Motivational Enhancement Therapy

Joy Chudzynski, PsyD

UCLA Integrated Substance Abuse Programs

Basis for MET

Six critical elements are necessary and sufficient to induce change:

• Feedback regarding personal risk or impairment

• Emphasis on personal responsibility for change

• Clear advice to change

• A menu of alternative change options

• Therapist empathy

• Facilitation of client self-efficacy or optimism

(Miller & Rollnick, 1991):

What is MET?

• MET is a counseling approach that helps individuals resolve their ambivalence about engaging in treatment and stopping their drug use

• Aims to invoke rapid and internally-motivated change, rather than guide the client through a stepwise recovery process

What is MET?

• Consists of an initial assessment session – What is extent of drug use (severity, health,

family, financial, social, employment)?

– What is motivation for change?

• Then between 2-5 individual treatment and follow-up sessions

Outline of Sessions• Session 1

– Provide feedback from initial assessment– Stimulate discussion about personal substance

use

• Session 2 (thru 5)– Continue discussion about personal substance

use– Elicit self-motivational statements– Strengthen motivation/build plan for change using

motivational interviewing – Coping strategies for high-risk situations

suggested and discussed (CBT)

Outline of Sessions

• Follow-up Sessions– Monitor change

– Review cessation strategies being used

– Continue to encourage commitment to change and/or sustained abstinence

• Clients often encouraged to bring significant other to sessions

Brief Intervention Effect

• Brief interventions trigger change.

• A little counseling can lead to significant change, e.g., 5 min. has same impact as 20 min.

• Research is less extensive for illicit drugs, but promising.• A randomized study with cocaine and heroin users

found that patients who received a BI had 50% greater odds of abstinence at follow up compared with controls.

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Where do I start?

• What you do depends on where the client is in the process of changing

• The first step is to be able to identify where the client is coming from

Stages of ChangeProchaska & DiClemente

Dep

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Fa

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Pro

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Goal of MET

– Work concretely with consumers at any stage of readiness for change

– The MET session will help consumers:

• see the impactimpact of their substance use substance use on their mental health symptoms

• exploreexplore the good and not-so-good aspects of their current behaviors

• determine what change what change they are willingwilling to make

• formulate aformulate a plan plan to begin that change

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Strategic goals

• Resolve ambivalence• Avoid eliciting or strengthening

resistance• Elicit “Change Talk” from the client• Enhance motivation and commitment

for change• Help the client move through the Stages

of Change

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The Spirit

• Nonjudgmental and collaborative

• Based on client and clinician partnership

• Gently persuasive

• More supportive than argumentative

• Listens rather than tells

• Communicates respect for and acceptance for clients and their feelings

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Important considerations

The clinician’s counseling style is one of the most important aspects of motivational interviewing:

– Use reflective listening and empathy

– Avoid confrontation

– Work as a team against “the problem”

Blaise Pascal

“PEOPLE ARE BETTER PERSUADED BY THE REASONS THEY THEMSELVES DISCOVERED THAN THOSE THAT COME INTO THE MINDS OF OTHERS”

Four Principles ofMotivational Enhancement

Therapy

1. Express empathy

2. Develop discrepancy

3. Avoid argumentation

4. Support self-efficacy

MET Principles

• Empathy– May be the most crucial principle

– Creates environment conducive to change, instills sense of safety, of being understood and accepted, and reduces defensiveness

– Sets the tone within which the entire communication occurs. Without it, other components may sound like mechanical techniques

Listening with Empathy:Reflective Listening

• Listen to both what the patient says and to what the person means

• Show empathy and don’t judge what patient says• You do not have to agree

• Be aware of intonation• Reflect what patient says with statement not a

question, e.g., “You couldn’t get up for work in the morning.”

1. Simple Reflection (repeat)

2. Complex Reflection (emotion/continue the thought)

3. Double-Sided Reflection (captures both sides of the ambivalence)

Types of Reflective Statements

Reflections

Simple Reflection

(repeat)• You’re so tired of

using and you don’t know what to do about it.

• Every time you start using again it gets worse and you don’t know what to do.

Client says:• I’m so tired of this life. I’ve

tried to get clean so many times and it only works for a little while, then I’m out using again and it’s worse than before. I don’t know what to do.

Reflections

Complex Reflection(emotion/continue thought)

• You’re so tired of getting high and you’re confused as to how to get out of this.

• Every time you relapse it gets worse and you don’t know if you’ll be able to stop. You’re afraid you’ll always be hooked on meth.

Client says:• I’m so tired of this life.

I’ve tried to get clean so many times and it only works for a little while, then I’m out using again and it’s worse than before. I don’t know what to do.

Reflections

Double-sided Reflection

(point out both sides of ambivalence)

• On the one hand you want to get clean, but on the other hand, you’re not sure if you can do it.

Client says:• I’m so tired of this life.

I’ve tried to get clean so many times and it only works for a little while, then I’m out using again and it’s worse than before. I don’t know what to do.

Reflective Listening

• CLIENT: I guess I do use too much sometimes, but I don't think I have a problem with drugs.

– CONFRONTATION: Yes you do! How can you sit there and tell me you don't have a problem when . .

– QUESTION: Why do you think you don't have a problem?

– REFLECTION: So on the one hand you can see some reasons for concern, and you really don't want to be labeled as "having a problem."

Reflective Listening

CLIENT: My wife is always telling me that I'm a junkie.– JUDGING: What's wrong with that? She

probably has some good reasons for thinking so.

– QUESTION: Why does she think that?

– REFLECTION: And that really annoys you.

MET Principles

• Develop discrepancy– Help client to become more aware of the

discrepancy between their addictive behaviors and their more deeply-held values and goals

– Part of this is helping client to recognize and articulate negative consequences of use. More effective if the client does this, not the clinician

– Explore values and life goals and then ask client to reflect on how their addictive behavior fits into them

Develop Discrepancy

Tools for Developing Discrepancy:

• Open-ended Questions

• Pros & Cons (Decisional Balance)

• Importance & Confidence Scales

• Readiness Ruler

Developing Discrepancy

Close-ended Open-ended

Do you feel you have a problem with alcohol?

How will you know when your alcohol use is a problem?

Is it important for you to complete probation?

What would you gain by completing probation?

Anything else? What else?

Motivating Offenders to Change, US DOJ, 2007

Open-Ended Questions

Develop Discrepancy

•I’d like to hear your opinions about…

•What are some things that bother you about your use?

•What role do you think drugs/alcohol played in your injury?

•How would you like your drinking to be 5 years from now?

Develop Discrepancy

•Tell me about your drug use.

•What is that like for you?

•What was your life like before you started using?

•How do you want things to end up when you’re done with probation? Where do you want to be?

•What other ideas do you have? What else might work for you?

The Decisional Balance

Weighing the Decisional Balance

Strategies for weighing the pros and cons…

•Clinician states some “pros” about behavior“Some of my clients use alcohol because it makes them forget their problems, makes them more social, and helps with the pain.”

•Ask:•“What do you see as the downside of drinking?”•“How has alcohol negatively affected your life?”•“What is a good reason for making a change?”•“What else?”

Develop Discrepancy

Importance/Confidence/Readiness

On a scale of 1–10… • How important is it for you to change your

drinking?• How confident are you that you can change your

drinking?• How ready are you to change your drinking?

For each ask…• Why didn’t you give it a lower number?• What would it take to raise that number?

1 2 3 4 5 6 7 8 9 10

MET Principles

• Roll with resistance– In general, it is unhelpful to argue with clients.

Confrontation elicits defensiveness, which predicts a lack of change

– Particularly counter therapeutic for clinician to argue that there is a problem while client argues that there isn’t one

– Client does not need to accept diagnostic label (e.g. “addict” or “alcoholic”) for change to occur

Rolling with Resistance• Offender: It’s impossible to find a good job. Nobody

wants to hire a guy with a record.

• Counselor 1: There are lots of jobs out there, even for people on supervision. In fact, most offenders are able to find jobs. [Confrontational— less effective.]

• Counselor 2: It can be much more difficult for someone on supervision to find a job, sure. How do you think you might go about that? [Reflective—more effective.]

Example of NOT rolling with resistance

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You do not have the right to judge me. You don’t understand me.

I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it.

But, Anna, I think it is clear that drinking has caused you problems.

Example of rolling with resistance

That’s right, my mother thinks that I have a problem, but she’s wrong.

I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it.

You do have a drinking problem

Others may think you have a problem, but you don’t.

MET Principles

Support self-efficacy– Can be conceptualized as a specific form of

optimism, a “can-do” belief in one’s ability to accomplish a particular task or change.

– Crucial to help client see and experience their own ability to make positive changes.

– Part of this is the clinician believing in the client’s ability to change.

Affirmations• Focused on achievements of individual

• Helps to:– Reinforce something person has done or intends to

do– Calls attention to something admirable or interesting– “Blames” person for their success– Support individual’s proven strengths

Helps to assist person in seeing positives

Let’s practice:

• Pros and Cons (mostly cons)

• Importance/Confidence/Readiness Scales

• Develop Discrepancy

• Create movement in Client’s Stage of Readiness for Change

MET Example

The 3 Tasks of MET

Feedback

Enhance Motivation

Options Explored

Providing Feedback

• Elicit (ask for permission)

• Give feedback

• Elicit again (the person’s view of the feedback)

The 1st Task: Feedback1. Range of score and context - Scores on the ASSIST

range from 0-27. Most people who use alcohol socially score less than 11 and less than a 4 for other drug use.

2. Results - Your score was 14 on the methamphetamine screen.

3. Interpretation of results - 14 puts you in the moderate risk range. At this level, your use is putting you at risk for a variety of health issues.

4. Patient reaction/feedback - What do you make of this?

The 3 Tasks of MET

Feedback

Enhance Motivation

Options Explored

Enhance Motivation• Express empathy

– Reflective Listening

• Develop discrepancy

– Open-ended Questions

– Decisional Balance (pros/cons)

– Importance/Confidence/Readiness Rulers

• Avoid argumentation

– Role with Resistance

• Support self-efficacy

– Affirmations

The 3 Tasks of a BI

Feedback

Listen & Understand

Options Explored

What now?

•What do you think you will do?

•What changes are you thinking about making?

•What do you see as your options?

•Where do we go from here?

•What happens next?

The Third Task: Options for Change

Offer a Menu of Options

• Manage drinking/use (cut down to low-risk limits)

• Eliminate your drinking/drug use (quit)

• Never drink and drive (reduce harm)

• Utterly nothing (no change)

• Seek help (refer to treatment)

The Third Task: Options for Change

You can also explore previous strengths, resources and successes

•“Have you stopped drinking/using drugs before?”

•“What personal strengths allowed you to do it?”

•“Who helped you and what did you do?”

•“Have you made other kinds of changes successfully in the past?”

•“How did you accomplish these things?”

The Third Task: Options for Change

The Third Task: Options for Change

The Advice Sandwich

Ask permission

Give Advice

Ask for Response

The Third Task: Options for Change

1.Ask for Permission explicitly– Would it be alright if I told you some things

that have worked for my clients in the past?

2. Provide Clear Information or Feedback– What happens to some people is that…– My recommendation would be that…

3. Elicit their reaction– What do you think?– What are your thoughts?

Putting it all together

Feedback

Range

Pros and ConsImportance/Confidence/Readiness Scales

Summary

Options Explored

Enhance Motivation

Menu of Options

ENCOURAGE FOLLOW-UP VISITS

At follow-up visit:

•Inquire about use

•Review goals and progress

•Reinforce and motivate

•Review tips for progress

See reference list

Thank You!!

Joy Chudzynski, PsyD joychud@ucla.edu

www.uclaisap.org

www.psattc.org

http://sbirt.samhsa.gov/about.htm

http://www.motivationalinterview.org

http://www.niaaa.nih.gov/

http://www.drugabuse.gov/