MIDAS Therapist’s Reflections- integrating CBT and MI with

people who experience psychosis and use substances

Paul EarnshawRory Allott

The MIDAS TrialChristine 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

STAGE 1-6 ONWARDS – BUILDING MOTIVATION1) Building Engagement – developing and maintaining a relationship MI /Any2) 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 MI4) Identification of how the psychosis (onset, symptoms and consequences) fits into this

picture MI/CBT5) 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

PHASE 2: STAGE 7 ONWARDS – ACTION PHASE 7) Review, develop and modify formulation and from this identify and develop strategies for change MI/CBT8) Action planning, change Plans MICBT9) Relapse prevention/ maintenance/ Blue Prints MICBT

MIDAS - Barrowclough, Haddock et al 2010. BMJ online free

Sample- 327 people Randomised, largest study to date163 to treatment as usual and 164 to TAU and TherapyCould 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 outcomesSubstantial 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 useRisk Assessment and Legal Responsibilities - Suicide and Harm to others The interface between Mental health and Drug and Alcohol servicesMedication 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 ContextLimited social networksA lack of Social Capital- Drugs and AlcoholWhen significant others present – friends/ relatives/ tended to be in high EE environmentsLimited opportunities, ‘the Dually Diagnosed’ face discrimination, stigma and rejection. In relationships, neighbours, housing, work, amenities

Also Drugs and Alcohol are usefulOur clients used for the same reasons - Gregg, Gregg, Barrowclough and Haddock (2006), 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 beliefsThey 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 goalsThis was a varied group of people who showed considerable strength, determination and desire for change. They used alot of substances mostly poly substance useAnd 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.

ResultsSecondary outcomesFrequency of substance use – NSDAmount of substances used per day-SD maintained at 2 years Readiness to change substance use at 12mths- SD but not sustained at 24 mthsNo effects for relapses, psychotic symptoms, functioning, and self harm

SUCCESS FOR EVERYONE

What did therapy helped to do?Engage people, even when not help seeking

75% (124/164) of people completed between 11 and 21 sessions.

40% completed >21. 15% (25/164) withdrew trial by 24 months

Increase their motivation to change their substance use habitsReduce the amount of drugs or alcohol they use

WHO DOES IT WORK FOR?

Unplanned exploratory analysis suggests that the therapy more effective for alcohol abuse only group. Increased days abstinent over 2 yrs

Reflections/ QuestionsAlcohol group often less chaotic, less marginalisedReducing 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 work?

Reflections/ QuestionsClinically 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 change. 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 InterviewingCBTRelapse prevention workPsychoeducationFamily work/ TherapyContingency management

WHAT QUESTIONS DO YOU HAVE?

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 Co-existing Mental Health and Drug and Alcohol problems, Eds. Baker, A & Velleman. Routledge 2007. paul.earnshaw@gmw.nhs.uk

ReferencesBarrowclough, C., Haddock, G., Tarrier, N., et al (2001). Pilot study for MIDAS. In American Journal of Psychiatry, 158, 1706-1713.Martino, S. et al, (2002) Dual diagnosis motivational interviewing. Journal of Substance Abuse Treatment, 23, 297-308. Beck A, Wright F, Newman C & Liese B (1993) Cognitive Therapy of Beck A, Wright F, Newman C & Liese B (1993) Cognitive Therapy of Substance Abuse. Guildford Press.Substance Abuse. Guildford Press.Marlatt, G.A. and Gordon, J.R. (1985) Relapse Prevention: Marlatt, G.A. and Gordon, J.R. (1985) Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviours. New Maintenance Strategies in the Treatment of Addictive Behaviours. New York: Guilford PressYork: Guilford Press. .