Motivational Enhancement Therapy

1. Enhancing motivation
to change (MET)
Presenter : Dr. Nimish Savaliya JR-II
Moderator : Prof. Dr. Dinesh Singh Rathore (M.D.)

2. What is motivation?
• The need or desire to do a particular activity or
behave in a particular way.
• In the context of substance use: “ NEED/
DESIRE TO CHANGE FROM USING TO
QUITTING/ STOPPING.”

3. Factors influencing readiness to
change
• Perception of the need: discrepancy b/w the
current life situation and the probability of future
improvement.
• Change is possible and positive within a
reasonable period of time.
• Sense of self efficacy
• Stated intention to change

4. Significance of motivation in
SUDs
• People with substance use disorders often
– Terminate treatment early
– Continue to use substance during treatment
– Are noncompliant with treatment

5. Common misconception
regarding motivation:
• Motivation
– Is a stable trait, consistent across situations,
not modifiable because it lies within the patient
– Clinician’s behavior is irrelevant to patient’s
motivation
– Denial is standard defense mechanism for
people with addictions
– Resistance is the patient’s problem

6. Changed understanding of
motivation
• Motivation
– Is a process that happens between a patient and
a clinician
– Is a fluid state that changes across situations, in
different environments, and is at least partially
determined by interpersonal interactions
– Resistance is a “therapist skill challenge”

7. Changed understanding of
motivation
• A persons motivation can thus be changed.
There are factors that mediate the need or
desire to change.
• Clinicians working with substance users
need to identify these mediating factors and
facilitate the process of change.

8. What is MET?
• Motivational Enhancement Therapy (MET) is a
systematic intervention approach for evoking change
in problem drinkers, based on principles of
motivational psychology, grounded in research on
processes of natural recovery in addictive behaviors
(Prochaska and Di Clemente,) and is designed
to produce rapid, internally motivated change.

9. Stages of Change Model
(Prochaska & DiClemente, 1992)
Precontemplation
Preparation
Contemplation
Maintenance
Action
Relapse

10. Precontemplation
• Defensive
• No awareness of problem
• Resistant to suggestions of problems associated
with alcohol/drug use
• Uncommitted to treatment
• Consciously or unconsciously avoiding steps to
change behavior
• May seek treatment because of others’ pressure
• May feel coerced by significant others

11. Contemplation
• Seeking to evaluate and understand their
behavior
• May experience some level of distress
• May be thinking about making changes
• Have not taken action and are not prepared
to do so
• May have made previous attempts to
change

12. Preparation
• Have intention to change behavior
• Exhibit readiness to change both in attitude
and behavior
• Engaged in the change process and are on
the verge of taking action
• Decision to change has been made and they
are ready to commit to the actions involved

13. Action
• Firm decision to initiate change; this has
been verbalized or somehow committed to.
• Taking action to change behavior and
environment
• Patient exhibits motivation
• Willing to follow suggested strategies and
activities

14. Maintenance
• Working to sustain changes
• Attention focused on avoiding relapses
• May express fear/anxiety about facing high-
risk situations
• Less frequent but still intense cravings to
use substance, particularly in response to
various stressors

15. What is motivational
interviewing?
• Developed in early 80’s; by Miller,
– originally designed to be a prelude to treatment
and increase patient compliance with help.
• Good evidence to show that treatment outcomes
are enhanced by adding initial motivational
interview (Bien et al., 1993; Brown & Miller,
1993; Saunders et al., 1995).

16. General Principles of Brief
Interventions (FRAME)
• FEEDBACK of personal risk or
impairment
• Emphasis on personal RESPONSIBILITY
for change
• Clear ADVICE to change
• A MENU of alternative change options
• Therapist EMPATHY

17. Basic principles
• Express Empathy
• Develop Discrepancy
• Avoid Argumentation
• Roll with Resistance
• Support Self-Efficacy
- Miller and Rollnick (1991)

18. Express empathy
• Communicate respect for the patient
• Listening rather than telling
• Gentle, subtle persuasion
• Change is up to the patient

19. Develop Discrepancy
• Perception of a discrepancy between where
they are and where they want to be.
• Raising the awareness of personal
consequences

20. Avoid argumentation
• Argumentation evokes resistance
• No attempt at diagnostic labeling
• It is the patient and not the therapist who
voices the argument for a change

21. Roll with Resistance
• Not to meet resistance head on
• Roll with the momentum
• Ambivalence not viewed as pathological
• Solutions evoked from the patient

22. Self efficacy
• Hope for success
• It is a critical determinant of behavior change
• Support belief that he or she can change
• Responsibility of change in the patients hand.

23. Helpful Strategies
• Decisional balance:
• You may draw a 2x2 table with examples to initiate the exercise.
Once the client is through with it, do the following……
• 1. Encourage him to compare the costs to the benefits.
• 2. Ponder if the costs are worth the benefits.
Good things about
drinking
Not so good things
about drinking
Good things about
quitting
Not so good things
about quitting

24. • The 5 Rs can also be used to develop discrepancy and
enable the client contemplate change.
• Relevance: what is the personal relevance of quitting
substance for the client?
• Risks: what are the potential negative consequences of
using substance for the client?
• Rewards: what are the potential benefits of stopping the
substance for the client?
• Roadblocks: what are the barriers in quitting the
substance and elements in treatment that may help in
handling the barriers.
• Repetition: the motivational intervention should be
repeated every time the unmotivated client visits you.

25. Scaling motivation
• Ask your patient to rate his/her desire to
stop alcohol/ drugs in a scale of 0 to 10.
• Helps in objective measurement of
motivation.
• Helps patient to see where he is.

26. Techniques
• O-open ended questions
• A-affirmations
• R-reflections
• S-summaries

27. O-open ended questions
 Tell me a little about your drinking. What do you like about
drinking? And what are your worries about drinking?
 Tell me what you’ve noticed about your drinking.How has it
changed over time ?
 What have other people told you about your drinking ? What are
other people worried about ?
• And so on, proceed to inventory of other areas:
• Tolerance - does he/she seem to be able to drink more than other
people without showing as much effect?
• Relationships-
has drinking affected relationships with spouse, family or friends
?
• Health - is he aware of any health problems related to alcohol?
• Financial - Has drinking contributed to money problems ?

28. A-affirming the Client
• Affirm, compliment and reinforce the client
sincerely - strengthen the working
relationship,enhance the self responsibility.
I think it is great that you’re strong enough to
recognize the risk here and that you want to do
something before it gets more serious.
You really have some good ideas for how you
might change.

29. R-reflections
Simply reflect what the client is saying
Amplified reflection
Client: I’m not addicted to alcohol.
Therapist: So as far as you are concerned you have
not had any problems with alcohol.
C: well I can not say that exactly.
T: So you think that alcohol is a problem but you
don’t want to be called an addict.

30. R-reflections
Simply reflect what the client is saying
Double sided reflection
C: I can’t quit because I will offend my boss if I
say no.
T: You can’t imagine how you could not drink, and
at the same time be working for your boss.

31. Summarize
• Ensures clear communication
• Use at transitions in conversation
• Be concise and reflect ambivalence too.
• “ let me see if I understand so far……”

32. Phases of MET
• Phase 1: Building motivation for change
• Phase 2: Strengthen commitment to change
• Phase 3: Follow through strategies
• Phase 1
Shift balance from the persons current status
(drinking/drug use), to change (quitting the use).
Aims at resolving ambivalence.
Through expressing empathy, questioning,
feedback, handling resistance, affirmation,
summarizing….

33. • Phase 2:
• Discussing a Plan, Communicating Free Choice,
Consequences of action and inaction,
Emphasizing abstinence,
• Changed Plan Worksheet
• The changes I want to make are :
• The most important reasons why I want to make these
changes are:
• The steps I plan to make in changing are :
• The ways other people can help me are :

34. • I will know that my plan is working if :
• Some things that could interfere with my plan are
• Involving a significant other.
• Phase 3:
• Follow through strategies :
reviewing progress, renewing motivation and
redoing commitment

35. Things to remember
• Motivation is a state, NOT a trait.
• Resistance is not a force we must overcome
• Ambivalence is good
• Our client should be an ally rather than an
oposition
• Recovery and change/growth are intrinsic to the
human experience

36. THANK YOU