MOTIVATION ENHANCEMENT THERAPY

1. MOTIVATIONAL INTERVIEWING Dr Sushil Kumar S V MB BS, MD (psychiatry), MHA, FIPS

2. Motivation The need or desire to do a particular activity or behave in a particular way In the context of substance use motivation can be explained as NEED/ DESIRE TO CHANGE FROM USING TO QUITTING/ STOPPING.

3. What is MET? A systematic intervention approach Based on principles of motivational psychology Designed to produce rapid, internally-motivated change Mobilize the client's own change resources

4. Factors influencing readiness to change Perception of the need: discrepancy b/w the current life situation and the probability of future improvement Change is possible and positive within a reasonable period of time Sense of self efficacy Stated intention to change

5. Motivation A process that happens between a patient and a clinician Is a fluid state that changes across situations, in different environments, and is at least partially determined by interpersonal interactions Resistance is a “therapist skill challenge”

6. Stages of Change ( Prochaska & DiClemente , 1992)

7. Pre contemplation No awareness of problem Resistant to suggestions of problems associated with alcohol/drug use Uncommitted to treatment May seek treatment because of others’ pressure Barriers: Lack of knowledge of risks/consequences , Lack of self-efficacy, Contentment

8. Contemplation Seeking to evaluate and understand their behavior May experience some level of distress May be thinking about making changes Barriers: Lack of knowledge of risks/ consequences,Lack of self-efficacy, Contentment, Indecisiveness

9. Determination/Preparation Exhibit readiness to change both in attitude and behavior Engaged in the change process and are on the verge of taking action Decision to change has been made and they are ready to make commitment Barriers : Loss of commitment, Lack of knowledge of options for change

10. Action Firm decision to initiate change Taking action to change behavior and environment Exhibits motivation Willing to follow suggested strategies and activities

11. Maintanence Working to sustain changes Attention focused on avoiding relapses May express fear/anxiety about facing high-risk situations Less frequent but still intense cravings to use substance, particularly in response to various stressors

12. Brief Interventions FEEDBACK of personal risk or impairment   Emphasis on personal RESPONSIBILITY for change   Clear ADVICE to change   A MENU of alternative change options   Therapist EMPATHY

13. Basic motivational principles Express Empathy Develop Discrepancy Avoid Argumentation Roll with Resistance Support Self-Efficacy (Miller and Rollnick (1991)

14. Express Empathy Communications implying a superior/ inferior relationship b/w therapist and client are avoided The therapist role is listening rather than telling Persuasion should be gentle and subtle Assumption that change is up to the client Reflective listening

15. Develop Discrepancy Motivation occur – Client perceives a discrepancy An unrealistic (from the client's perspective) attack on his or her drug use tends to evoke defensiveness and opposition Therapist employs other strategies than argument No attempt to make the client accept a diagnostic label

16. Roll with Resistance Not to meet resistance head on Roll with the momentum Ambivalence not viewed as pathological Solutions evoked from the patient Handling client "resistance" is a crucial and defining characteristic of the MET approach

17. Support Self-efficacy Self-efficacy is the client's specific belief that he or she can change the drinking behaviour. Hope for success Critical determinant of behavior change Support belief that he or she can change Responsibility of change in the patients hand

18. Avoid Argumentation Therapist, therefore, does not : argue with the client impose a diagnostic label on the client tell the client what he or she "must" do seek to "break down" denial by direct confrontation which imply a client's "powerlessness"

19. PRACTICAL STRATEGIES Phase 1: Building Motivation for Change Shift balance from the person’s current status (drinking/drug use), to change (quitting the use). Aims at resolving ambivalence. Building Motivation for Change 8 strategies

20. 1. Eliciting Self-Motivational Statements The words which come out of a person's mouth are quite persuasive to that person One  way  to  elicit  such  statements  is  thro open   ended statements Tell me a little about your drinking. What do you  like  about drinking? And what are your worries about drinking? Tell  me what you’ve noticed about your drinking. How  has  it changed  over time ? What have other people told you about  your drinking ? What are other people worried about ?

21. 2. Listening with Empathy Empathy is having an immediate understanding of their situation by virtue of having experienced it oneself Client: I guess I do drink too much sometimes but I dont think  I have a problem with alcohol   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  one hand you can  see  some  reasons  for concern,  and  you really don’t want to be labeled  as  having  a problem

22. 3. Questioning MET uses  questioning  as  an   important therapist  response. Rather than telling clients how they  should feel  or  what  to  do the therapist  asks  them about  their  own feelings, reactions, ideas, concerns and plans and  responds  with reflection, affirmation or reframing.  

23. 4. Presenting Personal Feedback The  first MET session should also include feedback  to  the client  from his pre-treatment assessment A very important  part of  this process is the therapist’s monitoring of and responding to the client during feedback

24. 5. Affirming the Client Affirm, compliment and reinforce  the client sincerely - strengthen  the  working relationship, enhance  the self  responsibility I think it is great that you’re strong enough to recognize  the risk  here and that you want to do something before it gets  more serious You really have some good ideas for how you might change

25. 6. Handling Resistance Interrupting- cutting off or talking over the therapist. Arguing- challenging, discounting the therapist’s views, disagreeing, open hostility. Sidetracking-changing the subject, not responding, not  paying attention. Defensiveness

26. Deflecting resistance SIMPLE  REFLECTION - Has the effect of eliciting the opposite and  balancing the picture. REFLECTION  WITH  AMPLIFICATION -Exaggerate  or amplify  what the client is saying to the point where the  client is likely to disavow it. SHIFTING FOCUS ROLLING  WITH - A paradoxical strategy especially  with  highly oppositional clients who seem to reject every idea or suggestion. Client: But I cant quit drinking. All my friends drink. Therapist:  And it may very well be that when we’re through  this you will decide that it’s worth it to keep on drinking  as  you have been. It may be too difficult for you to make a change. That will be up to you.  

27. 7. Reframing A strategy whereby the therapist invites the client to examine his or her perceptions in a new light, or a reorganized form New meaning is given to what has been said A spouse’s  reaction of  “I’m right and I told you so !” can be recast  to  “You’ve been  so  worried  about him and you care  about  him  so much” You may have the need  to  reward yourself  on the weekends for successfully handling  a  stressful and  difficult  job  during the  week........The  implication  is that there  are  other ways foreword oneself without  going  on  a binge.

28. 8. Summarizing It  is useful to summarize periodically during  the  session especially toward the end of a session

29. Phase 2: Strengthening Commitment to Change The strategies outlined above are designed to build motivation. Help the client's decisional balance in favor of change A second major process in MET is to consolidate the client's commitment to change , once sufficient motivation is present (Miller & Rollnick , 1991).

30. Recognizing Change Readiness Some  changes which might be helpful in identifying in  this stage: The client stops resisting and raising objections The client asks fewer questions The  client makes self-motivational  statements  indicating  a decision/ openness to change He/she begins imagining how life might be after a change

31. Discussing a Plan The therapist could signal this shift by asking a transitional question such as: What do you make of all this? What are you thinking you’ll  do about it? I wonder what you’re thinking about your drinking at this point The  goal  is to elicit from the client (and  significant  other) some  ideas  and  ultimately  a plan for what to do  about  the client’s  drinking

32. Communicating Free Choice This  theme should be stressed during the commitment-strengthening process: It’s up to you what to do about this. You can decide to go on drinking just as you were or to change  

33. Consequences of Action and Inaction Generate a  written  list  of  the possible negative consequences of not changing One possibility  is  to construct a formal  ‘decisional’  balance  by having the client generate the pros and cons of change options.

34. Information and Advice Often  clients and significant others (SO) will ask for  key information which might be important for their decision  process They  might also ask you for advice It is quite  appropriate  to provide  your own views in this circumstance with qualifiers  and permission to disagree

35. Emphasizing Abstinence Successful abstinence is a safe choice. If you don’t drink  you can  be  sure  that you wouldn’t have problems  because  of  your drinking. There are good reasons to try a period of abstinence No one can guarantee a safe level of drinking that will  cause you more harm.

36. The Change Plan Worksheet The changes I want to make are : The most important reasons why I want to make these changes are: The steps I plan to make in changing are : The ways other people can help me are : I will that my plan is working if : Some things that could interfere with my plan are :

37. Asking for Commitment Ask  what concerns fears or doubts the client  may  have  that might interfere with the client carrying out the plan. What  other obstacles might be encountered that  could  divert him/her from the plan. How could one deal with this ? Clarify the SO’s role in helping the client make  the  desired change. Make an appointment for follow up visits  

38. Dealing with Resistance Recapitulating Involving A Significant Other

39. Phase 3 : Follow through strategies   Now MET focuses  on  follow through. Three processes are involved:   reviewing  progress, renewing motivation  and   redoing commitment .  

40. The “5As” The 5 major steps in this intervention are: ASK about substance use Advise -- Advise to quit ASSESS commitment and barriers to change ASSIST patients committed to change Arrange -- Arrange follow-up to monitor progress

41. The “5Rs” Relevance : what is the personal relevance of quitting substance for the client? Risks : what are the potential negative consequences of using substance for the client? Rewards : what are the potential benefits of stopping the substance for the client? Roadblocks : what are the barriers in quitting the substance and elements in treatment that may help in handling the barriers. Repetition : the motivational intervention should be repeated every time the unmotivated client visits you.

42. THANK YOU !!!