Motivational Enhancement Therapy

1. Motivational Enhancement Therapy Joy Chudzynski, PsyD UCLA Integrated Substance Abuse Programs

2. 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):

3. 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

4. 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

5. 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)

6. 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

7. 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.

8. Where do I start? What you dodepends 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

9. Stages of ChangeProchaska & DiClemente Precontem- plation Contemplation Recurrence Determination Maintenance Action

10. SUD SUD Depression Family Problems Legal Problems

11. Work concretelywith consumers at any stage of readinessfor change The MET session will help consumers: see the impactof their substance use on their mental health symptoms explorethe good and not-so-good aspects of their current behaviors determine what change they are willingto make formulate aplan to begin that change Goal of MET

12. 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

13. 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

14. 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”

15. Blaise Pascal “People are better persuaded by the reasons they themselves discovered than those that come into the minds of others”

16. Four Principles ofMotivational Enhancement Therapy 1. Express empathy 2. Develop discrepancy 3. Avoid argumentation 4. Support self-efficacy

17. 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

18. 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.”

19. Types of Reflective Statements • Simple Reflection (repeat) • 2. Complex Reflection (emotion/continue the thought) • 3. Double-Sided Reflection (captures both sides of the ambivalence)

20. 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.

21. 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.

22. 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.

23. 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."

24. 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.

25. 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

26. Develop Discrepancy • Tools for Developing Discrepancy: • Open-ended Questions • Pros & Cons (Decisional Balance) • Importance & Confidence Scales • Readiness Ruler

27. Developing Discrepancy Open-Ended Questions Motivating Offenders to Change, US DOJ, 2007

28. 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?

29. 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?

30. The Decisional Balance

31. 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?”

32. 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

33. 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

34. 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.]

35. Example of NOT rolling with resistance 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. You do not have the right to judge me. You don’t understand me.

36. Example of rolling with resistance 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. That’s right, my mother thinks that I have a problem, but she’s wrong.

37. 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.

38. 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

39. Let’s practice: Pros and Cons (mostly cons) Importance/Confidence/Readiness Scales Develop Discrepancy Create movement in Client’s Stage of Readiness for Change

40. MET Example

41. The 3 Tasks of MET Feedback Enhance Motivation Options Explored

42. Providing Feedback Elicit (ask for permission) Give feedback Elicit again (the person’s view of the feedback)

43. The 1st Task: Feedback 1. 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?

44. The 3 Tasks of MET Feedback Enhance Motivation Options Explored

45. 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

46. The 3 Tasks of a BI Feedback Listen & Understand Options Explored

47. The Third Task: Options for Change • 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?

48. 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)

49. 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?”

50. The Advice Sandwich The Third Task: Options for Change Ask permission Give Advice Ask for Response