Motivation Enhancement

MOTIVATION ENHANCEMENT
Dr. Bhakti
Psychiatry JR3, SMS Medical College, Jaipur

Introduction
 The abuse of substances that alter mood, behavior or
cognition and leading to abuse and eventual psychological,
social or physical harm has been a part of human life across
numerous social contexts throughout history
 The issue of controlled use (harm reduction) rather than
abstinence has been debated at length for many years
 Whatever the treatment goal, a key issue is the client’s
commitment to implementing real and permanent change in
his pattern of abuse

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 v/s continued use
 It is a :
 Client centred : centers on the client’s perspective of
the problem
 Directive : to move the client in the direction of making
a positive change
 Therapeutic style to resolve ambivalence and promote
greater commitment to change

MYTHS
 Change is motivated by discomfort
 If you can make people feel bad enough,
they will change
 People have to “hit bottom” to be ready
for change
 Corollary: People don’t change if they
haven’t suffered enough

Someone who continues to use is
“in denial”
The best way to “break through” the
denial is direct confrontation.

Traditional approach
You better!
Or else!

9
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 Change
Prochaska & DiClemente

Stages of Change
Recognizing the need to change and
understanding how to change doesn’t happen
all at once. It usually takes time and patience.
People often go through a series of “stages” as
they begin to recognise that they have a
problem.

First Stage: Pre-contemplation
People at this stage:
 Are unaware of any problem related to their
drug use
 Are unconcerned about their drug-use
 Ignore anyone else’s belief that they are
doing something harmful

Second Stage: Contemplation
People at this stage are considering whether or not
to change:
 They enjoy using drugs, but
 They are sometimes worried about the increasing
difficulties the use is causing.
 They are constantly debating with themselves
whether or not they have a problem.

Third Stage:
Determination/preparation
People at this stage are
deciding how they are
going to change
 May be ready to change their
behaviour
 Getting ready to make the change
It may take a long time to move to the next stage (action).
?

Fourth Stage: Action
People at this stage:
 Have begun the process of changing
 Need help identifying realistic steps, high-risk
situations and new coping strategies

Fifth Stage: Maintenance
People in this stage:
 Have made a change and
 Are working on maintaining the change

Relapse
People at this stage have reinitiated the
identified behaviour.
 People usually make several attempts to quit
before being successful.
 The process of changing is rarely the same in
subsequent attempts.
 Each attempt incorporates new information
gained from the previous attempts.

MOTIVATIONAL INTERVIEWING
Resolving ambivalence in the direction of change is a key element of
motivational interviewing

Principles of Motivational
Interviewing
Motivational interviewing is founded on 4 basic
principles:
 Express empathy
 Develop discrepancy
 Roll with resistance
 Support self-efficacy

Principle 1: Express empathy
 May be the most crucial principle
 Attitude of acceptance
 Client ambivalence is normal; the clinician should
demonstrate an understanding of the client’s perspective
 Creates environment conducive to change, instills sense
of safety and reduces defensiveness
 Skilful reflective listening is fundamental to the client’s
feeling understood and cared about.

Example of expressing empathy
I am so tired
that I cannot
even sleep…
So I drink some
wine.You drink wine
to help you
sleep.
…When I wake
up…I am too late
for work already…
Yesterday my
boss fired me.
So you are
concerned
about not
having a job.
...but I do not
have a
drinking
problem!

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.
Client says:
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:
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."

Principle 2: Develop discrepancy
 Clarify important goals for the client and explore their deeply held
values and life goals
 Explore the consequences or potential consequences of the client’s
current behaviour
 Ask client to reflect on how their addictive behavior fits into the
goals
 Create and amplify in the client’s mind a discrepancy between the
two
 Thus, making the client recognize and articulate negative
consequences of use. More effective if the client does this, not the
clinician

Example of developing discrepancy
Well…as I said, I lost
my job because of my
drinking
problem…and I often
feel sick.
I only enjoy having some drinks
with my friends…that’s all.
Drinking helps me relax and have
fun…I think that I deserve that for a
change…
So drinking has
some good things
for you…Now tell me
about the not-so-
good things you
have experienced
because of drinking.

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

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

•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?
•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?

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?

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

Principle 3: Roll with resistance
 Avoid resistance
 If it arises, stop and find another way to proceed
 Avoid confrontation : it 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
 Invite, but do not impose, new perspectives
 Value the client as a resource for finding solutions to
problems
 When MET is conducted properly, it is the client and not the
therapist who voices the arguments for change

Example of NOT rolling with resistance
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.

Principle 4: Support self-efficacy
 Belief in the ability to change (self-efficacy) is an
important motivator
 The client is responsible for choosing and carrying out
personal change
 Part of this is the clinician believing in the client’s
ability to change
 Crucial to help client see and experience their own
ability to make positive changes

Example of supporting self-efficacy
I hope things will
be better this
time. I’m willing to
give it a try.
I am wondering if
you can help me. I
have failed many
times.
Anna, I don’t think you
have failed because you
are still here, hoping
things can be better. As
long as you are willing to
stay in the process, I will
support you. You have
been successful before
and you will be again.

OARS
Skills to help clients move trough the process of
change

Open-ended questions
 “Are there good things about using?” vs.
 “What are the good things about your substance use?”
 “Are there bad things about using?” vs.
 “Tell me about the not-so-good things about using”
 “Do you have concerns about your substance use?” vs.
 “You seem to have some concerns about your substance use.Tell me more
about them.”
 “Do you worry a lot about using substances?” vs.
 “What most concerns you about that?”
CloseVersus Open-ended questions:

Affirmations
 Focused on achievements of individual
 Examples :
 “Thanks for coming today.”
 “I appreciate that you are willing to talk to me about your substance
use.”
 “It’s hard to talk about....I really appreciate your keeping on with this.”
 Helps to:
 Reinforce something person has done or intends to do
 Calls attention to something admirable
 Support individual’s proven strengths
Helps to assist person in seeing positives

Reflective listening
Reflective listening is used to :
 Check out whether you really understood the client
 Highlight the client’s ambivalence about their
substance use
 Steer the client towards a greater recognition of her or
his problems and concerns, and
 Reinforce statements indicating that the client is
thinking about change.

OARS : Summarize
 Summarizing is an important way of gathering
together what has already been said
 Making sure you understood the client correctly
 Preparing the client to move on
 Putting together a group of reflections and
especially, client’s own self-motivated
statements

CONTINGENCY MANAGEMENT
…also known as
Motivational Incentives

Rewards
•Teach new behaviors and promote
growth
• Promote self-esteem and confidence
• Promote positive atmosphere &
communication

Incentives in Drug Abuse
Positive Negative
- award ceremonies - extra therapy
- certificates; key chains - time restriction
- status/recognition - dismissal
- take-homes in methadone - probation, referral
to judge

It is theCONTINGENCY
that matters……….
BEHAVIOR REWARD
Giving things away for free
does NOT change behavior

 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 now?
What NEXT? : 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)

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?”

Advise
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 Cons
Importance/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

Spouse/SO Involvement
GOALS
 To establish a working rapport among the client,
the CSO and the counselor
 To raise the awareness of the CSO's concerns
about the extent and severity of drug problems
 To strengthen the CSO's commitment to help
the client overcome the drug problem
 To strengthen the CSO's belief in the importance
of his or her own contribution in changing the
client's drug use patterns

 In some cases, CSO involvement could become
an obstacle in motivating the client to change
and could even lead to a worsening of the drug
problem
 In such scenario :
 Limit the amount of involvement of the CSO in
sessions
 Focus the session(s) on the client
 Limit the CSO's involvement in decision-making
activities

Pre-contemplation
 Establish rapport
 Elicit the patient’s perception of the problem
 Explore the pros and cons of substance use
 Give factual information about the risk of sub-
stance use
 Examine the discrepancies between the patient
and others’ perception of the problem behavior
 Provide personalized feedback about
assessment findings

Contemplation
 Normalize ambivalence
 Help the patient tip the decisional balance
weighing pros and cons of substance use and
change
 Examine the patient’s personal values in relation
to change
 Emphasize the choice of responsibility and self-
efficacy
 Elicit self motivational statements of intent and
commitment from the client
 Summarize clients’ self motivational statements.

Preparation
 Clarify the patient’s own goals and strategies for
change
 Offer a menu of options
 With permission, offer advice
 Negotiate a change or treatment plan and behavior
contract
 Help the patient enlist social support
 Explore treatment expectancies and the patient’s role
 Elicit what has worked in the past for him or others
whom he knows
 Have the person publicly announce plans to change

Action
 Engage the patient in treatment and reinforce
the importance of remaining in recovery
 Support a realistic view of change through small
steps
 Help in identifying high risk situation and
develop appropriate coping strategies to
overcome them
 Assist in finding new re-inforcers of the change
 Assess whether the person has strong family and
social support

Maintenance
 Help in identifying and other sources of pleasure
 Support lifestyle changes
 Affirm person’s resolve and self efficacy
 Assist in practicing the use of new coping
strategies to avoid return to drug use
 Maintain supportive contact
 Develop a ‘fire-escape’ plan if the patient
resumes substance use (Relapse)
 Review long-term goals

References
 Substance use disorders, Manual for Physicians, Dr. Rakesh Lal, National
Drug DependenceTreatment Centre, AIIMS
 Motivational EnhancementTherapy with Drug Abusers,William R. Miller,
Ph.D. Department of Psychology and Center on Alcoholism, Substance
Abuse, and Addictions (CASAA),The University of New Mexico
 UCLA Integrated Substance Abuse Programs

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