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 internallymotivated 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.
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
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Stages of Change
Prochaska & DiClemente
Depression
Family Problems
Legal Problems
SUD
SUD
Goal of MET
– Work concretely with consumers at any
stage of readiness for change
– The MET session will help consumers:
• see the impact of their substance use on
their mental health symptoms
• explore the good and not-so-good
aspects of their current behaviors
• determine what change they are willing
to make
• formulate a plan to begin that change
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
•
•
•
•
•
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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”
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Blaise Pascal
“PEOPLE ARE BETTER PERSUADED BY THE
REASONS THEY THEMSELVES DISCOVERED
THAN THOSE THAT COME INTO THE MINDS OF
OTHERS”
Four Principles of
Motivational 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.”
Types of Reflective Statements
1. Simple Reflection (repeat)
2. Complex Reflection (emotion/continue
the thought)
3. Double-Sided Reflection (captures both
sides of the ambivalence)
Reflections
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.
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.
Reflections
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.
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.
Reflections
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.
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.
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
Open-Ended Questions
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
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
The good
things
about
______
The notso-good
things
about ____
The notso-good
things
about
changing
The good
things
about
changing
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
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.
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Example of rolling with
resistance
You do
have a
drinking
problem
Others may
think you have
a problem, but
you don’t.
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.
That’s right, my
mother thinks that I
have a problem, but
she’s wrong.
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: 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?
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
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?
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 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
Enhance Motivation
Pros and Cons
Importance/Confidence/Readiness Scales
Summary
Options Explored
Menu of Options
ENCOURAGE FOLLOWUP VISITS
At follow-up visit:
• Inquire about use
• Review goals and progress
• Reinforce and motivate
• Review tips for progress
See
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/