1. Motivational Enhancement Therapy
At UCLA, we have been working in the area of screening and brief intervention since 2005 when we were awarded a 3-yr SAMHSA grant to apply these techniques with students.
Joy Chudzynski, PsyD
UCLA Integrated Substance Abuse Programs

2. 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):

3. 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 internally-motivated change, rather than guide the client through a stepwise recovery process

4. 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

5. Outline of Sessions Session 1 Session 2 (thru 5)
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)

6. 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

7. 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.

8. 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

9. Stages of Change Prochaska & DiClemente
Precontem-
plation
Contemplation
Recurrence
Determination
Maintenance
Action

10. Family Problems
Legal Problems
Depression
SUD
SUD

11. 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

12. 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

13. The Spirit 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

14. 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”

15. Blaise Pascal
“People are better persuaded by the reasons they themselves discovered than those that come into the minds of others”

16. Four Principles of Motivational Enhancement Therapy
1. Express empathy
2. Develop discrepancy
3. Avoid argumentation
4. Support self-efficacy

17. 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

18. 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.”

19. Types of Reflective Statements
Simple Reflection (repeat)
2. Complex Reflection (emotion/continue the thought)
3. Double-Sided Reflection (captures both sides of the ambivalence) 19

20. 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.

21. (emotion/continue thought)
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. You’re afraid you’ll always be hooked on meth.
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.

22. Reflections Client says:
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:
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.

23. 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."

24. 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.

25. Reflections
“I’m really discouraged about using again. I should know better.”
“Yes, you should. This is your 4th time here.” No – that’s not listening and is judgmental. I want to tell him what he needs to do (complete treatment, really apply himself this time, get rid of his old friends) but I need to understand. What is discouraging him? Does he mean that he’s unsure if he’ll ever be able to stay clean? Does he feel guilty that he relapsed and disappointed his family. Now make it a reflection. “You’re disappointed in yourself that you had a relapse and you’re afraid that you won’t be able to stay clean.”

26. 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

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

28. 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

29. 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?

30. 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?

31. The Decisional Balance
The good things about ______
The not- so-good things about ____
The not-so-good things about changing
The good things about changing
The way we explore ambivalence in motivational interviewing is to ask open-ended questions.
Use pointer to direct attention to related boxes
Upper Left: For example, “What are the good things about your substance use?”
Upper Right: “What about the not-so-good things?”
Lower Left: “What would be good about using less?”
Lower Right: “What would be not so good about cutting back?”
Someone tell me if this is an open or a closed question, “Do you drink when you are alone?”
Elicit responses. Correct answer: This is a closed question.
How could you make it an open-ended question?
Suggestion: Who do you drink with on a typical day?

32. 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?”

33. Importance/Confidence/Readiness
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?

34. 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

35. 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.]

36. 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.

37. Example of 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.
You do have a drinking problem
Others may think you have a problem, but you don’t.
That’s right, my mother thinks that I have a problem, but she’s wrong.

38. 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.

39. 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
Audience give examples of affirmations
Want to comment on an enduring trait (smart, resourceful, patient, strong) or effort (I appreciate your willingness)
Comment on something that would be behind health promoting bx (You really want to be the best mother you can be) 39 39

40. Let’s practice: Pros and Cons (mostly cons)
Importance/Confidence/Readiness Scales
Develop Discrepancy
Create movement in Client’s Stage of Readiness for Change

41. MET Example

42. The 3 Tasks of MET
Feedback
Enhance Motivation
Options Explored

43. Providing Feedback Elicit (ask for permission) Give feedback
Elicit again (the person’s view of the feedback)

44. The 1st Task: Feedback
1. Range of score and context - Scores on the ASSIST range from 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?

45. The 3 Tasks of MET
Feedback
Enhance Motivation
Options Explored

46. Enhance Motivation Express empathy Develop discrepancy
Reflective Listening
Develop discrepancy
Open-ended Questions
Decisional Balance (pros/cons)
Importance/Confidence/Readiness Rulers
Avoid argumentation
Role with Resistance
Support self-efficacy
Affirmations

47. The 3 Tasks of a BI
Feedback
Listen & Understand
Options Explored

48. 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?

49. 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)

50. 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?”

51. The Third Task: Options for Change
The Advice Sandwich
Ask permission
Give Advice
Ask for Response

52. 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?

53. Putting it all together
Feedback
Range
Enhance Motivation
Pros and Cons
Importance/Confidence/Readiness Scales
Summary
Options Explored
Menu of Options

54. Encourage Follow-Up Visits
At follow-up visit:
Inquire about use
Review goals and progress
Reinforce and motivate
Review tips for progress
Encourage a follow-up visit with the patient. This way you can monitor their substance use, review progress toward any goals the patient may have agreed upon during your initial brief intervention session, reinforce their movement toward change, and provide tips for making additional changes.
See reference list

55. Thank You!!
Joy Chudzynski, PsyD