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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
J Subst Abuse Treat. Author manuscript; available in PMC 2013 December 17.
Published in final edited form as:
PMCID: PMC3865805

Dual Diagnosis Motivational Interviewing: a modification of Motivational Interviewing for substance-abusing patients with psychotic disorders


Motivational Interviewing (MI) is a brief treatment approach for helping patients develop intrinsic motivation to change addictive behaviors. While initially developed to target primary substance using populations, professionals are increasingly recognizing the promise this approach has for addressing the motivational dilemmas faced by patients who have co-occurring psychiatric and psychoactive substance use disorders. Unfortunately, this recognition has not lead to a clear explication of how MI might be adopted for specific diagnostic populations of dually diagnosed patients. In this article we describe how we have applied the principles and practices of MI to patients who have psychotic disorders and co-occurring drug or alcohol use problems. Specifically, we provide two supplemental guidelines to augment basic MI principles (adopting an integrated dual diagnosis approach, accommodating cognitive impairments and disordered thinking). We present recommended modifications to primary MI skill sets (simplifying open-ended questions, refining reflective listening skills, heightening emphasis on affirmations, integrating psychiatric issues into personalized feedback and decisional balance matrices). Finally, we highlight other clinical considerations (handling psychotic exacerbation and crisis events, recommended professional qualifications) when using MI with psychotic disordered dually diagnosed patients.

Keywords: Motivational interviewing, Dually diagnosed, Substance abuse, Psychotic disorder, Treatment engagement

1. Introduction

Motivational Interviewing (MI) is a brief psychotherapeutic intervention for helping patients change addictive behaviors. Over the past two decades William Miller and his colleagues have detailed the principles, practices, and research supporting this treatment approach. Motivational Interviewing: Preparing People for Change Addictive Behavior by Miller and Rollnick (2002) provides the most comprehensive singular and updated presentation of MI techniques and strategies. In addition, there are several comprehensive research reviews of the efficacy of MI (Dunn, Deroo, & Rivara, 2001; Miller, 1983; 1985; 1996; 1998).

Conceptually, MI is a blend of principles drawn from motivational psychology, Rogerian therapy, and the stages of change model of recovery. MI aims to facilitate and enhance the patient’s intrinsic motivation to change substance use or other problem behaviors by engaging the patient in an empathetically supportive but strategically directed conversation about the patient’s use of substances and related life events. Typically, the MI therapist uses a variety of techniques to help increase intrinsic motivation for change. These techniques can be divided into two categories: microskills and strategies (Rollnick, Heather, & Bell, 1992).

Microskills function to initiate and facilitate an open discussion with the patient about problem areas. These skills include the use of open-ended questioning, reflective listening, using affirmations, and summarizing the patient’s comments in a balanced manner. The therapist uses these skills to accurately understand the patient’s perceptions about a problem, heighten the patient’s problem recognition, and resolve ambivalence about changing it. The therapist’s consistent and competent use of microskills is essential for the creation of MI’s highly empathic and collaborative style.

Motivational Interviewing strategies involve increasingly directive techniques for building intrinsic motivation for change, particularly when the microskills alone have not achieved this aim. These techniques involve asking direct open-ended questions to increase problem awareness, concern, or intention and optimism to change. Therapists may construct decisional balance matrices to elicit the patient’s perceptions of the costs and benefits of remaining the same or trying to change. Additionally, therapists may attempt to create discrepancies between the patient’s current behavior and his or her goals, values, or self-perceptions. Therapists also commonly use supportive feedback of selected objective assessment results within the body of an overall MI style to promote problem recognition and desire to change. Through the skillful use of these skill sets, the therapist attempts to move the patient from a position of establishing the patient’s motivation for change to strengthening the patient’s commitment to attempt the change. If the patient’s resistance to change arises during any phase of the interview, the therapist avoids argumentation and encourages the patient to conversationally explore his or her resistance using one or more of the microskills or MI strategies.

Support for the efficacy of MI has come from many sources. It has been effective in reducing alcohol consumption in nontreatment community samples of drinkers (Miller, Benefield, & Tonigan, 1993; Miller, Sovereign, & Krege, 1988), in patients participating in an inpatient alcohol treatment facility (Brown & Miller, 1993), and among outpatients seeking traditional substance abuse treatment services (Bien, Miller, & Boroughs, 1993) or receiving MI as the sole intervention (Project MATCH Research Group, 1997). Across these studies positive treatment outcomes persisted during follow-up periods ranging from 3 to 15 months.

As a consequence of Miller’s compelling rationale for MI, its potential for wider application, and research supporting its clinical utility and efficacy for alcoholism treatment, investigators have begun to systematically apply MI to additional problem areas. Some of these areas have included heroin dependence (Saunders et al., 1995), cocaine dependence (Stotts, Schmitz, Rhoades, & Grabowski, 2001), nicotine dependence (Butler et al., 1999) and adolescent smoking (Lawendowski, 1998), HIV risk behavior (Carey et al., 1997), obesity (Smith, Heckemeyer, Kratt, & Mason, 1997), diabetes care (Stott, Rollnick, Pill, & Rees, 1995), and bulimia nervosa (Treasure et al., 1999). Recently, the use of motivational techniques with patients who have cooccurring substance abuse and psychiatric problems or dual disorders has begun to be explored (Carey, 1996; Daley & Zuckoff, 1998; Van Horn and Bux, 2001; Ziedonis & Fischer, 1996; Ziedonis & Trudeau, 1997).

1.1. Rationale for MI with dually diagnosed patients

As a therapeutic approach MI seems very well suited for dually diagnosed patients. The severe and disabling symptoms, frequent failed treatment episodes, and poor functional adjustments often contribute to the patient’s demoralization and lack of intrinsic motivation for alcohol and drug abstinence or sustained efforts to productively manage their dual disorders (Brady et al., 1996; Carey, 1996; Ziedonis & Fischer, 1996). References to these patients’ low motivation for change occur throughout the literature (Drake & Wallach, 1989; Minkoff, 1989) and have led many who specialize in dual diagnosis treatment to emphasize the primary importance of engagement and motivational enhancement strategies (Carey, 1996; Kofoed & Keyes, 1988; Ziedonis & Fischer; 1996; Ziedonis & Trudeau, 1997). Given these observations and recommendations, MI’s emphasis on building motivation for change and strategies for handling resistance to the change process have made MI a very appealing approach in the dual diagnosis field.

Very few studies, however, have been conducted to examine MI’s efficacy with dually diagnosed patients. In one pilot study (Swanson, Pantalon, & Cohen, 1999), the effect of MI on outpatient treatment adherence among psychiatric and dually diagnosed inpatients was investigated. The results suggested that the proportion of dually diagnosed patients who attended their first outpatient appointment was significantly higher for patients who had received the MI (42%) than for those in standard treatment alone (16%). Substance use treatment outcomes were not evaluated in this study.

In a pilot study conducted by our group (Martino, Carroll, O’Malley, & Rounsaville, 2000), we randomly assigned patients with co-occurring psychotic or mood disorders and alcohol or drug abuse or dependence to either a one-session 45–60 minutes MI or equivalently long standard preadmission session. The session occurred immediately before the patients started a dual diagnosis partial hospital program. We found that MI, in comparison to the standard preadmission interview, yielded better patient program attendance patterns (less program tardiness and early departures and greater number of days attended). While we did not find significant differences in substance use between the conditions, the MI group had lower substance use indices than the standard interviewing condition using a small pilot study sample size (n = 23).

Despite these encouraging initial pilot study results and the consensus about the probable utility of MI for patients who have dual disorders, few professionals have written about how to modify MI for this population. Published reports of motivation-based interventions for patients with dual disorders typically imply a direct application of MI. Namely, these reports state that many patients who have dual disorders have little motivation to change their substance abuse problems or have recurrent wavering commitments to alcohol or drug abstinence. Additionally, the reports uphold the nonconfrontational MI approach as preferable to the traditionally confrontational substance abuse treatment strategies when working with dually diagnosed patients (Beeder & Millman, 1992; Bellack & DiClemente, 1999; Carey, 1996). Beyond summarizing the now familiar MI strategies, the reports do not describe modifications needed to effectively use MI as an interviewing strategy within this population or detail how to use MI with specific psychiatric diagnostic groups of substance abusing patients within the larger rubric of dually diagnosed patients. Moreover, the numerous clinical challenges posed by dually diagnosed patients, such as active psychotic symptoms, treatment and medication noncompliance, cognitive impairments and disordered thinking, and social stigma suggest that a direct application of MI may be ill advised and ineffective. To address this shortcoming, this article describes our experience in using MI with patients who have psychotic disorders (Schizophrenia, Schizoaffective Disorder, Schizophreniform Disorder, and Psychotic Disorder NOS) and co-occurring drug or alcohol use problems (henceforth referred to as dually diagnosed patients). We call our approach Dual Diagnosis Motivational Interviewing or DDMI.

2. Methods

2.1. Subjects

Two groups of dually diagnosed patients participated in the development of DDMI. The first group consisted of 12 patients with psychotic disorders who had been subjects in our initial pilot study (Martino et al., 2000). Clinical experience with these patients provided the basis for the first draft of a two-session manualized DDMI. The second group included 7 patients who received this initial version of DDMI. In both groups the patients had been referred to a dual diagnosis ambulatory program (see Martino, McCance-Katz, Workman, & Boozang, 1995, for program description) by clinicians from inpatient and outpatient facilities. Prior to entering the program, we approached patients who met eligibility criteria to request their participation in the respective phases of DDMI’s development. Eligible subjects had to have co-occurring DSM-IV psychotic and substance use disorders based upon the clinical consensus of the referring treatment team. In addition, they had to report abuse of at least one substance in the past two months, take at least one psychotropic medication for their psychiatric condition, not have active symptoms necessitating inpatient psychiatric or detoxification treatment, and have basic reading and comprehension skills. All subjects provided written informed consent.

Table 1 describes the demographic and diagnostic characteristics of both participant groups. Across the groups, the subjects typically were in the 25–45 age range, single, unemployed, experiencing severe psychiatric symptoms, and abusing alcohol, cocaine, or cannabis. Most subjects abused more than one substance. The number of male and female participants was similar. The first group, however, had a higher percentage of ethnic minorities, a somewhat lower level of educational attainment, and a more even distribution of types of psychotic disorders than the second group.

Table 1
Demographic and diagnostic characteristics of participant groups

2.2. Procedures for developing DDMI

We developed DDMI using a Stage I Model of Behavior Therapy research (Rounsaville, Carroll, & Onken, 2001). Initially, we used standard MI techniques within a onesession, 45–60 minute ambulatory program preadmission interview for the first group of subjects who had participated in our pilot study. Within the overall MI therapeutic style, common techniques used in the session included querying patients to elicit self-motivational statements, providing feedback from preadmission questionnaires, and completing a decisional balance activity.

Based on this experience, we isolated MI principles and practices that we believed required modification to better accommodate the clinical challenges posed by dually diagnosed patients. We organized these modifications into a two-session manualized working version of DDMI following the procedures outlined by Carroll and Nuro (1997). The second group of subjects received this initial version of DDMI. We videotaped all sessions. Using informal subject feedback, review of videotaped sessions, and our clinical judgment, we further refined the DDMI approach and made final modifications to recommended guidelines and techniques. The Human Investigation Committee of the institution where we conducted this project approved all the procedures.

3. Dual Diagnosis Motivational Interviewing

While the DDMI approach adheres to the basic tenets of MI and relies upon many of its fundamental strategies, we have found that specific emphases and technical modifications of MI make it more clinically amenable for substance abusing patients who have psychotic disorders. We have organized our discussion of applying MI to dually diagnosed patients into four areas: (a) supplemental guidelines to MI basic principles; (b) MI microskill modifications; (c) modifications to MI strategies and (d) other clinical considerations. Table 2 provides an overview of how we have modified the standard practices of MI to address the clinical challenges posed by dually diagnosed patients. We detail each area of modification below.

Table 2
Overview of recommended modifications for motivational interviewing with dually diagnosed patients

3.1. Supplemental guidelines to MI basic principles

The foundation of DDMI lies in its adoption of the four MI basic principles that guide all therapists’ interactions with patients, namely: (a) expressing empathy; (b) developing discrepancy; (c) rolling with resistance and avoiding argumentation; and (d) supporting self-efficacy. The therapist upholds these principles throughout the interview to create and sustain an environment that promotes the patient’s comfortable exploration of problem areas, resolution of ambivalence toward change, and planning and initiation of change efforts. In this regard DDMI is no different than MI. However, we have found two supplemental guidelines to MI’s basic principles helpful to increase the chance that DDMI achieves similar aims as MI when working with dually diagnosed patients who have psychotic disorders. The two supplements are: (a) adopting an integrated dual diagnosis interview approach that targets more than substance use; and (b) accommodating cognitive impairments and disordered thinking.

3.1.1. Adopting an integrated dual diagnosis approach that targets more than substance use

Adopting an integrated approach to substance abuse and psychiatric treatment is the sine qua non of the dual diagnosis field (Drake, Bartels, Teague, Noordsy, & Clark, 1993; Drake, Mercer-McFadden, Mueser, McHugo, & Bond, 1998; Drake et al., 2001; Minkoff, 2001; Minkoff & Drake, 1991; Rosenthal, Hellerstein, & Miner, 1992). In this regard, dual diagnosis interventions attempt to address both problem areas equally and with an understanding of how the dual disorders and related life events interact with one another. For example, dually diagnosed patients may use substances to lessen negative psychotic symptoms such as blunted affect, depersonalization, or social inhibition or to reduce discomfort caused by positive psychotic symptoms such as auditory hallucinations or paranoid delusions. In other instances, patients might not acknowledge psychotic difficulties and prefer to see their psychiatric symptoms as substance-induced. As applied to DDMI, therapists remain mindful of these types of potential interactions, so they can strategically explore with the patient both the problem areas and their effects on one another using the microskills and MI strategies. For example, the therapist may query the patient with general open-ended questions such as, “How does your drug use affect your psychiatric symptoms?” or use more evocative questions that pull for specific selfmotivational statements, such as, “How does your use of drugs cause problems for you psychiatrically?” Failure to discern how both areas inform the patient’s motivational base may reduce the therapist’s effectiveness in building and strengthening the patient’s motivation and capacity to prepare for change.

As a corollary to this integrated approach, DDMI targets a wider array of behavior than is typical in MI. Though several investigators have begun to apply MI to behavioral domains other than addiction problems (Dunn, DeRoo, & Rivara, 2001), MI’s traditional primary target for change has been on substance use. This focus is insufficient to meet the complex change challenges confronted by substance abusing patients with psychotic disorders. Thus, DDMI includes two other domains as additional targets for change, treatment and medication compliance.

Enhancing motivation for treatment compliance is crucial for several reasons. First, dually diagnosed patients are notorious for treatment program noncompliance (Drake & Wallach, 1989; Richardson, Craig, & Haugland, 1985) if they participate in treatment at all (Drake, McLaughlin, Pepper, & Minkoff, 1991). Second, noncompliance with treatment can lead to numerous adverse consequences such as poorer clinical outcomes (Eisenthal, Emery, Lazare, & Udin, 1978), violent behavior (Zitrin, Hardesty, Burdock, & Drossman, 1976), and increased rates of rehospitalization (Drake, Osher, & Wallach, 1989; Lyons & McGovern, 1989) and utilization of emergency services and jails (Bartels et al., 1993). DDMI attempts to enhance the patient’s motivation for treatment compliance by building and strengthening the patient’s commitment to participate in dual diagnosis specialty ambulatory programs and other related outpatient services.

Regarding medication compliance, adherence to appropriate pharmacotherapy is essential to the successful treatment of dually diagnosed psychotic disordered patients (Drake et al., 1989; Osher & Kofoed, 1989; Owen, Fischer, Booth, & Cuffel, 1996; Zweben & Smith, 1989). DDMI tries to promote the patient’s motivation for medication compliance by exploring the patient’s view about taking prescribed medications and to attend to obstacles that may have diminished the patient’s adherence to medication regimens in the past.

3.1.2. Accommodating cognitive impairments and disordered thinking

The second supplemental guideline to MI’s basic principles is the need to accommodate cognitive impairments and disordered thinking resulting from the patient’s psychotic disorder, prolonged substance abuse, preoccupation with present crisis or combinations of these factors (Bellack & DiClemente, 1999). Cognitive impairments among dually diagnosed patients may include problems with attention and concentration, short-term and working memory, organizing and abstracting information, and mental flexibility (Bell, Lysaker, Milstein, & Beam-Goulet, 1994; Green, 1996; Lysaker, Bell, Zito, & Bioty, 1995; Seidman et al., 1993). To address these information processing impediments, DDMI incorporates strategies of repetition, use of simple and concrete verbal and visual materials, and breaks within sessions. Disordered thinking may include circumstantiality, tangentiality, thought blocking, or other pervasive psychotic symptoms such as paranoia or grandiosity that may impede the motivational enhancement process. In particular, interviews that have insufficient structure or that excessively delve into emotionally laden material or psychotic belief systems may heighten the patient’s psychotic symptoms and reduce the effectiveness of the therapist to motivate the patient for change. Likewise, trying to follow the patient’s conversational lead when the patient continues to veer from a logical pathway may be very difficult for the therapist and patient and result in the therapist becoming confused and uncertainty about what part of the patient’s discourse to reflect. To navigate these occurrences, the DDMI therapist places more emphasis on the strategic nature of guiding the conversation with the patient in a manner that promotes the patient’s logical organization and reality testing without sacrificing the collaborative and respectful tenor of MI. This article’s subsections that describe recommended modifications to MI microskills and strategies provide specific examples of how DDMI accommodates cognitive impairments and disordered thinking processes common to dually diagnosed patients.

3.2. MI microskill modifications

The core MI microskills are asking open-ended questions, listening reflectively (including summarizing), and affirming the patient. These microskills also are fundamental to the DDMI approach. We have found, however, that each microskill requires slight modification or unique emphasis to be most effective when used with dually diagnosed patients. We also have found that the general supportive and collaborative MI style of interaction established by the therapist’s use of microskills often is unfamiliar to patients with dual disorders who may have become accustomed to a more directive and authoritarian style of traditional psychiatric interviewing. In traditional interviewing, the therapist most often controls the immediate direction of the interview by using numerous closed-ended questions to determine diagnoses, obtain biopsychosocial information, and prescribe treatments. Because many dually diagnosed patients expect a traditional interviewing framework, the DDMI therapist first provides the patient with a brief and simple introduction to DDMI before asking openended questions and beginning the reflective listening process. For example:

“Before we begin, I would like to explain what we will do in this meeting. I recognize that you may have talked with many professionals in the past about your use of substances and psychiatric issues. We also will talk about these areas today and any other areas that are important to you but perhaps in a slightly different way. My main interest is in understanding how you view your problems and get to know you better. I would like to talk with you about how alcohol or drug use and psychiatric issues have affected your life from your point of view. I may ask you a few questions along the way, but mostly I want to listen to what you have to say and make sure I have correctly understood what you have told me.”

3.2.1. Simplifying open-ended questions

After the opening remarks, the therapist typically begins with an open-ended question (e.g., What brings you here today?). Asking open-ended questions is a primary MI strategy, particularly at the early stages of the interview when a therapist encourages the patient to talk about his or her perception of specific problem areas. Open-ended questions (e.g., What type of psychiatric issues have you been grappling with in your life?) are questions that result in more than a “yes/no” response and that encourage the patient to elaborate on a topic rather than to provide a terse answer or very specific information. These types of questions generally provide the patient with ample opportunities to express his or her viewpoint uninterrupted by the therapist. While fairly straightforward, we have found that open-ended questions are most effective with dually diagnosed patients when the therapist asks them in very clear and concise terms and avoids compound questions that may be difficult for psychotic patients to track. For example, the question, “What types of psychiatric symptoms do you experience and how does your use of cocaine affect your symptoms in the short term and long term?” is complex and may overwhelm the patient’s organizational capacity to respond to it. DDMI therapists try to avoid these types of open-ended questions and strive to simplify them at all times.

3.2.2. Refining reflective listening skills

Listening reflectively to patients is a vital MI microskill that infuses the entire interviewing process. Reflective listening means that the therapist takes time to carefully understand what the patient has said and confirms this understanding with the patient by repeating it back to him or her in similar (simple reflection) or somewhat transformed ways (restatement, paraphrasing, double-sided reflection). By using this microskill, the therapist unveils the structure of the patient’s motivational base and uses this structure as a foundation from which to establish and resolve ambivalence toward change. In MI, competent reflective listening is a difficult task that requires keen therapist attention and capacity to organize and rephrase what the patient has said.

Yet in DDMI, by comparison, reflective listening is an even more challenging microskill for a therapist to implement effectively. Patients with psychotic disorders may exhibit some degree of disordered thinking and poor reality testing that might unravel further in the absence of a sufficiently structured interview or in the face of a therapist’s repeated reflection of fundamentally psychotic material. Beyond requiring therapists to heighten their active attention to meaningful and logically organized elements of the patient’s discourse, we have found several other recommendations useful for how to most effectively listen reflectively with psychotic disordered substance abusing patients. These recommendations are: (a) using simple and concise language; (b) reflecting often; (c) using metaphors; (d) avoiding excessive focus on despairing patients’ statements and negative life events; (e) logically organizing patients’ statements with summaries; and ( f ) giving patients enough time to respond to reflections. We summarize these recommendations with examples in Table 3.

Table 3
Recommendations for effective reflective listening with substance abusing patients with psychotic disorders

3.2.3. Heightening emphasis on affirmations

The last MI microskill is affirming the patient. The therapist affirms the patient by acknowledging the patient’s personal qualities and efforts that promote change. The execution of this microskill is the same in DDMI as it is in MI. The caveat to its use in DDMI is in the heightened emphasis placed upon affirming patients during the interview process. Dually diagnosed patients often have had the personally invalidating experience of combined social stigma associated with their substance use and psychotic disorders (Evans & Sullivan, 1989) and feeling misfit to treatment systems that do not have integrated dual diagnosis care (Ridgely, Goldman, & Willenbring, 1990). In DDMI, the therapist strives to affirm patients who may not be accustomed to receiving such support. For example, a therapist might express appreciation for a patient’s candor and ability to talk about what the patient sees as problematic after the patient has criticized several prior treatment experiences. Likewise, a therapist might express appreciation to a patient who has had a history of treatment noncompliance for attending a session or taking medications as prescribed. We have found that dually diagnosed patients experience a therapist’s frequent complimenting of their personal qualities and initial change efforts inspiring and very helpful in establishing a supportive and collaborative interviewing tone.

3.3. Modifications to MI strategies

DDMI incorporates many of the commonly used MI strategies. These strategies include the use of evocative open-ended questions to elicit self-motivational statements (e.g., What concerns you about how your drug use affects your psychiatric condition?). They also include a variety of MI techniques for handling resistance skillfully. Mastery of this skill set is very important for DDMI therapists because dually diagnosed patients often express resistance in reaction to perceived coercive forces (therapists or case managers, psychiatrists, residential or vocational counselors, probation officers, child protective services personnel) compelling them to make changes. Dually diagnosed patients also may have paranoid proclivities that heighten their baseline levels of resistance irrespective of external contingencies on them. An area of significant modification to standard MI practice is in the DDMI therapist’s efforts to develop discrepancy in the patient’s perceptions of his or her problems. Specifically, in DDMI we have revised the methods of providing personalized feedback and constructing decisional balance matrices as a means to alter the patient’s view that substance use or psychiatric issues are not problematic. We describe these modifications to MI strategies below.

3.3.1. Providing personalized and engaging feedback that addresses dual diagnosis concerns

In MI, feedback typically involves a therapist providing a structured review of objective assessment results in an empathetic and collaborative style. The therapist explores with patients their reaction to the feedback and the possible relationships between the patients’ use of substances, their problems or concerns, and their intention to change their behavior. In DDMI, feedback also must include information about psychiatric symptoms and contain mechanisms for exploring the interaction of these symptoms with the patients’ use of substances and the impact on their functioning overall. In addition, the feedback needs to be simple in presentation, flexible to accommodate different areas relevant to dual diagnosis recovery, and capable of compelling patients to look at their long-standing problem areas in a renewed light.

To accommodate these requirements, we prepared a pamphlet for patients to organize the presentation of feedback into areas relevant for dual diagnosis recovery. These areas include feedback about the patient’s substance use from the Addiction Severity Index or ASI (McLellan, Luborsky, Woody, & O’Brien, 1980; McLellan et al., 1985), the patient’s psychotic symptoms from the Positive and Negative Syndrome Scale or PANSS (Kay, Fizbein, & Opler, 1987), how substance use and psychotic-related problems interact, and a model of dual diagnosis recovery. Both the ASI and PANSS are structured clinical interviews administered to patients, scored and compiled into feedback forms prior to the DDMI sessions. The ASI is designed to provide problem severity ratings (lifetime and past 30 days) in areas commonly affected in people who abuse alcohol and drugs (alcohol and drug use, medical condition, employment, legal status, family relations, and psychiatric condition). For each problem area, patients also provide subjective ratings of their recent (past 30 days) problem severity by indicating the importance they attach to seeking treatment for it. Using a color-coded bar chart comparing the recent ASI and patient-rated severity items per problem area, the DDMI therapist compares and contrasts the ratings, notes rating discrepancies, and promotes the patients’ exploration of their substance use in relationship to other areas, particularly in interaction with the psychiatric condition.

The PANSS is designed to evaluate positive, negative, and other symptom dimensions of schizophrenia phenomenon. The PANSS provides a score for how much a patient experiences symptoms that are in excess of what most people experience (positive symptoms), such as delusions or hallucinations. It also provides a score for how much a patient experiences symptoms that involve the absence of thoughts and feelings that most people experience (negative symptoms), such as feeling emotionally flat or having slowed thinking. As in the ASI feedback, we present these two dimensions in a color-coded bar chart format. Based on patient input, we renamed the positive symptoms “hot” symptoms (i.e., symptoms that make patients feel like they are boiling inside) and color-coded the bar in red. Similarly, we renamed the negative symptoms “cold” symptoms (i.e., symptoms that make patients feel like they are frozen inside) and color-coded the bar in blue. We found this metaphor helped the patients understand and relate to the scores better and made the feedback activity more engaging. As with the ASI, the DDMI therapist reviews and explores the patient-specific information with the patient to promote psychiatric problem recognition and related motivation for change.

The pamphlet ends with a discussion of the interaction of substance use and psychotic disorders and presents a metaphor of a three-legged stool model of dual diagnosis recovery (see Fig. 1). In brief, the therapist describes how many dually diagnosed patients have found that their ability to make productive change in their lives has rested upon three principles: staying clean and sober, taking medications as prescribed, and participating in a dual diagnosis treatment program. Using a demonstration model, the therapist notes how these principles represent three legs of the stool supporting the seat of dual diagnosis recovery. Beginning with an open-ended question, the therapist asks the patient what happens when an individual does not use or strengthen one or more legs of the stool. Next, the therapist unscrews one of the stool’s legs and demonstrates how the stool falls in the absence of a critical area of support. While this feedback strategy contains elements that are not unique to MI (e.g., Socratic questioning), we have found that this simple and interactive model is very engaging for patients and helpful in garnering and organizing their motivation for productively addressing their dual disorders.

Fig. 1
Three-legged stool model of dual diagnosis recovery.

3.3.2. Constructing decisional balance matrices appropriate for dually diagnosed patients

Another frequently used technique in MI is the construction of a decisional balance matrix. In this technique, the therapist tries to normalize ambivalence by having the patient discuss the positive and negative aspects of continuing a behavior (e.g., drinking alcohol) and trying to change it (e.g., not drinking alcohol). The therapist typically records what the patient enumerates into a 2 × 2 matrix and then explores with the patient the array of underlying attitudes that make up the competing dimensions of the patient’s motivation for change. Beyond applying this technique to the patient’s substance use, DDMI also uses the decisional balance technique to explore the patient’s ambivalence about getting treatment for his or her dual disorders. Here, we defined treatment as participation in a dual diagnosis specialty program and taking prescribed medications. The consolidation of two treatment areas into one decisional balance activity reduces the task demands placed on the patients without neglecting the primary targets of DDMI. We also determined that many dually diagnosed patients found completion of a 2 × 2 matrix confusing and redundant. For example, the negative expectancies for not using a substance (“I won’t feel good”) often are inversely related to the positive expectancies for continuing to use a substance (“I will feel good.”). To simplify the task, DDMI focuses only on the patient’s anticipation of positive and negative aspects of changing a behavior and the relative balance of these two areas in promoting or hindering a patient’s motivation for change. Examples of items that comprise the decisional balance activities used in DDMI (Positives and Negatives of Staying Clean and Sober and Getting Treatment for My Dual Disorders) are presented in Table 4.

Table 4
Example items in DDMI decisional balance activities

3.4. Other clinical considerations

We believe that the modifications described above help therapists use MI more effectively with dually diagnosed patients. Nevertheless, we qualify our recommendation of MI for use with this population by emphasizing how patients must have sufficient psychiatric stability to benefit from MI’s ample use of verbal persuasion and logical reasoning, albeit in the overall MI style. When patients are too psychotically disorganized to logically attend to the content of the interview or consistently remain based in reality, they are not appropriate for DDMI and may require other types of interventions (e.g., crisis intervention, pharmacotherapy) first. If patients’ psychotic symptoms are so severe that patients cannot make informed decisions or properly take care of their basic needs, DDMI therapists must be prepared to arrange for the patients’ hospitalization.

In addition to psychotic exacerbation, dually diagnosed patients have higher rates of suicidality and homicidality (Craig, Linm, El-Defrawi, & Goldman, 1985; Drake et al.,1989; Lyons & McGovern, 1989; Turner & Tsuang, 1990) than substance abusing patients without co-occurring psychiatric conditions. Therefore, DDMI requires that therapists are capable of performing risk assessments of patients’ dangerousness to self and others and are knowledgeable about the policies and procedures for handling patients who the therapists deem are at imminent risk for self- and otherdestructive behavior. As with grave disability caused by psychosis, when patients pose clear threats to themselves and others, therapists must alter their style of intervention away from DDMI where collaboration and patients’ freedom of choice operate, to crisis intervention where therapists’ decision making and direction, even if coercive, matter most. Under these circumstances, safeguarding the patient and the public through immediate protective measures supersedes the basic principles underlying DDMI. To anticipate these events and to be clear about the related clinical dilemmas posed by them, we routinely review with patients in the interview the circumstances that necessitate involuntary protective measures.

These issues and the general clinical complexity of most dually diagnosed patients dictate that DDMI therapists have special professional qualifications. We have found that beyond supporting the highly empathic and collaborative MI style, therapists should have at least one year of supervised work experience with dually diagnosed patients to demonstrate familiarity with psychotic phenomenon and to adequately appreciate the possible interactions of substance use and psychotic functioning. In addition, therapists must have familiarity with psychotropic medications and potential side effects, given that most of these patients receive prescribed antipsychotic and mood stabilizing medications for their psychiatric conditions. Finally, DDMI requires consistently scheduled and ad hoc therapist supervision to continuously refine the therapist’s skills in applying MI to dually diagnosed patients and to aptly handle crisis situations.

4. Conclusions

Motivational Interviewing is a promising treatment approach to use with dually diagnosed patients. Within this promise, we have found that MI requires modifications to accommodate the special needs of substance abusing patients who have psychotic disorders. DDMI is our initial attempt to systematically develop and describe how MI might be altered for this patient population and be most effective in promoting the patients’ productive efforts to change previously problematic behaviors. We recognize that the complex and severe problems experienced by dually diagnosed patients may limit the ultimate capacity of a brief two-session intervention like DDMI to render beneficial impact. Nonetheless, studies of brief motivational interventions have shown their effectiveness in reducing substance use outcomes with high-average effect sizes comparable to more extensive treatments (Bien, Miller, & Tonigan, 1993), particularly when they are used to enhance engagement in intensive treatment-as-usual (Dunn et al., 2001). If our initial pilot study (Martino et al., 2000) showing some benefit of a one-session motivational interview for dually diagnosed patients is any indication, a two-session and carefully developed DDMI may have the potential for greater merit as a brief intervention. Our current effort to examine the feasibility and effectiveness of DDMI in a randomized controlled trial will address this issue directly and will be the subject of future reports. Finally, while we have presented DDMI as an independent clinical intervention, we recognize that DDMI might best function as a complement to the many recommended health service system approaches described by Drake and others (Drake et al., 1993, 1998, 2001; Minkoff, 2001) to improve treatment outcomes for dually diagnosed patients. In this regard, DDMI may be viewed as a guideline for how service providers might best interact with dually diagnosed patients on an individual level while they work with these patients in the context of the broader service system.


Grant P50DA09241 from the National Institute on Drug Abuse (NIDA) supported this project. We also acknowledge the support provided by the staff members of the Yale New Haven Psychiatric Hospital’s Dual Diagnosis Service who permitted us to conduct this study in their clinical setting.


  • American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
  • Bartels SJ, Teague GB, Drake RE, Clark RE, Bush P, Noordsy DL. Service utilization and costs associated with substance abuse among rural schizophrenic patients. Journal of Nervous and Mental Disease. 1993;181:227–276. [PubMed]
  • Beeder AB, Millman RB. Treatment of patients with psychopathology and substance abuse. In: Lowinson J, Ruiz P, Millman R, editors. Substance abuse: A comprehensive textbook. 3rd ed. Baltimore: Williams & Wilkins; 1992. pp. 675–690.
  • Bien TH, Miller WR, Boroughs JM. Motivational interviewing with alcohol outpatients. Behavioural and Cognitive Psychotherapy. 1993;21:347–356.
  • Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: A review. Addictions. 1993;88:305–325. [PubMed]
  • Bell MD, Lysaker PH, Milstein RM, Beam-Goulet JL. Concurrent validity of the cognitive component of schizophrenia: Relationship of PANSS scores to neuropsychological assessments. Psychiatry Research. 1994;54:51–58. [PubMed]
  • Bellack AC, DiClemente CC. Treating substance use among patients with schizophrenia. Psychiatric Services. 1999;50:75–80. [PubMed]
  • Brady S, Hiam CM, Saemann R, Humbert L, Fleming MZ, Dawkins-Brickhaus K. Dual diagnosis: A treatment model for substance abuse and major mental illness. Community Mental Health Journal. 1996;32:573–578. [PubMed]
  • Brown JM, Miller WR. Impact of motivational interviewing on participation and outcome in residential alcoholism treatment. Psychology of Addictive Behaviors. 1993;7:211–218.
  • Butler CC, Rollnick S, Cohen D, Russell I, Bachmann M, Stott N. Motivational consulting versus brief advice for smokers in general practice: A randomised trial. British Journal of General Practice. 1999;49:611–616.
  • Carey KB. Substance use reduction in the context of outpatient psychiatric treatment: A collaborative, motivational, harm reduction approach. Community Mental Health Journal. 1996;32:291–306. [PubMed]
  • Carey MP, Maisto SA, Kalichman SC, Forsyth AD, Wright EM, Johnson B. Enhancing motivation to reduce the risk of HIV infection for economically disadvantaged urban women. Journal of Consulting and Clinical Psychology. 1997;65:531–541. [PMC free article] [PubMed]
  • Carroll KM, Nuro KF. The use and development of manuals. In: Carroll KM, editor. Improving compliance with alcoholism treatment. Project MATCH Monograph Series. Volume 6. Bethesda, MD: NIAAA; 1997. pp. 53–72.
  • Craig TJ, Linm SP, El-Defrawi MH, Goldman AB. Clinical correlates of readmission in a schizophrenic cohort. Psychiatric Quarterly. 1985;57:243–249.
  • Daley DC, Zuckoff A. Improving compliance with the initial outpatient session among discharged inpatient dual diagnosis clients. Social Work. 1998;43:470–473. [PubMed]
  • Drake RE, Bartels SJ, Teague GB, Noordsy DL, Clark RE. Treatment of substance abuse in severely mentally ill patients. Journal of Nervous and Mental Disease. 1993;181:606–611. [PubMed]
  • Drake RE, Essock SM, Shaner A, Carey KB, Minkoff K, Kola L, Lynde D, Osher FC, Clark RE, Rickards L. Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services. 2001;52:469–476. [PubMed]
  • Drake RE, McLaughlin P, Pepper B, Minkoff K. Dual diagnosis of major mental illness and substance disorder: An overview. New Directions for Mental Health Services. 1991;50:3–12. [PubMed]
  • Drake RE, Mercer-McFadden C, Mueser KT, McHugo GJ, Bond GR. Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin. 1998;24:589–608. [PubMed]
  • Drake RE, Osher FC, Wallach MA. Alcohol use and abuse in schizophrenia: A perspective community study. Journal of Nervous and Mental Disease. 1989;177:408–413. [PubMed]
  • Drake RE, Wallach MA. Substance abuse among the chronically mentally ill. Hospital and Community Psychiatry. 1989;40:1041–1046. [PubMed]
  • Dunn C, Deroo L, Rivara FP. The use of brief interventions adapted from motivational interviewing across behavioral domains: A systematic review. Addiction. 2001;96:1725–1742. [PubMed]
  • Eisenthal S, Emery R, Lazare A, Udin H. Adherence and the negotiated approach to patienthood. Archives of General Psychiatry. 1978;36:393–398. [PubMed]
  • Evans K, Sullivan JM. Dual diagnosis: Counseling the mentally ill substance abuser. New York: Guilford Press; 1989.
  • Green MF. What are the functional consequences of neurocognitive deficits in schizophrenia? American Journal of Psychiatry. 1996;153:321–330. [PubMed]
  • Kay SR, Fizbein A, Opler LA. The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin. 1987;13:261–276. [PubMed]
  • Kofoed LL, Keyes A. Using group therapy to persuade dual-diagnosis patients to seek treatment. Hospital and Community Psychiatry. 1988;39:1209–1211. [PubMed]
  • Lawendowski LA. A motivational intervention for adolescent smokers. Preventive Medicine. 1998;27:A39–A46. [PubMed]
  • Lyons JS, McGovern MP. Use of mental health services by dually diagnosed patients. Hospital and Community Psychiatry. 1989;40:1067–1069. [PubMed]
  • Lysaker PH, Bell MD, Zito WS, Bioty SM. Cognitive deficits in schizophrenia. Prediction of symptom change for participators in work rehabilitation. Journal of Nervous and Mental Disease. 1995;183:332–336. [PubMed]
  • Martino S, McCance-Katz E, Workman J, Boozang J. The development of a dual diagnosis partial hospital program. Continuum. 1995;2:145–165.
  • Martino S, Carroll KM, O’Malley SO, Rounsaville BJ. Motivational interviewing with psychiatrically ill substance abusing patients. The American Journal on Addictions. 2000;9:88–91. [PubMed]
  • McLellan AT, Luborsky L, Cacciola J, Griffith J, Evans HL, O’Brien CP. New data from the Addiction Severity Index: Reliability and validity in three centers. Journal of Nervous and Mental Disease. 1985;173:412–423. [PubMed]
  • McLellan AT, Luborsky L, Woody GE, O’Brien CP. An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index. Journal of Nervous and Mental Disease. 1980;168:26–33. [PubMed]
  • Miller WR. Motivational interviewing with problem drinkers. Behavioural Psychotherapy. 1983;11:147–172.
  • Miller WR. Motivation for treatment: A review with a special emphasis on alcoholism. Psychological Bulletin. 1985;98:84–107. [PubMed]
  • Miller WR. Motivational interviewing: Research, practice, and puzzles. Addictive Behaviors. 1996;21:835–842. [PubMed]
  • Miller WR. Why do people change addictive behavior? The 1996 H. David Archibald Lecture. Addiction. 1998;93:163–172. [PubMed]
  • Miller WR, Benefield B, Tonigan JS. Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology. 1993;61:455–461. [PubMed]
  • Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. New York: Guilford Press; 2002.
  • Miller WR, Sovereign RG, Krege B. Motivational interviewing with problem drinkers: II. The drinker’s check-up as a preventive intervention. Behavioural Psychotherapy. 1988;16:251–268.
  • Minkoff K. An integrated treatment model for dual diagnosis of psychosis and addiction. Hospital and Community Psychiatry. 1989;40:1031–1036. [PubMed]
  • Minkoff K. Developing standards of care for individuals with cooccurring psychiatric and substance use disorders. Psychiatric Services. 2001;52:597–599. [PubMed]
  • Minkoff K, Drake R, editors. Dual diagnosis of major mental illness and substance disorder (New Directions for Mental Health Services No. 50) San Francisco: Jossey-Bass; 1991. [PubMed]
  • Osher FC, Kofoed LL. Treatment of patients with psychiatric and psychoactive substance abuse disorders. Hospital and Community Psychiatry. 1989;40:1025–1030. [PubMed]
  • Owen RR, Fischer EP, Booth BM, Cuffel BJ. Medication noncompliance and substance abuse among patients with schizophrenia. Psychiatric Services. 1996;47:853–858. [PubMed]
  • Project MATCH Research Group. Matching alcoholism treatment to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol. 1997;58:7–29. [PubMed]
  • Richardson MA, Craig TJ, Haugland C. Treatment patterns of young chronic schizophrenic patients in the era of deinstitutionalization. Psychiatric Quarterly. 1985;57:104–110. [PubMed]
  • Ridgely MS, Goldman HH, Willenbring M. Barriers to care of persons with dual diagnoses. Schizophrenia Bulletin. 1990;16:123–132. [PubMed]
  • Rollnick S, Heather N, Bell A. Negotiating behaviour change in medical settings: The development of brief motivational interviewing. Journal of Mental Health. 1992;1:25–37.
  • Rosenthal RN, Hellerstein DJ, Miner CR. A model of integrated services for outpatient treatment of patients with comorbid schizophrenia and substance abuse patterns. Psychiatric Quarterly. 1992;63:2–26.
  • Rounsaville BJ, Carroll KM, Onken LS. NIDA’s stage model of behavioral therapies research: Getting started and moving on from Stage I. Clinical Psychology: Science and Practice. 2001;8:133–142.
  • Saunders B, Wilkinson C, Phillips M. The impact of a brief motivational intervention with opiate users attending a methadone programme. Addiction. 1995;90:415–424. [PubMed]
  • Seidman LJ, Pepple JR, Farone SV, Kremen WS, Green AI, Brown WA, Tsuang MT. Neuropsychological performance in chronic schizophrenia in response to neuroleptic dose reduction. Biological Psychiatry. 1993;33:575–584. [PubMed]
  • Smith DE, Heckemeyer CM, Kratt PP, Mason DA. Motivational interviewing to improve adherence to a behavioral weightcontrol program for older obese women with NIDDM: A pilot study. Diabetes Care. 1997;20:53–54. [PubMed]
  • Stott NC, II, Rollnick S, Pill R, Rees M. Innovation in clinical method: Diabetes care and negotiating skills. Family Practice. 1995;12:413–418. [PubMed]
  • Stotts AL, Schmitz JM, Rhoades HM, Grabowski J. Motivational interviewing with cocaine-dependent patients: A pilot study. Journal of Consulting and Clinical Psychology. 2001;69:858–862. [PubMed]
  • Swanson AJ, Pantalon MV, Cohen KR. Motivational interviewing and treatment adherence among psychiatric and dually diagnosed patients. Journal of Nervous and Mental Disorders. 1999;187:630–635. [PubMed]
  • Treasure JL, Katzman M, Schmidt U, Troop N, Todd G, DeSilva P. Engagement and outcome in the treatment of bulimia nervosa: First phase of a sequential design comparing motivation enhancement therapy and cognitive behavioural therapy. Behaviour Research and Therapy. 1999;37:405–418. [PubMed]
  • Turner WM, Tsuang MR. Impact of substance abuse on the course and outcome of schizophrenia. Schizophrenia Bulletin. 1990;16:87–95. [PubMed]
  • Van Horn DHA, Bux DA. A pilot test of motivational interviewing groups for dually diagnosed inpatients. Journal of Substance Abuse Treatment. 2001;20:191–195. [PubMed]
  • Zweben JE, Smith DE. Considerations in using psychotropic medication with dual diagnosis patients in recovery. Journal of Psychoactive Drugs. 1989;21:221–228. [PubMed]
  • Ziedonis D, Fischer W. Motivation-based assessment and treatment of substance abuse in patients with schizophrenia. Directions in Psychiatry. 1996;16:1–7.
  • Ziedonis D, Trudeau K. Motivation to quit using substances among individuals with schizophrenia: Implications for a motivationbased treatment model. Schizophrenia Bulletin. 1997;23:229–238. [PubMed]
  • Zitrin A, Hardesty AS, Burdock EI, Drossman AK. Crime and violence among mental patients. American Journal of Psychiatry. 1976;13:142–149. [PubMed]