1. 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

2. 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) ; ask for BKD342
William Miller & Stephen Rollnick, 1991
Most likely to change when motivation comes from themselves- have participants think of their own experience

3. 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

4. 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.

5. 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.”

6. 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.

7. 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

8. 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.

9. 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

10. 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).

11. 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"

12. 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

13. 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

14. 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.

15. 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)

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

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

18. 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.”

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

20. 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

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

22. 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

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

24. 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).

25. 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”

26. 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.

27. 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.

28. 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.

29. 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.

30. 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

31. 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

32. 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.

33. 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.

34. 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.

35. 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

36. 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.

37. 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

38. 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.

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

40. 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

41. 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.

42. 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

43. 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.

44. 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.