Psychotherapeutic, Behavioral, and Counseling Interventions
Core knowledge
Motivational interviewing (OARS: open questions, affirmations, reflections, summaries) is directive and goal-oriented; the clinician evokes change talk and explores sustain talk rather than arguing. Prochaska stages (precontemplation through maintenance) guide intervention selection but are not linear, and relapse is expected. CBT targets triggers, outcome expectancies, and coping skills; Marlatt relapse prevention distinguishes a lapse from a relapse and rehearses high-risk situations. Contingency management - tangible, escalating reinforcers for verified abstinence - has the strongest evidence base for stimulant use disorder, for which no medication is approved. Twelve-step facilitation works when the patient is willing; mandating attendance is not evidence-based. CRAFT trains families to change contingencies and outperform confrontation-based programs. DBT fits co-occurring emotion dysregulation and borderline traits; trauma-informed care assumes widespread trauma and avoids re-enactment. SBIRT pairs screening with a brief, structured intervention using ask-tell-ask or the 5 A's, then links to treatment.
Traps
- MI is not simply being agreeable; it requires directional evocation and specific skills.
- A brief intervention is not psychotherapy - it is short, structured, and referral-linked.
- Relapse is a clinical event, not a moral failure; discharge for recurrence is inappropriate.
- Older test items may present confrontational or purely educational models as best practice; they are not.
Rule of thumb
Match the tool to the stage. In precontemplation, build rapport and raise doubt with permission; in preparation, negotiate a concrete plan. Worked example: a patient says he sees no problem but his wife is worried. Reflect both sides, ask permission to discuss, and avoid an action plan he has not chosen - that preserves engagement for the next visit.