Screening and Motivational Enhancement
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC

CEUs are available for this presentation at https://www.allceus.com/member/cart/index/product/id/40/c/
Objectives
~    Compare and contrast MET with other approaches to therapy
~    Briefly review the FRAMES approach
~    Describe the stages of change
~    Define EE-DD-AA-RR-SS
~    Define OARS
~    Explore strategies for increasing motivation
MET Unique Characteristics
~    Emphasis on personal choice regarding future behavior
~    Objective evaluation focused on eliciting the CLIENT’s OWN concerns
~    Resistance is an interpersonal behavior pattern indicating failure to accurately empathize
~    Resistance is met with reflection
Motivational Enhancement Therapists Do NOT
~    Argue with clients
~    Impose diagnostic labels
~    Tell clients what they “must” do
~    Seek to “break down” denial through direct confrontation
~    Imply client’s powerlessness
OARS
~    Open Ended Questions
~    Affirmations
~    Reflective Listening
~    Summaries
Stages of Change
~    Motivation needs to be enhanced and maintained in all stages of change
~    Stages
~    Precontemplation
~    Contemplation
~    Preparation
~    Action
~    Maintenance
Basic Principles: EE-DD-AA-RR-SS
~    Express Empathy
~    Reflective listening (accurate empathy) is a key skill
~    Develop Discrepancy
~    Perceive a discrepancy between where they are and where they want to be
~    Raise clients’ awareness of the personal consequences of their drinking in order to precipitate a crisis increasing motivation for change
~    Avoid Arguing
~    No attempt is made to have the client accept or “admit” a problem

Basic Principles cont…
~    Roll with resistance
~    New ways of thinking about problems are invited but not imposed.
~    Ambivalence is viewed as normal, not pathological, and is explored openly.
~    Solutions are usually evoked from the client rather than provided by the therapist
~    Support self-efficacy
~    People will not try to change unless they believe there is HOPE for success

Hardiness
~    Control
~    Self-efficacy
~    Hope and Faith
~    Commitment
~    Courage and Discipline
~    Challenge
CBT vs. MET
Cognitive Behavioral
~    Assumes client is motivated
~    Identify and modify maladaptive cognitions
~    Prescribes change strategies
Motivational Enhancement
~    Builds client motivation
~    Explores and reflects client perception without correcting
~    Elicits change strategies from the client

Nondirective vs. MET
Nondirective
~    Client determines content and direction
~    Avoids injecting counselor’s advice and feedback
~    Empathy is used noncontingently
MET
~    Directs client toward motivation
~    Offers advice and feedback
~    Empathic reflection used selectively to reinforce certain points
Building Motivation
~    Since you are here, I assume you have been having some concerns or difficulties related to your use. Tell me about them.
~    Tell me a little about your drinking. What do you like about it? What’s positive about drinking for you? And what’s the other side? What are your worries about drinking?
~    How has your drinking has changed over time? What things do you think could be problems, or might become problems?
~    What have others said about your drinking? What are they worried about?
~    What makes you think that perhaps you need to make a change in your drinking?

More Motivational Questions
~    Tolerance—do you seem to be able to drink more than other people without showing as much effect?
~    Memory—have you had periods of not remembering what happened while drinking or other memory problems?
~    Relationships—has drinking affected your relationships?
~    Health—are you aware of any health problems related to use?
~    Legal—have you had any legal issues because of behavior while drinking?
~    Financial—has drinking contributed to money problems?

Consequences of Action or Inaction
~    Decisional Balance

Still More Motivational Questions
~    Drinking is really important to you. Tell me about that.
~    What is it about drinking that you really need to hang onto? (What are the benefits?)
~    Information and Advice
~    Do alcohol problems run in your family?
~    What do you think it means to be “addicted” or an “alcoholic”
~    If you quit drinking, will __(problems)__improve?

Empathy
~    Advantages
~    it is unlikely to evoke client resistance
~    it encourages the client to keep talking and exploring the topic
~    it communicates respect and caring and builds an alliance
~    it clarifies for the therapist exactly what the client means
~    it can be used to reinforce ideas expressed by the client
~    Reflect selectively, reinforcing parts of what the client has said and ignoring others.
~    Clients not only hear themselves saying a self-motivational statement, but also hear you saying that they said it.

Affirmation
~    Benefits
~    Strengthening the working relationship,
~    Enhancing a sense of self-responsibility and empowerment
~    Reinforcing effort and self-motivational statements
~    Supporting client self-esteem
Affirmation
~    Some examples:
~    I appreciate your hanging in there through this feedback, which must be pretty rough for you.
~    I think it’s great that you’re strong enough to recognize the risk and that you want to do something before it gets serious.
~    You really have some good ideas for how you might change.

Examples of Resistance
~    Interrupting—cutting off or talking over the therapist
~    Arguing—challenging the therapist, discounting the therapist’s views, disagreeing, open hostility
~    Sidetracking—changing the subject, not responding, not paying attention
~    Defensiveness—minimizing or denying the problem, excusing one’s own behavior, blaming others, rejecting the therapist’s opinion, pessimism

~    Identify some empathic statements that could be used to respond to the above types of resistance

Ineffective Responses to Resistance
~    Arguing, disagreeing, challenging
~    Judging, criticizing, blaming
~    Warning of negative consequences.
~    Seeking to persuade with logic or evidence.
~    Interpreting or analyzing the “reasons” for resistance.
~    Confronting with authority
~    Using sarcasm or incredulity

Effective Responses
~    Simple Reflection
~    Reflection with Amplification
~    C: I don’t think I have a drinking problem.
~    T: So as far as you can see, there really haven’t been any problems or harm because of your drinking
~    Double-sided Reflection (on one hand…)
~    C: But I can’t quit drinking. I mean, all of my friends drink!
~    T: You can’t imagine how you could not drink with your friends, and at the same time you’re worried about how it’s affecting you

More Effective Responses
~    Shifting focus away from the problematic issue
~    C: But I can’t quit drinking. I mean, all of my friends drink!
~    T: You’re getting way ahead of things. I’m not talking about your quitting drinking right now.  Let’s just stay with what we’re doing here and later on we can worry about what, if anything, you want to do about your drinking

Reframing
~    Reframing can motivate the client to deal with the behavior.
~    Placing current problems in a more positive or frame, communicates that the problem is solvable and changeable
~    It is important to use the client’s own views, words, and perceptions about drinking
~    Drinking as a reward (alternative ways to reward oneself)
~    Drinking as protective function—bearing too heavy of a load to protect family (alternate ways to deal with stresses)
~    Drinking as an adaptive function—method for avoiding conflict, or fitting in at work

Summarizing
~    Incorporate summary statements throughout the assessment or session
~    Summarize both motivational statements and statements of reluctance—Fair and Balanced

Recognizing Change Readiness
~    Signs
~    Client stops resisting and raising objections
~    Client asks fewer questions
~    Client appears more settled, peaceful
~    Client makes motivational statements indicating willingness to change

Discussing a Plan
~    Shift from talking about reasons for change to negotiating a plan for change
~    Ask for clients’ perceptions of what they need to do
~    Communicate free choice
~    It’s up to you what you do about this.
~    No one can decide this for you
~    List all of the things that contribute to your problem then identify which ones are modifiable

Discussing a Plan cont…
~    Have clients identify how they think each modifiable factor should be addressed
Change Plan Worksheet
~    The changes I want to make are…
~    The most important reasons I want to make these changes are…
~    The steps I will take are…
~    The ways other people can help me are…
~    I will know the plan is working when…
~    Some things that could interfere with my plan are…

Asking for Commitment
~    Clarify what, exactly, the client plans to do.
~    Reinforce what the clients perceive to be likely benefits of making a change, as well as the consequences of inaction.
~    Ask what obstacles, concerns, fears, or doubts might interfere with carrying out the plan. Ask the client (and SO) to suggest how they could deal with these.
~    Clarify the SO’s role in helping the client to make the change.
~    Remind the client (and SO) that you will be seeing the client for follow-up visits (scheduled at weeks 6 and 12)
Role of the SO
~    The Significant Other
~    Provides an alternative point of view during the assessment
~    Can serve a supporting function in identifying motivating statements outside of the session
~    Can assist in development and implementation of the plan
~    Questions
    What has it been like for you?
    What have you noticed about [client’s] drinking?
    What has discouraged you from trying to help in the past?
    What do you see that is encouraging?
    What do you like most about ___ when he/she is not drinking
The SO cont…
~    Emphasis is placed on positive attempts to deal with the problem
~    Negative experiences—stress, family disorganization are reframed as normative in families with addiction.
~    There is a danger of overwhelming or alienating clients if the counselor and SO both present negative feedback

The Follow Up Note
~    A handwritten personalized note
~    A “joining message” (“It was wonderful meeting you and your wife today”)
~    Affirmations of the client (and SO)
~    A reflection of the seriousness of the problem
~    A brief summary of highlights of the first session, especially self-motivational statements that emerged
~    A statement of optimism and hope
~    A reminder of the next session

Follow Through Strategies
~    Review progress and problems
~    Renew motivation
~    Review most important reasons for change
~    Redoing commitment (Reinforce self-efficacy)
~    Control
~    Commitment
~    Challenge
Termination
~    Review and recapitulate
~    Summarize, affirm and reinforce the commitments and changes that have been made
~    Explore additional areas for change the client wants to accomplish
~    Elicit self-motivational statements for the maintenance of change
~    Support client self-efficacy, emphasizing the client’s ability to change
~    Deal with any special problems that are evident

Special Problems
~    Missed Appointments (phone contact)
~    Clarify the reasons for the missed appointment.
~    Affirm the client—reinforce for having come initially
~    Express your eagerness to see the client again.
~    Briefly mention serious concerns that emerged and your appreciation (as appropriate) that the client is exploring these
~    Express your optimism about the prospects for change
~    Reschedule appointment

Special Problems
~    Treatment Dissatisfaction
~    Affirm expression of concern
~    Explore reasons for concern
Summary
~    MET can effectively be used with any patient who is medically and psychologically stable.
~    The focus is on
~    Eliciting self-motivational statements
~    Exploring ambivalence
~    Empowering the client to make positive changes
~    Enlisting the support of significant others
~    Encouraging continued follow through