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 EN
DED 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 !!!