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

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 Aims to invoke rapid and internally-motivated change, rather than guide the client through a stepwise recovery process

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

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)

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

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.

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 Precontem- plation Contemplation Recurrence Determination Maintenance Action

Family Problems Legal Problems Depression SUD SUD

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

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

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

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”

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

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

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

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.”

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

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.

(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.

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.

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."

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.

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.”

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

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

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

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?

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?

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?

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?”

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? 1 2 3 4 5 6 7 8 9 10

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

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.]

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.

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.

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.

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

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

MET Example

The 3 Tasks of MET Feedback Enhance Motivation Options Explored

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

The 1st Task: Feedback 1. Range of score and context - Scores on the ASSIST range from 0-27. 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?

The 3 Tasks of MET Feedback Enhance Motivation Options Explored

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

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

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?

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)

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?”

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

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?

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

Thank You!! Joy Chudzynski, PsyD joychud@ucla.edu www.uclaisap.org www.psattc.org http://sbirt.samhsa.gov/about.htm http://www.motivationalinterview.org http://www.niaaa.nih.gov/ http://www.drugabuse.gov/