CASC: Motivational interviewing — alcohol cut-down in dual diagnosis

Candidate instructions

You are the psychiatry registrar. Alex, 34, has schizophrenia managed with monthly paliperidone palmitate. Drinking has increased to most days. Mildly raised GGT. Missed one depot. Partner in the waiting room wants you to "tell him he has to stop or else." Your tasks in 10 minutes:[1][2]

1. Engage and set a collaborative agenda about alcohol and treatment adherence.
2. Use MI spirit and OARS; minimise advice stacks.
3. Elicit importance and confidence; respond to sustain talk without arguing.
4. Strengthen change talk and negotiate one specific next step.
5. Address risk briefly (falls/driving/withdrawal red flags) without abandoning MI style.
6. Manage the partner's demand without colluding with coercion.

Actor brief (Alex)

• Ambivalent: enjoys drinking with mates; worried about GGT and missing depot after a binge.
• Sustain talk ready: "I'm not an alcoholic"; "I'll stop later."
• Offers change talk if reflected well: kids' weekend visits, not wanting hospital again, injection keeps voices away.
• Becomes defensive if lectured; opens up if complex reflections used.
• Will accept a cut-down plan or AOD referral if commitment is evoked, not forced.

Marking grid (domains)

Model process (time map)

0–2 min — Engage/focus. Introduce role; ask permission to discuss drinking and depot. Agenda map: "We could talk alcohol, the injection, stress, or what matters at home — where shall we start?"[1]

2–6 min — Evoke. Typical day/good things and less-good things. Complex reflections of ambivalence. Importance/confidence rulers with "why that number not lower?" Selectively reinforce DARN; listen for CAT.[6][9]

6–8 min — Risk and information (EPE). Ask what he already knows about alcohol and GGT/med adherence; brief information; check meaning. Screen driving after drinking and withdrawal history without scare tactics.[1]

8–10 min — Plan. If mobilising language appears: menu (cut-down goals, AOD brief intervention, partner session later with consent, medical alcohol work-up). One next step e.g. "no drinks two days before depot" + review date. If still precontemplative: affirm honesty, leave door open, safety net.[2][16]

Partner pressure line

"I hear how worried they are. I won't force you — decisions about change are yours. With your permission we can include them later for support, not for control."[1][2]

Sample high-scoring utterances

• "Part of you wants mates and wind-down, and part of you doesn't want another hospital or missed injection."
• "A 6 on importance — what makes it a 6 rather than a 3?"
• "You've already connected the GGT with drinking — that awareness is a strength."
• "Would it be all right if I shared one medical point, then you tell me what it means for you?"

Common station fails

Lecturing "you must stop"; triple-barrelled questions; no reflections; deciding goals for the patient; promising cure; ignoring psychosis medication; colluding with partner threats; skipping any safety screen.[1][2]