MI and CBT Combination, Integration Synergy

Paul EarnshawPsychological Therapist

/Social WorkerSylvie Naar King

Associate ProfessorClinical 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

Motivational Interviewing

Problem Focused Strengths Focused

Formulation led Target-behaviour led

Schema Values

Expert-led Expert-trap

How? Why?

Thoughts-Feelings-Behaviour Values-Dissonance-Behaviour

Change as a function of the individual Change as a function of the relationship

Psychological-Medical 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

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

What to integrate from CBT?

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

Relapse

Maintenance

Action

Determination

Contemplation

Precontemplation

Style of TherapyClient’s Stage of ChangeM

otivational

Interviewing

Cognitive

Behavioural

Therapy

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