Brief Integrated Motivational Intervention

A Treatment Manual for Co-occuring Mental Health and Substance Use Problems

Hermine L. Graham, Alex Copello, Max J. Birchwood, Emma Griffith

• Publisher: Wiley-Blackwell
• Year: 2016
• Print ISBN: 9781119166658
• eBook ISBN: 9781119166672
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

BRIEF INTEGRATED MOTIVATIONAL INTERVENTION BRIEF INTEGRATED MOTIVATIONAL INTERVENTION

A TREATMENT MANUAL FOR CO-OCCURRING MENTAL HEALTH AND SUBSTANCE USE PROBLEMS

Brief Integrated Motivational Intervention provides clinicians and specialist practitioners with a brief, evidence-based treatment approach for motivating clients who have comorbid mental health and alcohol and drug misuse issues. Developed by an expert team with many years of research and practice experience in the fields of psychosis and addiction, this approach combines cognitive behavioural therapy (CBT), motivational interviewing, and the authors' own cognitive-behavioural integrated treatment (C-BIT). It allows practitioners to engage clients in meaningful dialogue for change during short windows of opportunity following relapses or admittance to psychiatric hospital, and helps clients consider the impact of substance misuse on their mental health. Easy to understand and implement, this guide also includes helpful tools for practitioners, such as session-specific content, illustrative case material, easy-to-use worksheets, and additional information for family members and friends.

CHAPTER ONE
Introduction

A Window of Opportunity

In healthcare settings, a number of opportunities to talk to clients about health‐related behaviors (e.g., tobacco, alcohol, or drug use) are often “missed,” which may have indirectly contributed to them being admitted or referred for treatment (e.g., Buchbinder, Wilbur, Zuskov, Mclean & Sleath, 2014). Often viewed as “precontemplators,” these clients do not recognize their behavior as causing any problems or as the primary presenting problem. However, it has been suggested that such occasions—that is, when problems are acute—represent “teachable moments” (e.g., Lau et al., 2010; Buchbinder et al., 2014) that present staff in healthcare settings with natural “windows of opportunity” to start conversations about behaviors that may have indirectly impacted on their clients’ physical and mental health (Graham, Copello, Birchwood et al., 2016). As such, there exists a significant need for brief interventions that can be delivered in inpatient or acute healthcare settings, when clients who are not necessarily motivated to talk about their substance abuse are more “open” to considering their use. This period can be viewed as a “window of opportunity” to help clients gain insight into the role of substance use in triggering acute mental health symptoms or hospital admissions, and to improve their engagement in treatment.

Drug and alcohol use and misuse are common in clients who experience severe mental health problems (Regier et al., 1990; Mueser et al., 2000; Graham et al., 2001; Swartz et al., 2006). Substance misuse in this population has been found to be associated with poorer engagement in treatment, more symptoms and relapses, and poor treatment outcomes (Mueser et al., 2000; Graham et al., 2001; Swartz et al., 2006). In addition, these clients often express low motivation to change their drug and alcohol use (McHugo, Drake, Burton & Ackerson, 1995; Carey, 1996; Swanson, Pantalon & Cohen, 1999), and are often poorly engaged in treatment, which forms a significant barrier for change and good treatment outcomes (Mueser, Bellack & Blanchard, 1992; Swanson et al., 1999; Drake et al., 2001; Mueser, 2003). Drug and alcohol misuse have also been found to be associated with increased psychiatric hospital admissions, and seems to have a negative impact on inpatient stays (Lai & Sitharthan, 2012). Therefore, unsurprisingly, 22–44% of those admitted in the United Kingdom into psychiatric inpatient facilities for mental health problems have been found to also have coexisting alcohol or drug problems (DOH, 2006). In the United Kingdom, national health policy guidance has pointed to the need to train staff to improve routine assessment and treatment of substance misuse as part of the clinical management strategy of a psychiatric admission (DOH, 2006). Nonetheless, this has remained a significant gap in service provision (DOH, 2006; Healthcare Commission, 2008), and this natural window of opportunity is often missed.

As the acute symptoms of mental ill health decline for an inpatient, this can be a time of contemplation, when he or she reflects on how they “ended up in hospital.” It may be a window of increased awareness and insight into the factors that contributed to him or her becoming unwell and/or being admitted in a hospital. However, this increased “insight” may result in increased emotional distress, and some research has shown that post‐discharge is a time when individuals may “seal over” the experience, in an attempt to reduce emotional distress. That is, the inpatient may deny or minimize any recent mental health symptoms or experiences and precipitating factors, because they may be too upsetting to think about. As a result, he or she may lose awareness of the triggers for becoming unwell (Tait, Birchwood & Trower, 2003). Sealing over the experience of relapse was found to predict low engagement with services 6 months after discharge for inpatients (Tait et al., 2003). However, we know that engagement in treatment is key to improving treatment outcomes for mental health clients (Carey, 1996; Swanson et al., 1999).

The Brief Integrated Motivational Intervention (BIMI) seeks to target this window of contemplation. It provides clinicians with a brief, targeted, easy‐to‐use intervention that motivates people who experience mental health problems to engage in treatment and make changes in their substance use (Graham, Copello, Griffith et al., 2015). The approach seeks to raise awareness of the impact of drugs and alcohol on mental health. BIMI is empirically grounded in cognitive behavioral therapy (e.g., Beck, Wright, Newman & Liese, 1993; Greenberger & Padesky, 1995) and motivational interviewing (e.g., Hettema, Steele & Miller, 2005). It draws on the initial phases of the longer‐term integrated treatment approach C‐BIT (Graham et al., 2004), and on developments in the use of brief interventions in the treatment of substance use in those who experience severe mental health problems (Carey, Carey, Maisto & Purnine, 2002; Kavanagh et al., 2004; Edwards et al., 2006; Kay‐Lambkin, Baker, Kelly, Lewin & Carr, 2008; Baker et al., 2009). It reflects the research evidence on increasing engagement and motivating behavior change in those with co‐morbid mental health and substance misuse. BIMI was initially developed and piloted in a randomized controlled trial in acute mental health inpatient settings and has demonstrated positive outcomes for engaging inpatients with severe mental health problems in addressing their drug and alcohol use (Graham, Copello, Griffith et al., 2015).

Brief Integrated Motivational Intervention (BIMI)

Approach

BIMI is designed to be delivered by routine mental health staff or specialist practitioners. This treatment manual provides a framework, session content, illustrative case material, and easy‐to‐use worksheets that can be used when delivering it. BIMI promotes a practical conversational style that seeks to build a good collaborative working relationship as you work together toward the client’s self‐identified goals. It is targeted in its approach and is recommended to take place over a brief period, ideally 2 weeks. Sessions can range from one to a maximum of six, depending on the client, and are intended to be delivered in short bursts, each of 15–30 minutes duration. The evaluation of BIMI was performed by staff members who were trained in the approach and who received case supervision. The evaluation found that, on average, an inpatient received three sessions, in addition to the initial assessment session, each of an average duration of 17 minutes, and that the total time that clinicians (i.e., nurses, occupational therapists, healthcare assistants, activity workers, specialist dual‐diagnosis clinicians) spent receiving the intervention was 57 minutes o...

Table of contents

• Cover
• Title Page
• Table of Contents
• About the Companion Website
• About the Authors
• Acknowledgments
• CHAPTER ONE: Introduction
• CHAPTER TWO: Getting Started
• CHAPTER THREE: Making Decisions About Change
• CHAPTER FOUR: Change
• CHAPTER FIVE: Boosting Change
• APPENDIX: Worksheets and Handouts
• References
• Index
• End User License Agreement