Establishing a Trusting Therapeutic Relationship with Patients Having Co-Occurring Disorders


It is well established that behavioral changes are not events but rather processes that occur in phases in the context of a trusting therapeutic relationship between a client and a counselor or clinician. Studies do show that the nature of the therapeutic relationship between a client and his or her counselor or clinician is directly linked to their motivation and commitment for change, change talk, and self-efficacy (Phillips, et al., 2010). Motivational interviewing (MI) is an evidence-based counseling technique that is a very effective method of working with clients having substance use disorders and mental health disorders to enable them to make the necessary changes in their lives. In this paper we will be taking time to examine; the use of MI in establishing a trusting therapeutic relationship, the nature and type of psychological interventions, and evidence that support the use of psychological interventions in co-occurring disorders.

Using the MI approach to establish a therapeutic relationship

Motivational interviewing is a “way of being” as a counselor or clinician in a therapeutic relationship with a client or it is the way a counselor or clinician engages a client in the therapeutic process. The core objective of MI is to ensure the establishment of a collaborative relationship between the therapist and the client as the bedrock for building a trusting relationship, gives the client room to make autonomous decisions, evoke change talk, and build motivation and commitment for change (Romano, et al., 2010).

The quality of any therapeutic relationship between a client and a therapist is principally depending on the spirit with which the practitioner engages with the client and the level of collaboration in the relationship. Several recent studies do show that the higher the quality of a therapeutic relationship during treatment the more significant are the changes or decreases in the symptomologies, whether it be substance use or mental illness (Kelly, 2015; Phillips, et al., 2010). Fundamental to developing this therapeutic relationship or alliance with the client is for the therapist to cultivate as his or her guiding principles in working with individuals struggling with substance use and mental health illness; a genuine desire to help others, a genuine sensitive consideration, and genuine respect for the autonomy and well-being of clients (Kelly, 2015). The above-mentioned principle is a simplification of the four core principles of MI which include; expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy. These principles are brought to bear in a therapeutic relationship as counselors or therapists employ the following four strategies in their interactions with the clients; open-ended questions, affirmations, active listening or reflective listening, and summarizing (Phillips, et al., 2010).

What most studies dedicated to examining treatment outcomes have shown, is that self-efficacy and change talk are key predictors of treatment outcomes, and MI is aimed at enabling clients to cultivate strong change talk and self-efficacy (Kelly, 2015; Romano, et al., 2010). It is worth mentioning here that knowledge of the above-listed principles and strategies that defines MI counseling technique does not necessarily translate into making one an effective counselor or therapist, but, rather, the effectiveness with which one employs them in a therapeutic relationship is critical. A well-trained professional who develops a therapeutic relationship but fails to recognize the fact that a client may sometimes choose not to change might try to force change or get frustrated. Thus, they will not be able to develop a high-quality therapeutic relationship (Ghosh, 2019). Another obstacle for the professional is not seeing his or her relationship with the client as collaborative. They instead see their role as an expert and seek to direct and define for the client what his or her change should look like.

The nature and type of psychological interventions

Psychology as a scientific discipline is multifaceted including sub-disciplines such as; mental health, addiction, human development, social behavior, cognitive processes, and many others. Psychology is the study of behavior and the mind with all the mental processes associated with it such as; cognition, memory, intelligence, personality, perception, sensations, beliefs, attitudes, thoughts, speech, and others. “Psychological interventions aim to effect a change in the way people interpret their experiences thus enabling a corresponding change in their behavior and aiding in their recovery from incapacitating mental problems” (Kelly, 2015, p. 67).

The need to come up with treatment models that adequately addresses the different psychological problems that individuals are dealing with has resulted in the development of various psychological theories or models which can be grouped or classified under the following broad headings:  behavioral, cognitive, psychodynamic, humanistic, systemic, motivational, social and environmental. Each of these has a theoretical foundation upon which interventions are developed. Therefore, the type of interventions used in helping individuals or their supporting family members, and group therapies, will be drawn from any of the above class of psychological models depending on the therapist’s training and the psychological needs of the person seeking help (Phillips, et al., 2010).

The evidence for psychological interventions in co-occurring disorders

From the findings of several studies that have sought to investigate the effectiveness of psychological interventions in treating co-occurring disorders, there is ample evidence to support the effectiveness of several psychological interventions.  The recent movement towards the integrated treatment model of co-occurring disorders, rather than parallel or sequential treatment models, accounts for most of the evidence that has been gathered so far to demonstrate the relevance of psychological interventions in dealing with the dual disorder (Phillips, et al., 2010).

The usefulness and relevance in application of psychological interventions, such as cognitive-behavioral counseling,  contingency management, and motivational interviewing in treating those diagnosed with substance use and mental health issues, were demonstrated by Mueser and colleagues in their work recorded in the book Integrated Treatment for Dual Disorders (Phillips, et al., 2010).

Baillie, et al., (2010), in their examination of recent clinical trials in which psychological interventions were used in treating patients with co-occurring disorders, reviewed six randomized controlled trials, among which were the following:

  • Schade et al., (2005) looked at the treatment of 96 patients diagnosed with co-occurring disorders (severe alcohol use disorder and various anxiety disorders). The authors provided evidence to demonstrate the fact that when additional psychological interventions were employed along already existing psychosocial programs, not only did the additional psychological interventions help to reduce their anxiety symptoms, but also there was a not too significant impact on the reduction of alcohol relapse rate.
  • Tull et al., (2007), in their psychoeducational intervention package developed to target anxiety sensitivity in heroin users who were also diagnosed with anxiety disorder, provided evidence that showed not only a reduction in anxiety sensitivity but also a significant reduction in the craving intensity for heroin by the patients.
  • Thomas et al., (2008) investigated the effectiveness of paroxetine in treating social anxiety for individuals diagnosed with comorbidity of alcohol use disorder and social anxiety disorder. They noticed that not only did it helped in reducing social anxiety in the patients but their reliance on alcohol to deal with social anxiety was also significantly reduced, though not their overall drinking.

One thing is clear about the studies reviewed by Baillie and colleagues (year).  Though most of the studies didn’t provide evidence to show that the psychological interventions employed directly impacted both the substance use disorder and the mental health disorder of the patients, there was substantial evidence to show that the interventions were helpful to address addictive behaviors such as craving intensity for heroin users, and self-medication which are significant factors when it comes to relapse prevention. There is a sufficient body of research that shows the integrated treatment model to be superior to other treatment models when it comes to the treatment of co-occurring disorders (Rundell, et al., 2019).

It is very challenging to manage and treat patients that are diagnosed with co-occurring disorders due to the interconnectedness of the mental health and substance use symptoms with these patients, such that, the intensification of either mental health symptoms or substance use symptoms invariably affect the other. Below are evidence-based psychological interventions that are significantly effective in dealing with co-occurring disorders:

  • Individual therapies; motivational interviewing (MI) techniques are one of the most effective individual therapy approach commonly used in treating patients with dual diagnosis because it helps to raise awareness to the problems associated with their co-occurring disorders. MI helps dually diagnosed patients to move from one stage of change to another (that is, from pre-contemplation stage to the contemplation stage, then to determination stage, then action stage, and finally maintenance stage) (Horsfall, 2009; Phillips, et al., 2010).
  • Group therapies are very cost-effective compared to individual therapy and it is very helpful in addressing social attitudes and behaviors linked to comorbid substance users with a mental disorder. One of the principal purposes for group therapy as a treatment approach in co-occurring disorders is to enable patients to create a social support network which is very key in dealing with the stigma associated with mental illness and to some degree severe substance use (Horsfall, 2009). It is worth mentioning that there are also specific psychosocial therapy groups like “Integrated group therapy for bipolar disorder and substance use” (Subodh, 2018).
  • Cognitive behavior therapy and relapse prevention; is an integrated therapy approach in treating patients with a wide range of mental health disorders such as schizophrenia, depression, anxiety, and substance use disorder. It is very helpful to enable patients to build relapse prevention skills, develop social skills, gain abstinence, and also enhance self-efficacy (Horsfall, 2009).
  • Family interventions; are psychoeducational interventions aimed at educating family members of individuals diagnosed and being treated for co-occurring disorders. Interventions are designed so that they can be equipped to be of better support to their loved ones or significant others.
  • Contingency management; gives vouchers or rewards to people who practice healthy behaviors. This is simply rewarding behaviors associated with positive behavioral changes and commitment to change. Also, there is room for the use of technology to help with the implementation of contingency management procedures in various treatment programs through the use of apps and web-based tools (Oluwoye, et al., 2020).


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