A language for integrated care

Though the term “behavioral healthcare” (BHC) is defined to include mental health and addiction treatment, many clients also bring an array of integrated problems—legal, housing, physical health (HIV, Hepatitis C, diabetes, smoking, obesity, blood pressure, liver functions), and relationship problems. Typically, these problems are addressed by multiple providers across multiple sites and systems—if they are addressed at all. As a result, continuity of care is disrupted. Adding to this complexity is the fact that clients present across a spectrum of readiness to change in different areas of their symptoms and issues.

The partnering of behavioral and physical care parallels the development of integrated treatment for co-occurring mental illness and substance disorders in many ways. This new partnership aims at preventing detriment to clients as a result of parallel or sequential versus simultaneous and integrated treatment.

The physical healthcare model has evolved in large part without attention to behavioral change, though such change is now deemed necessary to improve client and provider outcomes. Treatment for Hepatitis C, for example, is frequently offered to clients with histories of addiction, but clients cannot receive it unless they are abstinent. Clients know that their past or present substance use will be a central topic of discussion and behavior change.

While many providers now recognize the value of partnering physical and behavioral health, few have yet focused on the communication style or interventions needed to address the array of behavioral changes and physical health issues, wherever the client is met across systems. This challenge must not be overlooked. Now is the opportunity to improve our communication approach and drive the necessary continuity. Here are five things that can be developed and accomplished by this effort:

•    A common language regarding client change or lack of change across providers, sites and systems, symptoms and issues..
•    A common client-provider communication style that facilitates the client’s discovery of his or her underlying motivation to change.
•    A common means of measuring and communicating incremental change that can be understood across providers and systems, enabling providers to match interventions with client’s stages of readiness to change.
•    A collaborative, empathic approach that respects each client’s autonomy, conveys client responsibility, and is directional in evoking the client’s side.
•    A set of common interventions for engagement that provide a safe, trusting environment in which each client can explore his or her thoughts, feelings, motivations, solutions and decisions.

Client-centered interventions effective across systems

One well-respected communication approach that has proven effective for various areas of behavior change is Carl Rogers’¹ client-centered counseling. This client-centered approach highlights the importance and skill of empathic reflective listening: the ability to listen, to be present, and to reflect understanding of client thoughts and perceptions by reflecting them back to the client in a statement. Such listening conveys empathy and serves to deepen the client’s exploration. It often helps to lead the client to his or her intrinsic motivations, decisions, and solutions.

Rogers described this process: “… in most, if not all, individuals there exist growth forces, tendencies toward self-actualization, which may act as the sole motivation...” Eugene Gendlin² explained: “Rogers eliminated all interpretation. Instead, he checked his understanding out loud, trying to grasp exactly what the patient wished to convey. When he did that, he discovered something: The patient would usually correct the first attempt. The second would be closer, but even so, the patient might refine it. Rogers would take in each correction until the patient indicated. "Yes, that's how it is. That's what I feel." Then there would be a characteristic silence. During such a silence, after something is fully received, the next thing comes in the client. Very often it is “something deeper.” Rogers discovered that a self-propelled process arises from inside. “Rogers renamed his ‘non-directive’ therapy ‘client-centered therapy.’” The person was the main figure of importance.

Client-centered Motivational Interviewing:

Client-centered communication, including empathic reflective listening, is the central skill and primary intervention in motivational interviewing (MI)³. The provider practices Rogers’ “non-directive” empathic reflective listening without imposing his or her values or preferences. The “spirit” of MI encompasses:

•    collaboration/partnership – respectful collaboration with the client’s side, opinions, feelings;
•    evoking - one works to evoke the clients ideas, perceptions, reasons to change;
•    autonomy/support - one evokes the client’s experience of choice and control, respects the client’s autonomy and decisions. Recently added are
•    compassion – Rogers professed “when people are able to understand one another’s needs, compassion is likely to be stimulated, and then people are often motivated to help one another get needs met…” and
•    acceptance – which is equal to Rogers' unconditional positive regard.

Dr. Carlo DiClemente maintains that a change in behavior requires daily intent, determination, persistence and focus. A client is unlikely to sustain this perseverance if he or she is ambivalent or unmotivated. Significant behavior changes require high motivation based on personal conviction about the value and importance of making the change.

The Practice of MI

MI is a communication style specifically about change. A central focus is client “change talk,” an area where directional interventions are utilized. This may begin with the guiding process of bringing a target behavior into focus, followed by the directional process of evoking and reinforcing the client’s reason(s) for change.⁴

It is the provider’s responsibility to assure that a target behavior or goal is decided upon collaboratively; thus the meaning of “directional” in MI does not conflict with Rogers’ “non-directive" reflective listening approach.
When communicating about change, the provider must be directional in facilitating the client’s exploration of thoughts, opinions, and perceptions about a target behavior, yet avoid telling the client what to do or influencing the client’s opinions. In this regard, being directional means keeping the discussion focused on the target behavior.

Within the conversation, an MI provider may give less attention to the client’s reasons not to change (sustain talk). Or, when the client voluntarily speaks of reasons to change, the provider may reinforce this talk and attempt to deepen it with reflective listening. And, the provider can evoke change talk, for example, by asking evocative questions: “What do you see as the worst thing that can happen if you don’t make a change?”
MI includes five communication skills and strategies, four of which are known by the acronym OARS:

•    Open questions
•    Affirming
•    Reflective listening, and
•    Summarizing.

The fifth skill is reinforcing and evoking change talk.

Open questions elicit the client’s thoughts and may result in responses that go beyond simple yes-or-no answers; Affirming includes actively listening for and then reflecting back the client’s values, strengths, effort, and perseverance. Reflective listening can be a simple reflection that clarifies client thoughts, or more complex, perhaps conveying the possible meaning behind what is said–the story behind the story. Summarizing is directional: one concludes a session with a collaborative summary and reinforces change talk.
Recently, it has been suggested that MI skills and strategies be practiced within four processes. These are not new to counseling but serve as a guide for the MI practitioner. They include: Engagement, Focusing, Evoking and Planning.

Throughout the MI process, the provider maintains a balance. The provider always avoids the “expert trap”—the attempt to make a client change—yet maintains the ability to provide information, educate, or make suggestions. Collaborative communication includes asking permission to offer information, then eliciting the client’s feedback to what is offered.

Because both physical and behavioral healthcare acknowledge a client’s right to make “informed” decisions, the non-judgmental, non-confrontational approach espoused by MI is both powerful and appropriate. It requires the provider to accept the possibility that the client may not be ready for change and may decide not to change or participate in a course of treatment.

The Stages of Change model

The Stages of Change (SOC) model is a separate, distinct model that preceded MI.⁵ The SOC model may be applied with many types of interventions. SOC and MI are complementary; both profess that, in order for a treatment to be effective, a provider’s intervention must be matched with the client’s readiness to accept that intervention.

Consider two examples: First, a client who has not accepted he or she has a physical illness and is therefore not ready to accept treatment may be presented with a medical treatment plan. Similarly, a client who disagrees that he or she has an addiction problem may be court-ordered to adhere to an action plan that requires abstinence.
Both of these examples would, in terms of the SOC model, be instances of a classic mismatch: Both would represent a premature intervention because they would match a client who, in SOC language, is in the “pre-contemplation stage”—a stage that does not yet see reason to change—with an “action stage” of treatment. The SOC model holds that the “action stage” of treatment should be matched by a client’s readiness to accept it, e.g., a client who is self motivated to make the changes needed to participate in the action plan.

This wasteful mismatch of the pre-contemplative client with the action of treatment is all too common, as is the resulting discord between the client and provider, and less-than-optimal outcomes due to client defensiveness or passivity.

Benefits of using the Stages of Change Model

The SOC model can be integrated rather easily into both behavioral and medical practice. In my experience, it has enhanced my work with MI, cognitive behavioral therapy, and dual-diagnosis individual and group treatment.

Among the benefits of this revolutionary model are:
1.    Clearly defined stages that allow providers to identify changes in client readiness, respond with appropriate interventions or withhold mismatched interventions until there is client motivation and readiness to accept them.
2.    A set of broadly accepted definitions that allow multiple providers to understand where a client may be at a given moment or over longer periods of time. The SOC definitions make clear to providers that a client’s readiness to change with regard to a target behavior is a progression that may take time, not an indication of negativity or deliberate non-compliance.
3.    The stages are pertinent to supervisor-supervisee relationships and provider-client relationships. As clients/providers become educated about the SOC/increments of change, both can share where they are with a given target. More importantly, they understand that all of the stages are “normal” and necessary. For example, a client who is in the SOC contemplation stage may feel ambivalent about changing, and could be wrongly perceived as “weak” or “ignorant.” But this is normal for that stage: it is a part of the SOC process one must go through to reach an intrinsic decision.
4.    The SOC revolutionizes the way we chart outcomes. Where “action” is traditionally what defines progress, the SOC defines increments of change that represent real progress in client understanding and motivation. Clients are seen to progress incrementally—an effort deserving of affirmation for themselves, the provider, and the agency.
5.    Using the SOC model in progress notes enables diverse treatment-team providers to relate to the client in a consistent way, relative to the client’s SOC. The result is a stage-matched, community of care approach—an approach likely to dramatically improve client care and outcomes when it is used as a key element in the partnership of physical and behavioral healthcare.

Working with clients who are addressing multiple issues and behavior change goals requires providers to chart client progress clearly, since they may be at one stage for one target behavior and another stage for a different target behavior. For example, a client may be in pre-contemplation regarding mental health treatment; contemplation regarding domestic violence; preparation regarding Hepatitis C treatment; and action regarding treatment for drug addiction.

From the inception of dual-diagnosis treatment (1984), and prior to my knowledge of the SOC, it was necessary to design readiness scales⁶ to determine client readiness and chart incremental progress or regression across multiple symptoms and behaviors.

In my work, both as a provider and as a trainer of MI and SOC for 20 years, I found it valuable to develop a tracking form for multi-focused care⁷ that clearly documents:

•    each target behavior
•    the last known stage of client readiness to address that target behavior
•    the intervention that matches that client readiness stage
•    the thought or behavior changes that indicate client progress—forward or backward—between stages, along with the respective dates, and,
•    the outcome of those changes.

As we strive to build integrated systems of treatment that focus on optimal client care, we have much to gain by embracing Rogers’ notion of ‘the person as the main figure of importance.’ MI and the SOC model are two powerful, client-centered approaches that can serve the coordination requirements of physical and behavioral health integration, reshape providers’ understanding of clients, and mobilize client motivation for better treatment outcomes. Both of these approaches can be readily integrated with other models of intervention^8,9 to provide essential care continuity, while offering clients respectful, deeply human, and high-quality care. ■

Kathleen Sciacca is a pioneer in the development of integrated treatment for co-occurring mental illness and substance disorders, a consultant and trainer for national and international programs that specialize in integrated treatment for co-occurring health issues, and a consultant and trainer of motivational interviewing. She has been a member of the Motivational Interviewing Network of Trainers since 1995. She can be reached at ksciacca@ix.netcom.com. More information about MI can be found at https://motivationalinterviewingtraining.com.

References
    1.    Rogers, C.R. Significant Aspects of Client-centered Therapy. American Psychologist. 1946; 1:415-422.
    2.    Gendlin, E.T. Carl Rogers (1902-1987), American Psychologist. February,1988; Vol. 43, No.2. 127-128.
    3.    Miller W, Rollnick S. In: Miller W, Rollnick S (eds). Motivational Interviewing: Preparing People for Change, Second Edition. New York: Guilford Press; 2002.
    4.    Sciacca, K. Motivational Interviewing Glossary and Fact Sheet. Publ. Kathleen Sciacca. Copyright 2009; 1-7.
    5.    Prochaska, J.O. DiClemente, C.C. Norcross, J.C. In Search of How People Change: Applications to addictive behaviors. American Psychologist, September 1992; Vol. 47(9) 1102-1114.
    6.    Sciacca, K. Best Practices for Dual Diagnosis Treatment and Program Development: Co-occurring Mental Illness and Substance Disorders in Various Combinations. The Praeger       International Collection on Addictions, Editor, Angela Brown-Miller, 2009:Vol. 3, Chapt.9: 161-188, Westport, CT. London.
    7.    Sciacca, K. Client Behavior Change up-date form. Unpublished, © Kathleen Sciacca 1996-2012.
    8.    Sciacca, K. Dual Diagnosis Treatment and Motivational Interviewing for Co-occurring Disorders. National Council Magazine, 2007; Vol. 2, 22-23.
    9.    Sciacca, K. Removing Barriers: Dual Diagnosis Treatment and Motivational Interviewing. Professional Counselor, February 1997, Vol. 12, No.1, pp. 41-46.