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Co-Occurring Schizophrenia and Substance Dependence/Abuse

Applying MI: Develop Discrepancy
Substance Dependence
Substance Abuse
Assessment of Co-occurring Disorders
Motivational Interviewing
Applying MI: Express Empathy
Applying MI: Develop Discrepancy
Applying MI: Avoid Argument
Applying MI: Roll With Resistance
Applying MI: Support Self-Efficacy
Evidence Based for Motivational Interviewing
Future Research and Barriers to Service
Web sites of Interest

Develop discrepancy between client’s goals or values and their current behavior:

The therapist’s task is to help the client focus their attention on how current behavior differs from ideal or desired behavior.  Discrepancy is initially highlighted when the therapist raises the clients’ awareness of the negative personal, familial, or community consequences of a problem behavior and helping them confront the substance use that contributed to the consequences.


The therapist should separate the behavior from the person and help the client explore how important personal goals (e.g., good health, marital happiness, financial success) are being undermined by current substance use patterns.  This requires the therapist to listen to the client carefully about values and connections to the community, family, and church.  If the client should show concern about the effects of personal behavior, the therapist should highlight this concern to heighten the client’s perception and acknowledgement of discrepancy.


Once a client begins to understand how the consequences or potential consequences of current behavior conflict with significant personal values, amplify and focus on this discordance until the client can articulate consistent concern and commitment to change.

One useful tactic for helping a client perspective discrepancy is sometimes called the “Columbo approach” (Kanfer and Schefft, 1988).  This is particularly useful with a client who prefers to be in control.  The clinician would essentially express understanding and continuously seek clarification of the client’s problems but appear unable to perceive any solution.  A stance of uncertainty or confusion can motivate the client to take control of the situation by offering a solution to the clinician.


 Examples of this include:


“Hmm.  Help me figure this out.  You’ve told me that keeping custody of your daughter and being a good parent are the most important things to you now.  How does your heroin use fit in with that?”


“So, sometimes when you drink during the week, you can’t get out of bed to get to work.  Last month, you missed 5 days.  But you enjoy your work, and doing well in your job is very important to you.”


In both cases, the clinician expresses confusion, which allows the client to take over and explain how these conflicting desires fit together.  This reinforces the notion that the clients are the experts on their won behavior and values.  They are the only ones who can resolve the discrepancy.  If the clinician attempts to do this instead of the client, the clinician risks making the wrong interpretation, rushing to his or her own conclusions rather than listening to the client’s perspective, and most importantly, making the client a passive rather than an active participant in the process.


           Tools, instead of talking, may be used to reveal discrepancy.  An example is showing a video and then the therapist discussing it with the client, but allowing the client to make the connection to his own situation.  Juxtaposing different media messages or images that are meaningful to a client can also be effective. 


           Substance use might also conflict with the client’s personal identity and values, the values of the larger community, with spiritual or religious beliefs, or use of the client’s family members.  Clinicians can help their clients perceive discrepancy on different levels, from physical to spiritual, and from different domains, from attitudinal to behavioral, thus it is important for clinicians to understand what the individuals values are as well as the values of the larger community.


           The client’s cultural background can affect perceptions of discrepancy.  Different cultures may view this and have different beliefs on this than others.


Nicole & Colleen