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The chapter describes how to manage ruptures in the therapeutic alliance. It opens by outlining a conceptual model to understand the ruptures and proceeds to consider the ways that ruptures may manifest at different points in psychotherapy. One way to respond to some ruptures in alliance in via enhancing motivation and therefore the technique of Motivational Interviewing is described in detail; outlining the steps of expressing empathy, developing discrepancies (between actual and desired outcomes), avoiding argumentation, rolling with resistance and supporting self-efficacy. The chapter reviews ways to manage the assignment and review of homework exercises so that they are a productive element in clinical psychology practice. The chapter concludes with a close examination of psychotherapeutic process; defining what “process” is, and how to work with transference and countertransference.
The chapter outlines for the clinical psychologist how longer treatments can be adapted in the form of brief interventions. As an example with a strong evidence base, we focus on brief interventions for alcohol use. The aim of these interventions is to raise awareness of alcohol-related risk and reduce hazardous and harmful drinking behaviour. The chapter outlines a detailed, practical example of a brief intervention for problem drinking.
This chapter introduces the intersections between mental health care and drug and alcohol care. It addresses the implications for holistic health care needs related to dual drug and alcohol use, and concurrent mental health conditions. It tells the contemporary, real-life story of a person who developed an episode of psychosis following consumption of premixed alcohol and caffeine drinks. The chapter also describes change models applied to substance use and recovery, such as motivational interviewing and stages of change readiness. Both common and less common drugs and their misuse affect the physical, social, cognitive and mental health dimensions of people with mental health conditions. Reflective exercises guide readers to consider how they will be able to promote mental health and well-being and minimise drug-related harm to individuals and communities in a practice context.
This chapter explores the biopsychosocial factors that influence prescribing behaviour. It begins by introducing theories of behaviour to explore how health systems, pharmaceutical companies, individual professions, roles and identities, colleagues, patients, the time of day, personal beliefs, habits, emotions and the environmental setting can all influence prescribers and their prescribing behaviour. It also discusses the influences of wider society and culture and how that has also shaped healthcare, prescribing practice and patients’ understandings of illness and their expectations around healthcare and treatment. Having taken a look at all these influences on prescribing behaviour, it gives an overview of interventions that help prescribers optimise their prescribing decision making and prescribing behaviours as well as optimise patient satisfaction with and adherence to treatment. These include person-centred and shared decision making, using motivational interviewing to enhance communication during consultations and evidence-based training programmes that have used these approaches to optimise non-medical prescribing.
A substantial proportion of patients receiving cognitive behavioural therapy (CBT) do not achieve remission, and drop-out is considerable. Motivational interviewing (MI) may influence non-response and drop-out. Previous research shows that MI as a pre-treatment to CBT produces moderate effects compared with CBT alone. Studies integrating MI with CBT (MI-CBT) are scarce.
To test the feasibility of MI-CBT in terms of therapist competence in MI and various participant measures, including recruitment and retention. In addition, separate preliminary evaluations were conducted, exploring the effects of CBT alone for anxiety disorders and depression, and of MI-CBT for anxiety disorders, depression and unhealthy lifestyle behaviours.
Using a randomised controlled parallel trial design, participants were recruited in routine psychiatric care and allocated to CBT alone or MI-CBT. Means in feasibility measures and within-condition Hedges’ g effect sizes in treatment outcome measures were calculated. Authors were not blind to treatment allocation, while independent raters were blind.
Seventy-three patients were assessed for eligibility, and 49 were included. Participant perceptions of treatment credibility, expectancy for improvement, and working alliance were similar for both conditions. Overall, effect sizes were large across outcome measures for both conditions, including anxiety and depressive symptoms and functional impairment. However, therapists did not acquire sufficient competence in MI and the drop-out rate was high.
MI-CBT proved feasible in some respects, but the present study did not support the progression to a randomised controlled trial designed to assess the effectiveness of MI-CBT. Additional pilot studies are needed.
Available evidence demonstrates that it is feasible to integrate Motivational Interviewing (MI) techniques with Enhanced Cognitive Behavioural Therapy (CBT) for the treatment of obesity and that this combined intervention has the potential to improve health-related outcomes of patients and to maintain behavioural changes over time. In addition, the use of Virtual Reality (VR) using embodiment techniques in the treatment of behavioural disorders has proved its preliminary effectiveness.
1) to adapt the embodiment tool for treating obesity in a clinical setting, and 2) to compare its preliminary effectiveness to usual care.
A randomized control trial (SOCRATES project, funded by the European Union’s H2020 program under grant agreement No 951930) will be carried out with 66 participants with a Body Mass Index (BMI) >30, who will be split into two groups (control and intervention). The participants will be recruited from the external consultations of the Vall d’Hebron University Hospital. Readiness to change, BMI, dietetic habits and physical activity, self-perception of the body size, satisfaction with self-image and quality of life in relation to body image will be assessed before and after the intervention and at 4-week follow-up. Finally, variables related to the adoption of the VR tool in terms of perceived usability, user’s satisfaction and technology acceptance will be also evaluated.
Not yet available
The study will provide an important advance in the treatment of obesity, first, by improving the effectiveness of available psychological treatments integrating embodiment, MI and CBT techniques, and second, reducing treatment duration and costs compared to conventional therapies.
One reason that motivational interviewing (MI) is thought to translate well to a variety of treatment domains is due to the focus on client ambivalence.
Therefore, the current study aimed to explore the construct of ambivalence in the context of MI and cognitive behavioural therapy (CBT) for social anxiety disorder (SAD).
Participants were 147 individuals diagnosed with SAD who were randomised to receive either MI or supportive counselling prior to receiving group CBT for SAD.
The results suggested that MI was not related to decreases in general ambivalence or treatment ambivalence, although an indicator of treatment ambivalence was found to predict worse treatment outcome.
The findings suggest that three sessions of MI prior to CBT may not decrease ambivalence in participants with SAD, which may underscore the potential importance of tackling ambivalence as it arises during CBT.
Family therapies for adolescents with attention deficit hyperactivity disorder (ADHD) face notorious engagement problems related to population-specific barriers. Supporting Teens’ Autonomy Daily (STAND) is an empirically-supported engagement-focused therapy for parents and teens with ADHD. In this chapter, we step into the lives of adolescents with ADHD and their parents, uncovering why therapeutic behavior change historically eluded this population. We describe the STAND model and discuss specific strategies that therapists can employ to enhance parent and teen engagement. Our approach draws from social psychology research on human motivation, change-oriented therapies such as motivational interviewing (MI), research on therapy homework and habit formation, behavioral principles and our own trial and error working with families. We share the results of three clinical trials that established STAND’s efficacy and discuss limitations and future directions for the evolving STAND model. We invite readers to collaborate with us in this process, creating their own brand of STAND to improve the lives of families.
Evidence for the idea that some individuals may experience an addictive-like response to certain foods has grown in the past decade. Food addiction parallels substance use disorders to suggest that highly processed foods (e.g., chocolate, French fries) may exhibit an addictive potential and trigger addictive-like responses in vulnerable individuals. An opposing conceptualization of addictive-like eating was recently developed, suggesting that the behavioral act of eating may be addictive rather than highly processed foods. However, the arguments for a behavioral eating addiction do not consider the central role of behaviors within substance use disorders and are not supported by preliminary research demonstrating that highly processed foods may directly contribute to the addictive-like eating phenotype. The primary goal of this chapter is to argue that a substance-based, food addiction framework is the most appropriate reflection of the current state of the literature and more closely parallels scientific understanding of addictive disorders. Specifically, this chapter will review theoretical debates between the food versus eating addiction perspectives, raise concerns about discrepancies between eating addiction and existing behavioral addictions, and review assessment tools for food and eating addiction. Finally, implications for stigma, intervention, and future research are discussed.
Approximately 23.5 million people in America need assistance for an alcohol, tobacco, or other drug use (ATOD) disorder, although many do not obtain the help that they need. This disorder is extremely difficult to resolve, as it can be hard to make the necessary lifestyle changes to accommodate sobriety. Sometimes, individuals may recover without formalized treatment, otherwise known as natural recovery. Other times, inpatient or outpatient treatment, or partial-hospitalization, is warranted. Even for individuals taking the proper steps and going to treatment, attrition rates are high, with consistent drop-out rates of 30 percent to 40 percent within three months of treatment initiation. Racial and gender disparities in both treatment participation and outcomes exist, indicating a need for tailoring of treatments and further research on breaking barriers to treatment entrance. Motivation is central in several recovery models proposed to explain stages of change in treatment. Treatment options include initial detoxification and pharmacological options (such as medication-assisted treatment using buprenorphine for opioid use disorder), cognitive-behavioral therapy, motivational interviewing, cue exposure, attentional retraining, twelve-step programs, and group/family therapy. Relapse rates are high, and oftentimes individuals move from one addiction to another. Harm reduction approaches may be beneficial to those that cannot fully quit an addiction, and relapse prevention is an important treatment component, as addiction is a life-long battle.
Skin cancer is a major public health issue with global rates of disease steadily on the rise. Intentional tanning behaviors, including sunbathing and indoor tanning, are high-risk practices strongly associated with an increased risk of skin cancer. Despite the known health risks, both indoor and outdoor tanning remain popular, particularly among young adult non-Hispanic white women. While all tanning increases the risk of skin cancer, in a subset of those who tan the behavior becomes frequent and excessive, with addiction-like properties. “Tanning addiction” is thus associated with the characteristics of other addictions such as craving for the behavior, a reinforcing effect, an inability to quit, and resulting adverse health consequences related to the behavior. Motivations driving tanning addiction may stem from both psychological factors such as appearance norms and from the physiologic effects of exposure to ultraviolet light on brain reward pathways influencing mood. In this chapter we present the concept of tanning as an addiction, reviewing its definition, measurement, and prevalence in the population, and outlining the empirical evidence for the behavioral and biological drivers of tanning addiction. The implications of this research, we suggest, warrants greater attention to this emerging addiction, and necessitates the development of effective prevention and treatment interventions in those at risk of addictive tanning.
This chapter provides an overview of the key areas of agreement and debate about workaholism, particularly its conceptualization, prevention, and treatment. The chapter integrates biomedical and health psychology perspectives with a view to challenging and advancing understanding on how to prevent people from developing a problematic relationship with work, and how best to support those experiencing the problem. The chapter begins by reviewing the conceptualization of workaholism, and then reviews the existing evidence concerning the main correlates and vulnerability factors. This discussion then leads to an exploration into alternative ways that workaholism can be theorized, in particular biopsychosocial models and critical theory of addiction. Building upon this combined theoretical perspective, the chapter ends by reviewing and speculating on different aspects of prevention and treatment according to the different stakeholders involved.
To assess whether the combination of motivational interviewing and psychoeducation affects relapse rate and stimulates involvement of people with psychosis in their treatment. We conducted an interventional study including patients with schizophrenia or schizoaffective disorder treated with oral antipsychotics, without previous experience of long-acting injectable antipsychotics (LAIs). They were randomised to either psychoeducation with motivational interviewing or a control group. Hospital admissions 18 months before and after the intervention, and switches to LAIs 18 months after the intervention, were recorded.
The two groups each comprised 101 participants. Fourteen from the intervention group and seven from the control group switched to LAIs. Five in the intervention group instigated the switch themselves, compared with zero controls (P = 0.06). Fourteen in the intervention group were readmitted to hospital during follow-up, compared with 23 in the control group (P = 0.14).
Psychoeducation with motivational interviewing may increase patients' involvement in their treatment and reduce the relapse frequency.
Most people get information about marijuana from friends, the Internet, newscasts and personal experience – all echo chambers filled with anecdotes, opinions, and little science. Clinicians receive little education about marijuana. From Bud to Brain provides health professionals the science of marijuana needed to offer the public objective and relevant advice about the safe and effective use of marijuana. The need is huge: 1 out of 5 US citizens can buy recreational marijuana legally and over 200 million have access to medical marijuana. Products from the cannabis plant include dried buds (marijuana), resin (hashish) and concentrates (dabs, budder) that can be smoked, vaped or fashioned into edibles. Understanding how THC produces the experience of being high requires understanding the brain’s natural THC-like chemistry and what parts of the brain are impacted by marijuana. Tracing the research discoveries leading to understanding the science of marijuana gives clinicians the scientific context to help patients make wise decisions about its use. The principles of motivational interviewing are reviewed to help clinicians communicate a science-based perspective on marijuana to recreational users, medical patients, adolescents, worried parents and heavy users.
Every clinician encounters patients compromised by marijuana, whether fully addicted or not and whether recognized by the individual or not. While adult heavy users usually seek help themselves (often in response to a partner’s pressure or for reasons seemingly unrelated to marijuana use), the parents of heavy adolescent users usually make the initial contact. The Cannabis Youth Treatment Study (CYT) demonstrated that several manualized brief treatment protocols have similar, but limited, success treating adolescents and recommended greater focus on long term monitoring and care. Although CYT established an evidence base for treatment, it was unable to evaluate the skill of individual therapists to engage patients and develop mutual ground for discussion. A motivational interviewing (MI) framework is presented emphasizing engagement and nonjudgmental exploration of patients’ experience and attachment to marijuana. The clinician’s curiosity about each individual’s favorite subjective experiences when high is used to discuss explanations for marijuana’s effects. Scientific information paves the way for introducing the concept of downregulation and potential negative side effects that create cognitive dissonance. The goal is to avoid evoking defensiveness and to help patients struggle with their own internal doubts about marijuana’s ability to help reach their life goals.
Clinicians who hope to modify patients’ unhealthy use of marijuana face potential frustration and difficulty trying to engage people in meaningful dialogue. The stages of change outlined by Prochaska and Di Clemente provide a useful guide for understanding how to initiate conversation with someone addicted to marijuana, whether they are in the precontemplation, contemplation, preparation (for change), action or maintenance stage. Utilizing the stages of change to guide the approach to promoting behavioral change introduces clinicians to one of the most essential principles of motivational interviewing (MI), often described as “meeting patients where they are”. Developed by Miller and Rollnick, MI shifts the focus away from resistance and denial in order to focus instead on ambivalence and moves clinicians away from confrontation and toward a more collaborative approach that is less likely to stimulate a patient’s defenses. Engagement through empathy for patients’ suffering enables clinicians to increase the cognitive dissonance between their behavior and their goals. Ultimately, the practice of motivational interviewing is an art, and not merely a set of techniques, that requires clinicians to explore their fundamental attitudes toward addiction.
The trend toward liberalizing medical and recreational marijuana use is increasing the obligation on clinicians to provide useful information to the public. This book summarizes the science all healthcare professionals need to know in order to provide objective and relevant information to a variety of patients, from recreational and medicinal users to those who use regularly, and to adolescents and worried parents. The author brings two and a half decades of studying cannabinoid research, and over forty years' experience in psychiatric and addiction medicine practice, to shed light on the interaction between marijuana and the brain. Topics range from how marijuana produces pleasurable sensations, relaxation and novelty (the 'high'), to emerging medical uses, effects of regular use, addiction, and policy. Principles of motivational interviewing are outlined to help clinicians engage patients in meaningful, non-judgmental conversations about their experiences with marijuana. An invaluable guide for physicians, nurses, psychologists, therapists, and counsellors.
The effects of the use of objective feedback in supervision on the supervisory relationship and skill acquisition is unknown.
The objective of this study was to evaluate the effects of two different types of objective feedback provided during supervision in motivational interviewing (MI) on: (a) the supervisory relationship, including potential feelings of discomfort/distress, provoked by the supervision sessions, and (b) the supervisees’ skill acquisition.
Data were obtained from a MI dissemination study conducted in five county councils across five county councils across Sweden. All 98 practitioners recorded sessions with standardized clients and were randomized to either systematic feedback based on only the behavioral component of a feedback protocol, or systematic feedback based on the entire protocol.
The two different ways to provide objective feedback did not negatively affect the supervisory relationship, or provoke discomfort/distress among the supervisees, and the group that received the behavioural component of the feedback protocol performed better on only two of the seven skill measures.
Objective feedback does not seem to negatively affect either the supervisor–supervisee working alliance or the supervisees’ supervision experience. The observed differences in MI skill acquisition were small, and constructive replications are needed to ascertain the mode and complexity of feedback that optimizes practitioners’ learning, while minimizing the sense of discomfort and distress.
Motivational interviewing (MI) is a patient-centered approach that encourages patients to change behaviors. MI training programs have increased residents’ knowledge and use of MI skills; however, many residency programs may not have the time to dedicate to lengthy MI programs. The purpose of this study was to evaluate the benefits of a brief MI didactic for residents in an academic internal medicine patient-centered medical home.
Thirty-two residents completed a 1-h MI training between October 2016 and June 2017 and completed measures on their knowledge of, confidence using, and utilization of MI skills prior to the training, immediately after the training, and at a 1-month follow-up.
The residents’ knowledge of and confidence using MI skills increased from pre-test to post-test and also increased from pre-test to the 1-month follow-up.
The utilization of MI skills increased from pre-test to the 1-month follow-up. A 1-h didactic offers benefits to residents.
Watching videotaped personal compulsions together with a therapist might enhance the effect of cognitive–behavioural therapy in obsessive–compulsive disorder (OCD) but little is known about how patients experience this.
To performed a qualitative study that describes how watching these videos influences motivation for treatment and whether patients report any adverse events.
In this qualitative study, data were gathered in semi-structured interviews with 24 patients with OCD. The transcripts were coded by two researchers. They used a combination of open and thematic coding and discrepancies in coding were discussed.
The experience of watching videos with personal compulsions helped patients to realise that these compulsions are aberrant and irrational. Patients report increased motivation to resist their OCD and to adhere to therapy. No adverse events were reported.
Videos with personal compulsions create more awareness in patients with OCD that compulsions are irrational, leading to enhanced motivation for treatment.