Created by Susan Sampl, Ph.D. Adapted by John P Thompson MA, CDP The Foundations of Motivational Enhancement Therapy & Motivational Interviewing Created by Susan Sampl, Ph.D. Adapted by John P Thompson MA, CDP

References Primary Resource: An additional resource (free !): Miller, W.R. and Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. New York: Guilford Press Miller, W.R. and Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Guilford Press An additional resource (free !): Enhancing Motivation for Change in Substance Abuse by Miller. Treatment Improvement Protocol Series (TIPS) # 35. Call 1(800) 729-6686; ask for BKD342 William Miller & Stephen Rollnick, 1991 Most likely to change when motivation comes from themselves- have participants think of their own experience

Introduction to MET & MI A style of intervention based on the premise that people are most likely to change when the motivation comes from themselves, rather than being imposed by the therapist Based on a trans-theoretical model: 1) stages of change theory 2) client-centered approaches 3) clinical research A strengths-based approach William Miller & Stephen Rollnick, 1991 Most likely to change when motivation comes from themselves- have participants think of their own experience

The Stages of Change Model Developed by Prochaska & DiClemente, 1986 A sequence of stages through which people typically progress as they think about, initiate, & maintain new behaviors Both within & outside of therapeutic environment Applies to a variety of behavioral changes, including substance use, eating, parenting, exercise, and health behaviors.

Stages of Change Model Prochaska & DiClemente, 1986      “I’ve got more to learn.” Precontemplation “I’ve changed a lot, and I’d like to stay clean.” Relapse “I don’t have a problem You do” Maintenance Contemplation Maybe I do have a problem “Lets make a plan. .. figure out some steps & strategies.” Action Preparation “I need to do something about this problem. I need to change.”

1. Precontemplation- “Problem . . . what problem?” Does not think has a problem, and does not consider change. May be more surprised than resistant when told has a problem. Rarely seeks treatment, unless compelled.

Inviting the Precontemplator to Look & Discuss: Gentle Encouragement Establish rapport & build trust Raise doubts by: Eliciting the client’s perceptions of the problem Providing feedback Facilitating feedback of a significant other Avoid premature prescriptive advice Express concern & keep the door open

2. Contemplation- “This may be a problem. I may need to make a change Experiencing ambivalence (mixed feelings), which comes about with growing awareness of risks and problems associated with substance use. Both considers and rejects change. This ambivalence is considered normal. Common for people to come to treatment in this stage.

Contemplation: Facilitating the Risk/Reward Analysis Normalize ambivalence Help “tip the decisional balance scales” by: Eliciting pros and cons of use & change Emphasizing client choice & responsibility Elicit self-motivational statements, & summarize them

Confrontation VS Non-confrontation Miller, Benefield, and Tonigan (1993) reported drinking outcomes at 12 months were strongly predicted by counselor style: the more the counselor confronted, the more the client drank. Random assignment to counseling styles also strongly predicted the degree of client resistance (higher with confrontation) expressed motivation for change (higher with MI).

The MI Therapist 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 Imply a client's "powerlessness"

Traps to Avoid The Labeling Trap While some clients benefit from accepting a label like “alcoholic” or “addict”, this is not necessary for each client’s success Pressuring clients to accept a label can reflect a power struggle in which therapist attempts to assert control Other buzzwords can elicit resistance, e.g., “your problem” The MI approach de-emphasizes labeling

Assumptions of MET Adolescents are presenting as concrete (vs. abstract) thinkers with low problem recognition, and low readiness for change Therapist style is a powerful determinant of client motivation and change Change is more likely when the motivation comes from adolescent, rather than being imposed by the therapist, family, school, or court Need to show respect for the client and demonstrate understanding (vs. confrontation) Ambivalence about change is normal Change involves a process

Foundations of MET & MI Therapist style is a powerful determinant of client motivation & change Show respect for the client Reflective listening is emphasized rather than confrontation Ambivalence about change is normal Therapist style- Research has found marked differences in therapist efficacy. MET is based, in part, on identifying therapist behaviors associated with positive client change. Respect- Don’t talk down to the client or label them. Be careful that you do not have a lecturing tone. Brainstorm ways to show interest verbally and nonverbally Don’t confront- example of how you feel if someone argues for only one side of something that you feel ambivalent about (ending a relationship) Miller & Sovereign (1989) In a study of treatment for alcohol abuse & dependence, clients were followed up one year after therapy. The more the therapist had confronted the client in treatment, the more the client was drinking one year later! The more the therapist supported and listened, the more the client changed.

Elements of Effective Brief Therapeutic Interventions (FRAMES) Feedback of personal risk or impairment Responsibility (Emphasis on personal RESPONSIBILITY for change) Advice to change Menus of alternative change options Empathy Self-Efficacy (Facilitation of client SELF-EFFICACY or optimism)

Early Methods in MI (Start by using your OARS) Open-Ended Questions Affirm Reflective Listening Summarize Elicit Change Talk

Use Open-Ended Questions Closed-Ended “Did you come here because of the court?” Open-Ended “What led to your coming to treatment?”

Use Open-Ended Questions Closed-Ended “How many times a week did you use cocaine when you first started?” Open-Ended “Tell me about your early experiences with cocaine.”

Use Open-Ended Questions Closed-Ended “You like smoking marijuana” Open-Ended “What do you like about smoking marijuana?”

Traps to Avoid The Question-Answer Trap Reinforces the client being in a passive role, waiting for the therapist to figure out the answer Encourages brief answers, without the additional info needed for MI Open-ended questions w/o reflective listening responses can have the same effect Generally, avoid asking 3 questions in a row

Affirm Notice and comment on the client’s strengths & efforts The extent of doing this depends on the context, including cultural issues

Reflective Listening A crucial skill for MET The clinician demonstrates through comments & gestures an understanding of what the client is communicating Improves with practice An alternative to the “Question and Answer” trap

Reflective Statements “So you. ” “It seems to you that Reflective Statements “So you . . .” “It seems to you that . . .” “you’re feeling . . .?”

Roadblocks to Reflective Listening Gordon, 1970 Warning or threatening Arguing or lecturing Shaming or ridiculing Humoring or withdrawing Moralizing, preaching, or “should”-ing Labeling Practice exercise (give them handouts)- Speaker talks about “Something I feel two ways about . . .” Pick a topic with some complexity, in which you have a personal investment. Listener- Only argues for the validity of one side of the speaker’s beliefs, trying to fit in as many “roadblocks” as possible. After 5 minutes switch roles. Group discussion. View early part of videotape with Dr. Bill Miller working with a client referred for marijuana abuse. It shows open-ended questions, avoidance of roadblocks, and reflections (telling the client what you think you just heard them saying).

QUESTION: What makes you think you don't have a problem? Example: 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: What makes you think you don't have a problem? REFLECTION: So you can see some reasons for concern, but you really don't want to be labeled as "having a problem”

Example: 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.

Example: CLIENT: If I quit using drugs, what am I supposed to Example: CLIENT: If I quit using drugs, what am I supposed to do for friends? ADVICE: I guess you'll have to get yourself some new ones. SUGGESTION: Well, you could just tell your friends that you don't use anymore, but you still want to see them. REFLECTION: It's hard for you to imagine living without drugs.

Practice Exercise: Reflective Statements In Groups of three . . . The purpose of this exercise is to demonstrate that sometimes we think we know what someone means, but that is not always true. Take turns being the Speaker: Speaker states an opinion about something that he/she has some feeling about, that is a bit of a complex topic. Listeners respond by asking “yes or no” questions, when you say _____, do you mean ______? Continue this with each speaker until you have a good sense of “what they mean”. Try to use statements rather than questions.

Practice Exercise: Reflective Statements In Groups of Three . . . 1) Speaker “Something about myself that I would like to change is . . .” 2) Listeners: Respond with reflective statements until the speaker feels understood. Then, switch to a new speaker. Reflective Statements “So you . . .” “It seems to you that . . .” “It sounds like you’re feeling . . .” Try to use statements rather than questions.

Summarize: Reinforce what the client has been saying Demonstrate your attention to what the client has been saying Often provoke additional change talk 3 types of summaries: Collecting summaries A brief summary, Linking summaries Intended to help the client see connections Transitional summaries Marks & announces a shift from one focus to another

Elicit Change Talk Contrasted to traditional style in which counselor advocates for change, & client argues against Methods for Eliciting Change Talk Asking evocative questions Using the importance ruler Exploring the decisional balance Elaborating Querying extremes Looking back Looking forward Exploring goals & values

Five Strategies of MET & MI Express Empathy Develop Discrepancy Avoid Argumentation Roll with Resistance Support Self-Efficacy Refer to handout. Express Empathy- Do Forming Reflections Exercise #4. Play early part of video with adolescent after describing Avoid Arg. And Roll w. Res. It illustrates Building Rapport, Rolling w/ Res., Avoid Arg., Supporting the client’s feelings of efficacy.

Five Strategies of MET & MI 1. Express Empathy Much of MET is listening rather than telling. Conveyed Non-verbally: eye contact body position facial expression Conveyed Verbally through reflections Refer to handout. Express Empathy- Do Forming Reflections Exercise #4. Play early part of video with adolescent after describing Avoid Arg. And Roll w. Res. It illustrates Building Rapport, Rolling w/ Res., Avoid Arg., Supporting the client’s feelings of efficacy.

Five Strategies of MET & MI 2. Develop Discrepancy Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be. Thought to be the engine that drives change Help the client describe the discrepancy between how their life is when abusing substances how it was/could be without Refer to handout. Express Empathy- Do Forming Reflections Exercise #4. Play early part of video with adolescent after describing Avoid Arg. And Roll w. Res. It illustrates Building Rapport, Rolling w/ Res., Avoid Arg., Supporting the client’s feelings of efficacy.

Traps to Avoid The Premature Focus Trap Trying too soon to focus in on substance abuse as the main issue may elicit much increased resistance Better to start with the client’s concerns-likely to eventually lead back to the substance abuse issues

Five Strategies of MET & MI 3. Avoid Argumentation It is the client and not the therapist who voices the arguments for change Resistance is a cue to modify your approach Treat ambivalence (mixed feelings) as normal Use double-sided reflections Refer to handout. Express Empathy- Do Forming Reflections Exercise #4. Play early part of video with adolescent after describing Avoid Arg. And Roll w. Res. It illustrates Building Rapport, Rolling w/ Res., Avoid Arg., Supporting the client’s feelings of efficacy.

Traps to Avoid The Expert Trap MI as a collaboration, instead of counselor/therapist imparting wisdom Client is the expert on his/her situation Similar to the question-answer trap in placing the client in the passive role Avoid shifting prematurely to prescribing solutions, & doing problem-solving

Five Strategies of MET & MI 4. Roll With Resistance How the therapist handles client "resistance" is a crucial and defining characteristic of the MET approach. Don’t get rattled when the client says something against change Best response is empathy, plus slightly hopeful comment Refer to handout. Express Empathy- Do Forming Reflections Exercise #4. Play early part of video with adolescent after describing Avoid Arg. And Roll w. Res. It illustrates Building Rapport, Rolling w/ Res., Avoid Arg., Supporting the client’s feelings of efficacy.

Responding to Resistance Reflective Responses Simple Reflection Amplified Reflection Double-Sided Reflection Shifting Focus Reframing Agreement with a Twist Emphasizing Personal Choice Coming Alongside

Traps to Avoid The Blaming Trap Client in early treatment may be very focused on figuring out who is to blame for the problem Useful to directly tell the client that therapy is not about figuring out who’s to blame

Five Strategies of MET & MI 5. Support Self-Efficacy Reinforce any willingness: to hear information to acknowledge the problem to take steps toward change Make the connection between previous successful change & potential to change the current problem Refer to handout. Express Empathy- Do Forming Reflections Exercise #4. Play early part of video with adolescent after describing Avoid Arg. And Roll w. Res. It illustrates Building Rapport, Rolling w/ Res., Avoid Arg., Supporting the client’s feelings of efficacy.

Traps to Avoid The Taking Sides Trap The most common trap Most important to avoid Increases the likelihood the client will argue for the other side of the ambivalence The more they hear themselves arguing against change, the more they reinforce their opinion that they don’t have a problem

Eliciting Self-Motivational Statements 1. being open to input about drug use and effects 2. acknowledging real or potential problems related to drug use 3. expressing a need, desire, or willingness to change 4. expressing optimism about the possibility of change.

MET & MI Guidelines Remember to use open-ended questions Affirm the client Elicit self-motivational statements Offer feedback Use reframing Summarize Refer to handout. After discussing Elicit Self/Mot. Statements, show the middle section of the tape with the adolescent (occurs a bit after the client puts his arms up & touches the wall- approx. #2600 to 2700 on the tape counter). This discussion about how he feels mj makes people stupid and his decline in grades especially shows elicit self-mot. Statements, develop discrepancy Panel discussion with Julia & Steve. View taped example and discuss.