August 8, 2010
Among two of the most ubiquitous counseling approaches at present for helping persons with substance use problems are Cognitive Behavioral Therapy (CBT) and Motivational Interviewing (MI). Last week, I had the honor to deliver a plenary talk and workshop on the topic of combining CBT and MI at the 39th Annual Summer Clinical Institute in Addiction Studies hosted by the University of California, San Diego School of Medicine’s Center for Criminality and Addiction, Research, Training, and Application. Below is a brief summary of the talk and the adjunctive workshop, along with links to the materials that were presented.
During the talk, I spoke about the strong base of empirical evidence supporting CBT and MI, the similarities and differences among the approaches, the rationale for combining them, and specific models for how they could be combined.
The audience was a diverse group of professionals comprised of treatment providers, program directors, researchers, and administrators. Based upon an informal survey of the audience, nearly all of the treatment programs represented by the audience were already delivering CBT in a group format to their clients. Considering that group-based CBT is an evidence-supported approach and relatively cost-effective, this was not surprising. Most of the treatment programs were also actively using MI, or in the process of incorporating MI into their clinical repertoire.
Considering the current structure of the majority of the programs represented at the conference, a logical next step for combining the approaches is to add MI as a precursor to existing treatments. MI as a precursor to treatment can be relatively brief, delivered by the same or different provider who delivers CBT, and can be effective at increasing engagement in subsequent treatment. During the workshop, participants explored a strategy for adding MI as a precursor to their current treatments. Specifically, they practiced eliciting clients’ reasons for engaging in treatment, clients’ concerns and barriers to success, and clients’ strengths and resources that may be accessed during the treatment process. For some participants, this approach felt ”weird” or “awkward” because they were more accustomed to “telling” clients about treatment or “warning” clients about dropping out of treatment. For other participants, the approach felt “natural” and like a good way to build clients’ motivation to engage in treatment.
Another model for combining CBT and MI that was discussed is called “contextually-based integration,” meaning that the provider could move back and forth between CBT and MI based upon the context of clients’ needs and responses. A good model for this approach is described in the Combined Behavioral Intervention Manual (also known as the COMBINE Manual), published by the National Institute on Alcohol Abuse and Alcoholism. In the workshop, participants were able to get a taste of this contextually-based integration process by engaging in a small group “real play” scenario. A “real play” is different from a “role play” in that, a “real play” focuses on a real life issue of the workshop participant, instead of a hypothetical client issue. This scenario was created with the intention of helping participants to develop a greater sense of what it would be like to take part in a group-based CBT module and practice client-centered counseling skills.
During the “real play,” participants reported, at times, feeling vulnerable, concerned that they didn’t have an appropriate example, and some of the other thoughts and feelings clients can experience in treatment. In short, the workshop participants experienced responses that their clients may routinely have while participating in their treatment programs. Other small group members in the “real play” practiced client-centered counseling skills, including open-ended questions, reflections, affirmations, and summary statements that focused on engagement with the CBT module. Not only did these client-centered counseling statements by other group members provide a safe space to practice CBT skill building, the client-centered statements also led to enriched discussions about why the CBT skill was important in their lives.
A copy of the slides and workshop materials are below:
Combining Cognitive Behavioral Therapy and Motivational Interviewing – Slides
Combining CBT and MI Workshop – Slides
CBT and MI Workshop – MI as a Precursor Worksheet
CBT and MI Workshop – DEESC Scripting Worksheet
CBT and MI Workshop – Small Group Exercise Roles
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If you have further questions, or would like to discuss your organization’s needs for training or consulting, please feel free to contact me at email@example.com.
Jim Carter, Ph.D.
Diplomate, Academy of Cognitive Therapy