Session 13Screening and Motivational

EnhancementInstructor: Dr. Dawn-Elise Snipes PhD, LPC-

MHSP, NCC

Compare and contrast MET with other approaches to therapy Briefly review the FRAMES approach Describe the stages of change Define EE-DD-AA-RR-SS Identify what actions to take in each of the sessions Explore strategies for increasing motivation and “rolling with

resistance” Discuss who is appropriate for MET Discuss ways to use MET with patients with co-occurring disorders

Objectives

4 session protocol De-emphasis on labels Emphasis on personal choice regarding future

behavior Objective evaluation focused on eliciting the CLIENT’s

OWN concerns Resistance is an interpersonal behavior pattern

indicating failure to accurately empathize Resistance is met with reflection

MET Unique Characteristics

Argue with clients Impose diagnostic labels Tell clients what they “must” do Seek to “break down” denial through direct

confrontation Imply client’s powerlessness

Motivational Enhancement Therapists Do NOT

Precontemplation Contemplation Preparation Action Maintenance

Stages of Change

Express Empathy◦ Reflective listening (accurate empathy) is a key skill

Develop Discrepancy◦ Perceive a discrepancy between where they are and where they

want to be◦ Raise clients’ awareness of the personal consequences of their

drinking in order to precipitate a crisis increasing motivation for change

Avoid Argumentation◦ No attempt is made to have the client accept or “admit” a problem

Basic Principles: EE-DD-AA-RR-SS

Roll with resistance◦ New ways of thinking about problems are invited but not

imposed. ◦ Ambivalence is viewed as normal, not pathological, and is

explored openly. ◦ Solutions are usually evoked from the client rather than

provided by the therapist Support self-efficacy

◦ People will not try to change unless they believe there is HOPE for success

Control◦ Self-efficacy◦ Hope and Faith

Commitment◦ Courage and Discipline

Challenge

Hardiness

CBT vs. MICognitive Behavioral Motivational Enhancement Assumes client is

motivated Identify and modify

maladaptive cognitions

Prescribes change strategies

Builds client motivation

Explores and reflects client perception without correcting

Elicits change strategies from the client

Nondirective vs. METNondirective MET Client determines

content and direction Avoids injecting

counselor’s advice and feedback

Empathy is used noncontingently

Directs client toward motivation

Offers advice and feedback

Empathic reflection used selectively to reinforce certain points

Since you are here, I assume you have been having some concerns or difficulties related to your use. Tell me about them.

Tell me a little about your drinking. What do you like about it? What’s positive about drinking for you? And what’s the other side? What are your worries about drinking?

What you’ve noticed about how your drinking has changed over time? What things do you think could be problems, or might become problems?

What have others said about your drinking? What are they worried about? What makes you think that perhaps you need to make a change in your

drinking?

Building Motivation

Tolerance—do you seem to be able to drink more than other people without showing as much effect?

Memory—have you had periods of not remembering what happened while drinking or other memory problems?

Relationships—has drinking affected your relationships? Health—are you aware of any health problems related to use? Legal—have you had any legal issues because of behavior

while drinking? Financial—has drinking contributed to money problems?

More Motivational Questions

Decisional Balance

Consequences of Action or Inaction

Benefits/ Good Things

Consequences/ Fears

Keep Drinking

Stop Drinking

Drinking is really important to you. Tell me about that. What is it about drinking that you really need to hang

onto? Information and Advice

◦ Do alcohol problems run in your family?◦ What do you think it means to be “addicted” or an

“alcoholic”◦ If I quit drinking, will __(problems)__improve?

Still More Motivational Questions

Information and Advice cont…◦ What’s a safe level of drinking?

0 --is the greatest amount someone with a history of drinking problems can safely drink. Safest for anyone

1—Largest amount in an hour 2 – Greatest amount in a day that won’t increase health risk 3 – Greatest amount in a day that won’t increase risk of

impairment 14 – Greatest amount in a week

More Questions

Advantages◦ it is unlikely to evoke client resistance◦ it encourages the client to keep talking and exploring the topic◦ it communicates respect and caring and builds an alliance◦ it clarifies for the therapist exactly what the client means◦ it can be used to reinforce ideas expressed by the client

Reflect selectively, reinforcing parts of what the client has said and ignoring others.

Clients not only hear themselves saying a self-motivational statement, but also hear you saying that they said it.

Empathy

Benefits◦ Strengthening the working relationship, ◦ Enhancing a sense of self-responsibility and empowerment◦ Reinforcing effort and self-motivational statements◦ Supporting client self-esteem

Some examples:◦ I appreciate your hanging in there through this feedback,

which must be pretty rough for you.◦ I think it’s great that you’re strong enough to recognize the

risk and that you want to do something before it gets serious.◦ You really have some good ideas for how you might change.

Affirmation

Interrupting—cutting off or talking over the therapist Arguing—challenging the therapist, discounting the therapist’s

views, disagreeing, open hostility Sidetracking—changing the subject, not responding, not paying

attention Defensiveness—minimizing or denying the problem, excusing one’s

own behavior, blaming others, rejecting the therapist’s opinion, pessimism

Identify some empathic statements that could be used to respond to the above types of resistance

Examples of Resistance

Arguing, disagreeing, challenging

Judging, criticizing, blaming

Warning of negative consequences.

Seeking to persuade with logic or evidence.

Ineffective Responses to Resistance

Interpreting or analyzing the “reasons” for resistance.

Confronting with authority

Using sarcasm or incredulity

More Ineffectiveness

Simple Reflection Reflection with Amplification

◦ C: I don’t think I have a drinking problem.◦ T: So as far as you can see, there really haven’t been any

problems or harm because of your drinking Double-sided Reflection

◦ C: But I can’t quit drinking. I mean, all of my friends drink!◦ T: You can’t imagine how you could not drink with your friends,

and at the same time you’re worried about how it’s affecting you

Effective Responses

Shifting focus away from the problematic issue◦ C: But I can’t quit drinking. I mean, all of my friends

drink!◦ T: You’re getting way ahead of things. I’m not talking

about your quitting drinking right now. Let’s just stay with what we’re doing here and later on we can worry about what, if anything, you want to do about your drinking

More Effective Responses

Rolling with resistance◦ There is a paradoxical element in this, which often will bring

the client back to a balanced or opposite perspective. ◦ This is useful with clients who present in a highly

oppositional manner and seem to reject every idea C: But I can’t quit drinking. I mean, all of my friends drink! T: It may very well be that when we’re through, you’ll decide

that it’s worth it to keep on drinking. It may be too difficult to make a change. That will be up to you.

More Responses…

Reframing can motivate the client to deal with the behavior. Placing current problems in a more positive or frame,

communicates that the problem is solvable and changeable It is important to use the client’s own views, words, and

perceptions about drinking◦ Drinking as a reward (alternative ways to reward oneself)◦ Drinking as protective function—bearing too heavy of a load to

protect family (alternate ways to deal with stresses)◦ Drinking as an adaptive function—method for avoiding conflict,

or fitting in at work

Reframing

Incorporate them throughout the assessment or session

Summarize both motivational statements and statements of reluctance—Fair and Balanced

Summarizing

Signs◦ Client stops resisting and raising objections◦ Client asks fewer questions◦ Client appears more settled, peaceful◦ Client makes motivational statements indicating

willingness to change◦

Recognizing Change Readiness

Shift from talking about reasons for change to negotiating a plan for change

Ask for clients’ perceptions of what they need to do Communicate free choice

◦ It’s up to you what you do about this.◦ No one can decide this for you

List all of the things that contribute to your problem then identify which ones are modifiable

Discussing a Plan

Have clients identify how they think each modifiable factor should be addressed

Discussing a Plan cont…

Provide a rationale for why it might be a safe choice Nobody can guarantee a safe level of drinking I want to tell you, however, that I am concerned about the

possibility of your continued use because◦ Medications◦ Mental or Physical Health Conditions◦ Strong external consequences (jail)◦ Prior history of severe consequences of use

Deal with resistance through◦ Reflection◦ Juxtaposition/contrasting wants

Abstinence

The changes I want to make are… The most important reasons I want to make these

changes are… The steps I will take are… The ways other people can help me are… I will know the plan is working when… Some things that could interfere with my plan

are…

Change Plan Worksheet

Clarify what, exactly, the client plans to do. Reinforce what the clients perceive to be likely benefits of

making a change, as well as the consequences of inaction. Ask what obstacles, concerns, fears, or doubts might interfere

with carrying out the plan. Ask the client (and SO) to suggest how they could deal with these.

Clarify the SO’s role in helping the client to make the change. Remind the client (and SO) that you will be seeing the client

for follow-up visits (scheduled at weeks 6 and 12)

Asking for Commitment

The Significant Other◦ Provides an alternative point of view during the assessment◦ Can serve a supporting function in identifying motivating

statements outside of the session◦ Can assist in development and implementation of the plan ◦ Questions

What has it been like for you? What have you noticed about [client’s] drinking? What has discouraged you from trying to help in the past? What do you see that is encouraging? What do you like most about ___ when he/she is not drinking

Role of the SO

Emphasis is placed on positive attempts to deal with the problem

Negative experiences—stress, family disorganization, employment difficulties—should be reframed as normative in families with an alcohol problem.

The counselor might compare the SO’s experiences to the stress experienced by families confronted with other disorders such as heart disease, diabetes, and depression

The SO can discuss the risks and costs of continued drinking There is a danger of overwhelming or alienating clients if the

counselor and SO both present negative feedback

The SO cont…

A handwritten personalized note◦ A “joining message” (“It was wonderful meeting you and your wife

today”)◦ Affirmations of the client (and SO)◦ A reflection of the seriousness of the problem◦ A brief summary of highlights of the first session, especially self-

motivational statements that emerged◦ A statement of optimism and hope◦ A reminder of the next session

◦ Write a sample note

The Follow Up Note

First follow-up session 1-2 weeks after initial session Sessions 3 and 4 are at weeks 6 and 12 Actions

◦ Review progress and problems◦ Renew motivation

Review most important reasons for change)◦ Redoing commitment (Reinforce self-efficacy)

Control Commitment Challenge

Follow Through Strategies

Discussed during 4th session◦ Review and recapitulate◦ Summarize, affirm and reinforce the commitments and changes

that have been made◦ Explore additional areas for change the client wants to

accomplish◦ Elicit self-motivational statements for the maintenance of change◦ Support client self-efficacy, emphasizing the client’s ability to

change◦ Deal with any special problems that are evident

Termination

Treatment Dissatisfaction◦ Affirm expression of concern◦ Explore reasons for concern

Missed Appointments (phone contact)◦ Clarify the reasons for the missed appointment.◦ Affirm the client—reinforce for having come initially◦ Express your eagerness to see the client again.◦ Briefly mention serious concerns that emerged and your

appreciation (as appropriate) that the client is exploring these◦ Express your optimism about the prospects for change◦ Reschedule appointment

Special Problems

Missed Appointments (no good explanation)◦ Explore uncertainty about whether or not treatment is

needed (e.g., “I don’t really have that much of a problem”)◦ Discuss ambivalence about making a change◦ Empathize with frustration or anger about having to

participate in treatment In either case of a missed appointment, send a

handwritten note summarizing the phone call and the new appointment

Special Problems cont…

Contacts should be kept brief Elicit, do not prescribe, change strategies Elicit information about what is happening Reflect and affirm progress Normalize feelings of ambivalence

Telephone Consultation

Can it be effectively used with co-occurring?◦ Stages of change◦ Self-motivational statements◦ Strengths and solutions focused planning◦ 12-week course

Characteristics of appropriate patients◦ Cognitive development◦ Level of impairment◦ Amount of social support◦ Co-Occurring issues◦ Other?

MET and Co-Occurring

MET is a 4 session evidence based practice It can effectively be used with any patient who is

medically and psychologically stable. The focus is on

◦ Eliciting self-motivational statements◦ Exploring ambivalence◦ Empowering the client to make positive changes◦ Enlisting the support of significant others◦ Encouraging continued follow through

Summary