MI and CBT Combination, Integration Synergy

Paul Earnshaw Psychological Therapist /Social Worker Sylvie Naar King Associate Professor Clinical Psychologist

Explore combination Integration Synergy in MI CBT

 Use an extract from training developed with Rory Allott-thanks.

 MI enhances CBT nearly all MINTIES agree  No definitive research to back that up  My clinical experience in a Beckian CT world and in MIDAS trial - MICBT integration suggests that is does.

 We are more interested in what you think

Combining/Integrating MI and CBT; Some Questions

 Why integrate?  What are similarities and differences between MI and CBT?

 How to integrate (prelude, combination, integration)?

 Why bother? Is there a synergistic effect?

 What are the challenges presented to therapist, clients, and trainer around integration?

 Other questions?

CBT & MI: What separates them and brings them together?

      Take the cards in front of you and distribute them around your group Elect three people to collect the cards    One person collects cards that apply to MI and CBT One person collects cards that apply more to MI One person collects cards that apply more to CBT Elect a fourth person to guide the conversation Consider each card and discuss the placement Obviously, there are no right or wrong answers or expectations about the size of piles We will give you 20 mins

Move about

 Place your cards on the continuum on the wall  All cards will go on the wall so we can discuss consensus  While you are doing this notice where the cards are going  Debrief  What themes emerged from your group’s discussion  What were the challenges of this activity

Combining/Integrating MI and CBT; Some Questions

 Why integrate?  What are similarities and differences between MI and CBT?

 How to integrate (prelude, combination, integration)?

 Why bother? Is there a synergistic effect?

 What are the challenges presented to therapist, clients, and trainer around integration?

MI and CBT

“ sort of like cousins ” Peter Prescott “some kinds of Cognitive therapy look a lot like MI” List serve discussions.

But what is different?

 Origins  Many ‘kinds’ of cognitive behaviour therapy  Beckian, Padesky, Metacognitive, REBT, CBT for substance use, DBT, ACT, Schema focussed, Compassionate Mind CBT, Method of Levels  Makes comparisons difficult  Only one Motivational Interviewing   Miller and Rollnick Though many variations: MET, DDMI, AMI’s, Compliance therapy ?

What other differences?

Traditional Cognitive-Behavioral Therapy Problem Focused Formulation led Schema Expert-led How?

Thoughts-Feelings-Behaviour Change as a function of the individual Psychological-Medical Motivational Interviewing Strengths Focused Target-behaviour led Values Expert-trap Why?

Values-Dissonance-Behaviour Change as a function of the relationship Humanistic- Psychological

But what is similar?

 Origins    Neither grounded in theory Emerged from detailed phenomenological research  Beck: Dreams  Miller: Client utterances and values Cognitive-Behavioural journals  Strong evidence-base and culture of evaluation

What else is similar?

Cognitive-behaviour Therapy & Motivational Interviewing Collaborative, Directive Empathic, Positive Regard Guided Discovery, Evocative Summaries, Questions, Reframe Self-monitoring, Relapse prevention, Normalising

What to integrate from CBT?

 Agendas       Formulation / Case conceptualisation Identifying Beliefs Problem solving Behavioural experiments Skills training Emphasis on self-monitoring

What to integrate from MI?

 Listening for & responding to readiness to change        Identifying core values Working with ambivalence Developing discrepancy Autonomy – client as agent of change NOT the therapy Supporting self-efficacy Reflective listening Affirmation

How to integrate?

 Combination approaches   MI as a prelude to CBT (Arkowitz et al 2008) Switching to MI during CBT to explore specific issues around ambivalence  Integrative approaches   Seamless joining together of CBT and MI “assimilative integration”an ‘Integrative Framework’

Stages of Readiness & Therapy Style Client ’s Stage of Change Precontemplation Contemplation Determination Action Maintenance Relapse Style of Therapy Th Be era Cog ha py vio nit ive ura l In te M rv oti ie va w tio in g na l

Training issues

 Is it easier to train a CBT therapist to do MI or an MI therapist to do CBT?

  Why If you could teach both to a naïve counselor, would you do it sequentially or simultaneously.

 How would you integrate MI and CBT training  In research trials use an MICT fidelity scale?

Other Challenges

 CBT not necessary to be in the Spirit of MI  Irrational thinking that needs to be corrected   MI can result in a cognitive shift is this CBT CBT experts don’t see the need to integrate MI  CBT models tend to be expert not client led  Switching from one to the other is confusing