MI, CBT and Psychosis: A Taster

MIDAS Therapist’s Reflectionsintegrating CBT and MI with
people who experience
psychosis and use substances
Paul Earnshaw
Rory Allott
The MIDAS Trial
Christine Barrowclough (PI), Gillian Haddock, Nick Tarrier, Jan Moring, Til Wykes, Tom Craig, Shon Lewis,
John Strang, Graham Dunn, Linda Davies
RCT evaluating the effectiveness of a psychological
therapy for people with psychosis and substance use.
Therapy consists of an integration of MI and CBT,
aimed at matching the client’s stage of change.
Focus on substance use but flexible to work with other
areas clients prioritizes for change.
Formulation driven.
Flexible and assertive in appointment setting.
Some liaison with services and carers.
MICBT - Stages of Therapy:
predominant style
1) Building Engagement – developing and maintaining a relationship MI /Any
2) Engagement of the client in talking about their concerns and life satisfactions MI
3) Identification of how substance use fits into the concerns and life satisfactions MI
4) Identification of how the psychosis (onset, symptoms and consequences) fits into
this picture MI/CBT
5) Collaborative development of initial understanding with the client outlining how life
concerns fit together with psychosis and substance use issues MI/CBT
6) Helping to motivate/consolidate motivation for the client to reach an action stage
of planned substance reduction. MI/CBT
7) Review, develop and modify formulation and from this identify and develop
strategies for change MI/CBT
8) Action planning, change Plans MICBT
9) Relapse prevention/ maintenance/ Blue Prints MICBT
MIDAS - Barrowclough, Haddock et
al 2010. BMJ online free
Sample- 327 people Randomised, largest study to date
163 to treatment as usual and 164 to TAU and Therapy
Could receive up to 26 sessions over a year
24 months of follow up
Low attrition rates 6 months (90%) 24 months (70%)
At 24 months 326 (99.7%) people were assessed on
primary outcomes and 246 (75.2%) on main secondary
Substantial number of therapy sessions delivered
- 35% - 11-20, 41%- 21+ stayed engaged
What did we do ?
We trained and practised in CBT, Psychosis, Substance
use (Beck 1993, Baker 2006, Stewart 2005), Relapse
prevention (Marlatt and Gordon, 1995)
And we trained and practised in MI, (Miller
Rollnick,2002, for DD Martino, 2002)
We combined them and then eventually we integrated
them, integration regarded as best practice.
It was not easy work and presented a number of
challenges for the clients and Therapists
What were the Challenges ?-The Social
context and wider system
Engagement with and experience of psychiatric
services- e.g.. Compulsory detention.
They did not always want to see us or want our help
only 28% at action for changing substance use
Risk Assessment and Legal Responsibilities
- Suicide and Harm to others
The interface between Mental health and Drug and
Alcohol services
Medication and its Side Effects
• Flat mood & Weight gain = take stimulants
• Dryness of mouth = drink beer
• Agitated & restless = smoke dope
‘Making the Pourer Richer’
The Challenges- The Social Context
Limited social networks
A lack of Social Capital- Drugs and Alcohol
When significant others present – friends/
relatives/ tended to be in high EE environments
Limited opportunities, ‘the Dually Diagnosed’
face discrimination, stigma and rejection. In
relationships, neighbours, housing, work,
Also Drugs and Alcohol are useful
Our clients used for the same reasons - Gregg,
Barrowclough and Haddock (2006), but had very
different personal circumstances and social situations
They can block out unpleasant emotions memories- ‘I
can forget stuff’
‘I am in my own world’…. ‘Its something just for me’
‘I can get out socialise’… particularly drinking
‘I have mates’ - ‘I am not bored’
‘I can sleep’
‘Its more important than…..?
Also you can get them cheaply and
just about everywhere- The dealers
The personal context- MIDAS clients
Had a wide range of human responses to life: Depression, anger,
anxiety, heard voices, saw things, felt things, had unusual beliefs
They tried hard to focus in our sessions
We tried hard to avoid the diagnostic shadow and to focus on
the person, their strengths, their cherished values and goals
This was a varied group of people who showed considerable
strength, determination and desire for change.
They used alot of substances mostly poly substance use
And in delivering this innovative psychological intervention in the
community- It was a privilege to work with them
What about the the Results?
Primary Outcomes- no significant differences
Death from any cause
Admission to hospital for reason related to
psychosis – 12 months after therapy.
Secondary outcomes
Frequency of substance use – NSD
Amount of substances used per day-SD
maintained at 2 years
Readiness to change substance use at 12mthsSD but not sustained at 24 mths
No effects for relapses, psychotic symptoms,
functioning, and self harm
What did therapy helped to do?
Engage people, even when not help seeking
75% (124/164) of people completed between 11 and 21
40% completed >21.
15% (25/164) withdrew trial by 24 months
Increase their motivation to change their
substance use habits
Reduce the amount of drugs or alcohol they use
Unplanned exploratory analysis suggests that the
therapy more effective for alcohol abuse only
group. Increased days abstinent over 2 yrs
Reflections/ Questions
Alcohol group often less chaotic, less
Reducing the amount of substance use &
particularly alcohol is likely to have enormous
health benefits for the clients. Most problematic.
It may not affect psychotic symptoms as much
we thought it did?
Control group had better outcomes on relapse
than previous studies- standard care and DD
Reflections/ Questions
Clinically clients were more motivated in
therapy but this reduced afterwards. You can
be more
motivated but not have the
resources/support to continue to make a
More Maintenance and Relapse prevention?
Longer interventions to support people
through lapses and relapses?
Clinically Integrating CBT with MI enhances
therapy but it takes longer to learn
Is an individual psychological intervention
enough for this client group?
Pilot study small RCT ( Barrowclough and
Haddock et al (2001) had a family intervention
and better outcomes
Do we need to add a social Intervention or
Family work, SBNT or CRAFT?
Finally What next?..
Do we need more research or can we use and integrate
existing evidence based practices?
NICE Guidance March 2011 Full guideline on
‘Psychosis with coexisting substance misuse’
Recommends that in clinical practice
‘That adults and young people with psychosis and
coexisting substance misuse are offered evidenced
base treatments for both conditions’
Psychological/ Psychosocial Interventions for
coexisting substance use and Psychosis.
NICE March 2001 full guidance lists them
Used either on their own or in combination are:
Motivational Interviewing
Relapse prevention work
Family work/ Therapy
Contingency management
References and Resources
William R. Miller, Stephen Rollnick, Kelly Conforti (2002).
Motivational Interviewing, Second Edition: Preparing
People for Change. Guilford Press: New York.
Barrowclough, C., Haddock, G., Lowens, I. Allott, R.;
Earnshaw, P., Fitzsimmonds, M., Nothard, S. Psychosis and
drug and Alcohol problems. In Clinical Handbook of Coexisting Mental Health and Drug and Alcohol problems, Eds.
Baker, A & Velleman. Routledge 2007.
[email protected]
Barrowclough, C., Haddock, G., Tarrier, N., et al (2001). Pilot
study for MIDAS. In American Journal of Psychiatry, 158,
Martino, S. et al, (2002) Dual diagnosis motivational
interviewing. Journal of Substance Abuse Treatment, 23, 297308.
Beck A, Wright F, Newman C & Liese B (1993) Cognitive
Therapy of Substance Abuse. Guildford Press.
Marlatt, G.A. and Gordon, J.R. (1985) Relapse Prevention:
Maintenance Strategies in the Treatment of Addictive
Behaviours. New York: Guilford Press.

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