Compare MI DARES and Frames model in addiction psychiatry management .
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MI DARES vs FRAMES model addiction psychiatry motivational interviewing comparison
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DARES motivational interviewing acronym Develop discrepancy Avoid argument Roll resistance Enhance self-efficacy Support
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MI DARES vs. FRAMES in Addiction Psychiatry Management
Both models serve the same overarching goal - motivating patients with substance use disorders to change - but they operate at different levels. DARES encodes the underlying principles of Motivational Interviewing (MI) that guide how a clinician thinks and behaves throughout any encounter, while FRAMES is a structured brief intervention protocol applied during a time-limited clinical interaction.
1. Origins and Theoretical Basis
| Feature | MI DARES | FRAMES |
|---|---|---|
| Developed by | Miller & Rollnick (2002) - 2nd edition MI | Miller & Sanchez (1994); endorsed by SAMHSA |
| Type | Core principles of a counseling philosophy | Structured brief intervention protocol |
| Parent framework | Motivational Interviewing (MI) | Brief Intervention (BI) tradition |
| Setting | Psychotherapy, counseling, any clinical encounter | Primary care, ED, brief clinical visits (15-60 min) |
| Duration | Ongoing - shapes the entire therapeutic relationship | 1-4 sessions; can be a single brief encounter |
| Applicable stage | Pre-contemplation through Action | At-risk drinkers/users; any AUDIT/CAGE-positive patient |
2. The DARES Model - MI Principles in Detail
DARES stands for the five core principles of Motivational Interviewing (Miller & Rollnick, 2002), arranged as a mnemonic:
D - Develop Discrepancy
- Change is motivated when the patient perceives a gap between their current behavior and their personal goals or values
- The patient - not the clinician - should articulate the arguments for change
- Technique: "What matters most to you in life? How does your current drinking affect that?"
- Avoids the clinician becoming the "pro-change" voice while the patient argues against it
A - Avoid Argumentation
- Arguing is counterproductive: it causes resistance, is not listening, and leads the patient to defend the status quo
- Direct confrontation ("you have a problem and you need to stop") triggers reactance
- The clinician must suppress the "righting reflex" - the urge to fix, correct, or persuade
R - Roll with Resistance
- Resistance is not opposed directly; it is a signal to respond differently
- New perspectives are invited, not imposed
- The patient is the primary resource in finding their own answers and solutions
- Techniques: reflection, reframing, agreement with a twist, emphasizing personal choice
E - Express Empathy
- Acceptance facilitates change - the foundational stance of MI
- Skillful reflective listening is fundamental; ambivalence is normalized ("it makes complete sense that part of you wants to keep drinking - it helps you cope")
- Non-judgmental, non-confrontational approach reduces shame, which is especially important in addiction where stigma is high
S - Support Self-Efficacy
- A patient's belief in the possibility of change is itself a motivator
- The clinician's belief in the patient's capacity becomes a self-fulfilling prophecy
- The patient, not the counselor, is responsible for choosing and carrying out change
- Techniques: affirm past successes, explore strengths, provide a menu of options
Source: Harrison's Principles of Internal Medicine 22E; BUMC/CRIT FIT Saitz 2013 (Miller & Rollnick, 2nd Ed.)
Note on variants: The same five principles are also taught as READS (Roll, Express, Avoid, Develop, Support) or DEARS in different training programs - the letters are identical, only the mnemonic ordering differs.
3. The FRAMES Model - Brief Intervention Protocol in Detail
FRAMES was identified by the SAMHSA Consensus Panel as the six elements critical to effective brief interventions for substance use. It is a structured checklist of what a clinician delivers in a brief encounter.
F - Feedback
- Personalized feedback about the patient's risk level, based on screening results (e.g., AUDIT score, liver enzymes, comparison to population norms)
- "Your AUDIT score of 18 places you in the harmful drinking range - higher than 90% of people your age"
- Distinguishes brief interventions from general health advice
R - Responsibility
- Explicitly placing responsibility for change with the patient, not the clinician
- "Only you can decide whether you want to make a change"
- Preserves autonomy; avoids paternalism
A - Advice
- Clear, direct advice to change behavior - from the clinician's medical perspective
- "As your doctor, I strongly recommend you cut down / stop drinking"
- Given in a non-coercive, collaborative manner
M - Menu of Options
- Offering a range of change strategies rather than a single directive
- Options may include: cutting down, abstinence, self-help groups (AA/NA), pharmacotherapy (naltrexone, acamprosate, buprenorphine), specialist referral, harm reduction
- Increases patient autonomy and likelihood of engagement
E - Empathy
- Empathic, non-judgmental listening style throughout the interaction
- Validates the difficulty of change; avoids labeling ("alcoholic," "addict")
- The overlap with DARES here is intentional - both models recognize empathy as non-negotiable
S - Self-Efficacy
- Expressing confidence in the patient's ability to change; offering optimistic reinforcement
- "Many people in your situation have successfully cut down - I believe you can do this too"
- Addresses hopelessness and demoralization common in addiction
Sources: Harrison's 22E, p. 548; Kaplan & Sadock's Comprehensive Textbook of Psychiatry (9781975175733), Brief Interventions section
4. Head-to-Head Comparison
| Dimension | MI DARES | FRAMES |
|---|---|---|
| What it is | Clinical principles / counseling philosophy | Structured protocol for brief intervention |
| Focus | How the clinician engages the patient | What the clinician delivers to the patient |
| Clinician role | Collaborative partner, evocative listener | Brief advisor delivering personalized feedback |
| Patient role | Active discoverer of own motivation | Recipient of structured information + choices |
| Ambivalence | Central - explored at length | Acknowledged but not the primary focus |
| Confrontation | Explicitly prohibited (Avoid Argumentation, Roll with Resistance) | Avoided but less explicitly theorized |
| Feedback | Not a defined element | Core element (personalized data-driven feedback) |
| Menu/Options | Implicit in respecting autonomy | Explicit structured element |
| Time required | Sessions can last 30-60+ min over multiple visits | 5-15 minutes per session; 1-4 sessions |
| Setting fit | Specialty addiction/psychiatric clinics, counseling | Primary care, ED, any brief encounter (SBIRT) |
| Screening tools | Integrates with readiness rulers, decisional balance | Integrates with AUDIT, CAGE, DAST scores |
| Best for | Pre-contemplation, high ambivalence, complex cases | At-risk/harmful users; brief opportunistic visits |
| Evidence base | Strong across substance types; works best for ambivalent patients | Strong for alcohol brief interventions, especially in primary care |
5. Relationship Between the Two Models
These are not competing models - they are complementary and hierarchical:
- FRAMES is the "what" - the content and structure of a brief intervention
- DARES is the "how" - the spirit and skill with which any interaction is conducted
A clinician delivering FRAMES optimally will be guided by DARES principles throughout. The empathy (E) in FRAMES is the same as Express Empathy (E) in DARES. The self-efficacy (S) is shared. However:
- FRAMES adds the feedback element (personalized data) that DARES does not explicitly require
- FRAMES adds the menu of options as a specific deliverable
- DARES adds explicit guidance on handling resistance and avoiding argumentation - which FRAMES does not address directly
- DARES describes the discrepancy development technique that drives intrinsic motivation - absent from FRAMES
As noted in Harrison's 22E: "Motivational interviewing techniques may be more useful than FRAMES for patients who are more ambivalent about change." This captures the clinical distinction well - FRAMES suits at-risk or mildly dependent patients who need structured advice, while DARES-informed MI is better suited to highly ambivalent or resistant patients.
6. Clinical Application in Addiction Psychiatry
When to use FRAMES (Brief Intervention):
- Positive screening in primary care / ED (SBIRT model: Screening, Brief Intervention, Referral to Treatment)
- At-risk or harmful drinkers who do not yet meet criteria for SUD
- Time-limited encounters (5-15 min)
- Initial contact before possible specialist referral
When to use MI DARES:
- Patient is pre-contemplative or highly ambivalent
- Patients with established SUD in ongoing treatment
- Complex comorbidities (dual diagnosis / co-occurring psychiatric disorders)
- Situations where resistance, denial, or low motivation are the primary barriers
- Longitudinal therapeutic relationship (multiple sessions)
Integration in SBIRT:
The full SBIRT model uses both:
- Screen (AUDIT, DAST, CAGE)
- Brief Intervention using FRAMES (feedback, responsibility, advice, menu, empathy, self-efficacy)
- Referral to specialty treatment where full MI guided by DARES principles continues
7. Shared Limitations
- Neither model is sufficient as a standalone treatment for severe SUD - both are adjuncts to pharmacotherapy (naltrexone, acamprosate, buprenorphine, methadone) and intensive psychosocial programs
- Evidence is strongest for alcohol; data for stimulants, cannabis, and polysubstance use is more mixed
- Cultural adaptation is required; both models were developed in Western, English-speaking contexts
- DARES principles (Roll with Resistance) have been updated in MI 3rd edition (Miller & Rollnick, 2013) - "resistance" is now reconceptualized as "sustain talk," and the newer change talk framework uses the DARN-CAT acronym (Desire, Ability, Reasons, Need - Commitment, Activation, Taking steps)
Quick Reference Summary
| MI DARES | FRAMES | |
|---|---|---|
| D | Develop Discrepancy | - |
| A | Avoid Argumentation | Advice |
| R | Roll with Resistance | Responsibility |
| E | Express Empathy | Empathy |
| S | Support Self-Efficacy | Self-Efficacy |
| F | - | Feedback |
| M | - | Menu of Options |
Both share Empathy and Self-Efficacy as core elements - affirming that these are non-negotiable in any addiction-focused clinical encounter.
Key references:
- Harrison's Principles of Internal Medicine, 22E - SBIRT and FRAMES, p. 548
- Kaplan & Sadock's Comprehensive Textbook of Psychiatry - Brief Interventions (FRAMES per SAMHSA Consensus Panel)
- Miller WR, Rollnick S. Motivational Interviewing, 2nd Ed. Guilford Press, 2002 (DARES principles)
- Saitz R. CRIT/FIT 2013 (Boston University Medical Center) - MI principles in medical practice
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