   |
| readiness scale.                  | b\. Client identifies adverse     |
|                                   | effects, and/or interaction       |
|                                   | between dual disorders            |
+-----------------------------------+-----------------------------------+
| 8\. Client continues in treatment | Continuation of Phase 2:          |
| and/or relapse prevention.        |                                   |
|                                   | c\. Client recognizes impact of   |
|                                   | 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 A*cross 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  | **Moti     | **Dual**     | **Dual Diagnosis**          |
| of        | vational** |              |                             |
| Change**  |            | **Diagnois** | **Intervention**            |
|           | **In       |              |                             |
| Prochaska | terviewing | **Phase**    | **Task**                    |
| and       | Task**     |              |                             |
| D         |            | Sciacca      | Sciacca                     |
| iClemente | Miller and |              |                             |
|           | Rollnick   |              |                             |
+-----------+------------+--------------+-----------------------------+
| 1\.       | Raise      | Id           | Engage client to            |
| Preconte  | doubt;     | entification | participate in a treatment  |
| m-plation | in­crease   | and          | process that includes       |
| stage:    | client\'s  | Engagement:  | exposure and discus­sion of  |
| Person    | perception | Client       | numerous elements of        |
| does not  | of risks   | ide          | addictive disorders,        |
| con-sider | and        | ntifica­tion; | recovery, mental illness    |
| the       | prob­lems   | engage-ment  | and interactions effects.   |
| po        | with       | pro­cess;     | Client participation does   |
| ssibility | current    | assessment   | not require acknowledgment  |
| for       | behavior.  | of readiness | of sub­stance abuse problem. |
| change.   |            | level.       |                             |
+-----------+------------+--------------+-----------------------------+
| 2\.       | Tip the    | Phase One:   | Provide information about   |
| Cont      | balance,   | Client is    | discrete disor­ders and dual |
| empla­tion | evoke      | not required | disorders; express empathy  |
| stage:    | reasons to | to disclose  | regarding the real          |
| Marked by | change,    | personal     | properties of these         |
| am­b       | risks of   | situation;   | dis­orders, including        |
| ivalence; | not        | partici­pates | physiology and the pro­cess  |
| per­son    | changing,  | in           | of recovery; dispel moral   |
| both      | strengthen | discussions  | beliefs and judgements;     |
| con­siders | self       | of           | allow client to participate |
| change    | -efficacy. | educational  | as critic of information;   |
| and       |            | top­ics and   | respect client\'s kno­wledge |
| rejects   |            | materials;   | and opinions.               |
| it.       |            | develops     |                             |
|           |            | trust.       |                             |
+-----------+------------+--------------+-----------------------------+
| 3\.       | Help       | Phase Two:   | Assist client to identify   |
| Prepara   | client     | Client       | and understand adverse      |
| tion-Dete | deter­mine  | discusses    | effects of symptoms and     |
| r­mination | best       | own          | behavior; provide           |
| stage:    | course of  | sub­stance    | information and discussion  |
| Person    | action.    | use and      | of strategies and treatment |
| considers |            | mental       | ap­proaches that have        |
| vari­ous   |            | health;      | potential to bring symptoms |
|           |            | iden­tifies   | into remission; administer  |
| s         |            | adverse      | com­prehensive as­sessment    |
| trategies |            | effects      | and convey findings to      |
| for       |            | and/or       | client.                     |
| change.   |            | inter­actions |                             |
|           |            | between dual |                             |
|           |            | disorders;   |                             |
|           |            | re­cognizes   |                             |
|           |            | impact of    |                             |
|           |            | symp­toms     |                             |
|           |            | upon well    |                             |
|           |            | being.       |                             |
+-----------+------------+--------------+-----------------------------+
| 4\.       | Help       | Phase Three: | Support client's efforts    |
| Action    | client to  | Client       | toward change, including    |
| stage:    | take steps | becomes      | self-efficacy; assist       |
| Person    | toward     | motivated    | client to make necessary    |
| engages   | change.    | for          | adjustments to utilization  |
| in        |            | treatment;   | of strategies and/or        |
| p         |            | ac­tively     | adjunct services or         |
| articular |            | engages in   | interventions; assist       |
| actions   |            | treatment or | client to recognize or      |
| de­signed  |            | symp­tom      | acknowledge positive        |
|           |            | management   | effects of change as it     |
| to bring  |            | until        | occurs; assist client to    |
| about     |            | stability    | recognize need for          |
| change.   |            | and/o­r       | continued supports for      |
|           |            | remission is | sustained chan­ge.           |
|           |            | achieved.    |                             |
+-----------+------------+--------------+-----------------------------+
| 5\.       | Help       | Phase Three: | Assist client to develop    |
| Ma        | client     | Client       | network of sup­ports;        |
| intenance | iden­tify   | participates | utilize and adjust to each  |
| stage:    | and use    | in           | of these supports; gain a   |
| Person    | strat­egies |              | working understanding of    |
| strives   | to prevent | relapse      | client\'s motivation for    |
| to        | relapse;   | prevention.  | change; explore and         |
| sus­tain   | client may |              | understand client's use of  |
| changes   | exit       |              | deterrents from previous    |
| made in   | wheel,     |              | behaviors; explore and      |
| action    | into       |              | avoid potential relapse     |
| phase.    | permanent  |              | pitfalls.                   |
|           | ma         |              |                             |
|           | intenance. |              |                             |
+-----------+------------+--------------+-----------------------------+
| 6\.       | Help       | Relapse:     | Assist client to renew      |
| Relapse   | client     | Client has   | motivation and efforts;     |
| stage:    | renew      | minor slip   | explore utilization of, or  |
| Person    | process of | or major     | failure to, utilize         |
| has minor | cont       | relapse.     | previ­ous deterrents to      |
| slips or  | em­plation, |              | relapse; explore and        |
| major     | det        |              | discover possible pitfalls; |
| re­lapses; | ermina­tion |              | help client to learn from   |
| seen as   | and        |              | re­lapse; relapse is not     |
| normal    | action,    |              | considered to be a failure  |
| part of   | without    |              | of treatment; client does   |
| change    | becoming   |              | not suffer                  |
| process.  | stuck or   |              | treatment-model-imposed     |
|           | d          |              | consequences; empathy,      |
|           | emoral­ized |              | sup­port and encouragement   |
|           | due to     |              | are provided until client   |
|           | relapse.   |              | 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    | Acceptance of all symptoms in all |
| seen as the corner-stone of the   | phases is essential. The          |
| intervention process and relates  | development of trust is a part of |
| to all and any experiences        | the treatment process.            |
| conveyed by the client. It is     | Understanding and pro-viding      |
| marked by the underlying attitude | information about the real        |
| of \"ac­ceptance.\" It includes    | properties of each disorder, and  |
| warmth and reflective listening   | dispelling moral beliefs, stigma  |
| in an effort to understand the    | and judgments is a formative      |
| client\'s feelings and            | goal.                             |
| 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 recognize |
| goals will moti­vate change. The   | adverse effects and consequences  |
| client should present the         | of singular/dual disorders and    |
| arguments for change.             | interaction effects through an    |
|                                   | integral under­standing of         |
|                                   | information and personal          |
|                                   | experi­ence. Acknowledge and       |
|                                   | actualize client\'s               |
|                                   | con­siderations for change through |
|                                   | discussion.                       |
+-----------------------------------+-----------------------------------+
| 3\. *Avoid Argumentation*.        | Client\'s opinions and beliefs    |
| Arguments are coun­ter productive. | are respected. Therapist and      |
| Defending breeds defensiveness.   | peers may hold different views    |
| Resistance is a signal to change  | but they are not expressed in     |
| strategies. Labeling is           | rebuttal to client\'s beliefs.    |
| 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, with |
| imposed. The client is a valuable | client as critic versus student.  |
| resource in finding solutions to  | The client is a valuable resource |
| problems.                         | in finding solutions to problems. |
|                                   | In group treatment all clients    |
|                                   | participate in finding solutions  |
|                                   | for them­selves and one another.   |
+-----------------------------------+-----------------------------------+
| 5\. *Support self-efficacy.*      | Support, encouragement and the    |
| Belief in the possibility of      | belief in the possibility of      |
| change is an important motivator. | change is essential. For clients  |
| The client is responsible for     | who have severe mental health     |
| choosing and carrying out         | symptoms that may impair a vision |
| personal change. There is hope in | for the future, the therapist     |
| the range of                      | must envision the outcome of      |
|                                   | change and pre-sent such          |
| alternative approaches available. | 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