MOTIVATIONAL INTERVIEWING

DR SUSHIL KUMAR S VMB BS, MD (PSYCHIATRY), MHA,

FIPS

MOTIVATION

• THE NEED OR DESIRE TO DO A PARTICULAR ACTIVITY OR BEHAVE IN A PARTICULAR WAY

• IN THE CONTEXT OF SUBSTANCE USE MOTIVATION CAN BE EXPLAINED AS NEED/ DESIRE TO CHANGE FROM USING TO QUITTING/ STOPPING.

WHAT IS MET?

• A SYSTEMATIC INTERVENTION APPROACH

• BASED ON PRINCIPLES OF MOTIVATIONAL PSYCHOLOGY

• DESIGNED TO PRODUCE RAPID, INTERNALLY-MOTIVATED CHANGE

• MOBILIZE THE CLIENT'S OWN CHANGE RESOURCES

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

MOTIVATION

• 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”

STAGES OF CHANGE (PROCHASKA & DICLEMENTE,

1992)

PRE CONTEMPLATION• NO AWARENESS OF PROBLEM• RESISTANT TO SUGGESTIONS OF PROBLEMS

ASSOCIATED WITH ALCOHOL/DRUG USE• UNCOMMITTED TO TREATMENT• MAY SEEK TREATMENT BECAUSE OF OTHERS’

PRESSURE

BARRIERS: LACK OF KNOWLEDGE OF RISKS/CONSEQUENCES , LACK OF SELF-EFFICACY, CONTENTMENT

CONTEMPLATION

• SEEKING TO EVALUATE AND UNDERSTAND THEIR BEHAVIOR• MAY EXPERIENCE SOME LEVEL OF DISTRESS• MAY BE THINKING ABOUT MAKING CHANGES

BARRIERS: LACK OF KNOWLEDGE OF RISKS/CONSEQUENCES,LACK OF SELF-EFFICACY, CONTENTMENT, INDECISIVENESS

DETERMINATION/PREPARATION

• 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 MAKE COMMITMENT

BARRIERS: LOSS OF COMMITMENT, LACK OF KNOWLEDGE OF OPTIONS FOR CHANGE

ACTION• FIRM DECISION TO INITIATE CHANGE

• TAKING ACTION TO CHANGE BEHAVIOR AND ENVIRONMENT

• EXHIBITS MOTIVATION

•WILLING TO FOLLOW SUGGESTED STRATEGIES AND ACTIVITIES

MAINTANENCE

• 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

BRIEF INTERVENTIONS• FEEDBACK OF PERSONAL RISK OR IMPAIRMENT  • EMPHASIS ON PERSONAL RESPONSIBILITY FOR

CHANGE  

• CLEAR ADVICE TO CHANGE  

• A MENU OF ALTERNATIVE CHANGE OPTIONS  

• THERAPIST EMPATHY

BASIC MOTIVATIONAL PRINCIPLES

EXPRESS EMPATHY

DEVELOP DISCREPANCY

AVOID ARGUMENTATION

ROLL WITH RESISTANCE

SUPPORT SELF-EFFICACY(MILLER AND ROLLNICK (1991)

EXPRESS EMPATHY• COMMUNICATIONS IMPLYING A SUPERIOR/ INFERIOR

RELATIONSHIP B/W THERAPIST AND CLIENT ARE AVOIDED

• THE THERAPIST ROLE IS LISTENING RATHER THAN TELLING

• PERSUASION SHOULD BE GENTLE AND SUBTLE

• ASSUMPTION THAT CHANGE IS UP TO THE CLIENT

• REFLECTIVE LISTENING

DEVELOP DISCREPANCY

• MOTIVATION OCCUR – CLIENT PERCEIVES A DISCREPANCY• AN UNREALISTIC (FROM THE CLIENT'S PERSPECTIVE)

ATTACK ON HIS OR HER DRUG USE TENDS TO EVOKE DEFENSIVENESS AND OPPOSITION

• THERAPIST EMPLOYS OTHER STRATEGIES THAN ARGUMENT

• NO ATTEMPT TO MAKE THE CLIENT ACCEPT A DIAGNOSTIC LABEL

ROLL WITH RESISTANCE

• NOT TO MEET RESISTANCE HEAD ON• ROLL WITH THE MOMENTUM• AMBIVALENCE NOT VIEWED AS PATHOLOGICAL• SOLUTIONS EVOKED FROM THE PATIENT• HANDLING CLIENT "RESISTANCE" IS A CRUCIAL

AND DEFINING CHARACTERISTIC OF THE MET APPROACH

SUPPORT SELF-EFFICACY

• SELF-EFFICACY IS THE CLIENT'S SPECIFIC BELIEF THAT HE OR SHE CAN CHANGE THE DRINKING BEHAVIOUR.

• HOPE FOR SUCCESS• CRITICAL DETERMINANT OF BEHAVIOR CHANGE• SUPPORT BELIEF THAT HE OR SHE CAN CHANGE• RESPONSIBILITY OF CHANGE IN THE PATIENTS HAND

AVOID ARGUMENTATION

THERAPIST, THEREFORE, 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 WHICH IMPLY A CLIENT'S "POWERLESSNESS"

PRACTICAL STRATEGIES

PHASE 1: BUILDING MOTIVATION FOR CHANGE• SHIFT BALANCE FROM THE PERSON’S CURRENT

STATUS (DRINKING/DRUG USE), TO CHANGE (QUITTING THE USE).

• AIMS AT RESOLVING AMBIVALENCE.• BUILDING MOTIVATION FOR CHANGE• 8 STRATEGIES

1. ELICITING SELF-MOTIVATIONAL STATEMENTS • THE WORDS WHICH COME OUT OF A PERSON'S MOUTH ARE

QUITE PERSUASIVE TO THAT PERSON• ONE  WAY  TO  ELICIT  SUCH  STATEMENTS  IS  THRO OPEN

  ENDED STATEMENTS• 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 ?

2. LISTENING WITH EMPATHY

• EMPATHY IS HAVING AN IMMEDIATE UNDERSTANDING OF THEIR SITUATION BY VIRTUE OF HAVING EXPERIENCED IT ONESELF• CLIENT: I GUESS I DO DRINK TOO MUCH SOMETIMES BUT I DONT

THINK  I HAVE A PROBLEM WITH ALCOHOL  • 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  ONE HAND YOU CAN  SEE  SOME  REASONS

 FOR CONCERN,  AND  YOU REALLY DON’T WANT TO BE LABELED  AS  HAVING  A PROBLEM

3. QUESTIONING

• MET USES  QUESTIONING  AS  AN   IMPORTANT THERAPIST  RESPONSE.• RATHER THAN TELLING CLIENTS HOW THEY

 SHOULD FEEL  OR  WHAT  TO  DO THE THERAPIST  ASKS  THEM ABOUT  THEIR  OWN FEELINGS, REACTIONS, IDEAS, CONCERNS AND PLANS AND  RESPONDS  WITH REFLECTION, AFFIRMATION OR REFRAMING.  

4. PRESENTING PERSONAL FEEDBACK

• THE  FIRST MET SESSION SHOULD ALSO INCLUDE FEEDBACK  TO  THE CLIENT  FROM HIS PRE-TREATMENT ASSESSMENT• A VERY IMPORTANT  PART OF  THIS PROCESS IS THE THERAPIST’S MONITORING OF AND RESPONDING TO THE CLIENT DURING FEEDBACK

5. 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

6. HANDLING RESISTANCE• INTERRUPTING- CUTTING OFF OR TALKING

OVER THE THERAPIST.• ARGUING- CHALLENGING, DISCOUNTING THE

THERAPIST’S VIEWS, DISAGREEING, OPEN HOSTILITY.• SIDETRACKING-CHANGING THE SUBJECT, NOT

RESPONDING, NOT  PAYING ATTENTION.• DEFENSIVENESS

DEFLECTING RESISTANCE• SIMPLE  REFLECTION - HAS THE EFFECT OF ELICITING THE

OPPOSITE AND  BALANCING THE PICTURE.• REFLECTION  WITH  AMPLIFICATION -EXAGGERATE  OR AMPLIFY

 WHAT THE CLIENT IS SAYING TO THE POINT WHERE THE  CLIENT IS LIKELY TO DISAVOW IT.

• SHIFTING FOCUS• ROLLING  WITH - A PARADOXICAL STRATEGY ESPECIALLY  WITH

 HIGHLY OPPOSITIONAL CLIENTS WHO SEEM TO REJECT EVERY IDEA OR SUGGESTION.• CLIENT: BUT I CANT QUIT DRINKING. ALL MY FRIENDS DRINK.• THERAPIST:  AND IT MAY VERY WELL BE THAT WHEN WE’RE THROUGH

 THIS YOU WILL DECIDE THAT IT’S WORTH IT TO KEEP ON DRINKING  AS  YOU HAVE BEEN. IT MAY BE TOO DIFFICULT FOR YOU TO MAKE A CHANGE. THAT WILL BE UP TO YOU.  

7. REFRAMINGA STRATEGY WHEREBY THE THERAPIST INVITES THE

CLIENT TO EXAMINE HIS OR HER PERCEPTIONS IN A NEW LIGHT, OR A REORGANIZED FORM

• NEW MEANING IS GIVEN TO WHAT HAS BEEN SAID• A SPOUSE’S  REACTION OF  “I’M RIGHT AND I TOLD YOU SO !”

CAN BE RECAST  TO  “YOU’VE BEEN  SO  WORRIED  ABOUT HIM AND YOU CARE  ABOUT  HIM  SO MUCH”

• YOU MAY HAVE THE NEED  TO  REWARD YOURSELF  ON THE WEEKENDS FOR SUCCESSFULLY HANDLING  A  STRESSFUL AND  DIFFICULT  JOB  DURING THE  WEEK........THE  IMPLICATION  IS THAT THERE  ARE  OTHER WAYS FOREWORD ONESELF WITHOUT  GOING  ON  A BINGE.

8. SUMMARIZING

• IT  IS USEFUL TO SUMMARIZE PERIODICALLY DURING  THE  SESSION ESPECIALLY TOWARD THE END OF A SESSION

PHASE 2: STRENGTHENING COMMITMENT TO CHANGE

• THE STRATEGIES OUTLINED ABOVE ARE DESIGNED TO BUILD MOTIVATION. HELP THE CLIENT'S DECISIONAL BALANCE IN FAVOR OF CHANGE• A SECOND MAJOR PROCESS IN MET IS TO

CONSOLIDATE THE CLIENT'S COMMITMENT TO CHANGE, ONCE SUFFICIENT MOTIVATION IS PRESENT (MILLER & ROLLNICK, 1991).

RECOGNIZING CHANGE READINESS

• SOME  CHANGES WHICH MIGHT BE HELPFUL IN IDENTIFYING IN  THIS STAGE:

• THE CLIENT STOPS RESISTING AND RAISING OBJECTIONS• THE CLIENT ASKS FEWER QUESTIONS• THE  CLIENT MAKES SELF-MOTIVATIONAL  STATEMENTS

 INDICATING  A DECISION/ OPENNESS TO CHANGE• HE/SHE BEGINS IMAGINING HOW LIFE MIGHT BE AFTER A

CHANGE

DISCUSSING A PLAN

• THE THERAPIST COULD SIGNAL THIS SHIFT BY ASKING A TRANSITIONAL QUESTION SUCH AS:• WHAT DO YOU MAKE OF ALL THIS? WHAT ARE YOU THINKING

YOU’LL  DO ABOUT IT?• I WONDER WHAT YOU’RE THINKING ABOUT YOUR DRINKING

AT THIS POINT• THE  GOAL  IS TO ELICIT FROM THE CLIENT (AND

 SIGNIFICANT  OTHER) SOME  IDEAS  AND  ULTIMATELY  A PLAN FOR WHAT TO DO  ABOUT  THE CLIENT’S  DRINKING

COMMUNICATING FREE CHOICE

• THIS  THEME SHOULD BE STRESSED DURING THE COMMITMENT-STRENGTHENING PROCESS:• IT’S UP TO YOU WHAT TO DO ABOUT THIS.• YOU CAN DECIDE TO GO ON DRINKING JUST AS YOU WERE

OR TO CHANGE  

CONSEQUENCES OF ACTION AND INACTION

• GENERATE A  WRITTEN  LIST  OF  THE POSSIBLE NEGATIVE CONSEQUENCES OF NOT CHANGING

• ONE POSSIBILITY  IS  TO CONSTRUCT A FORMAL  ‘DECISIONAL’  BALANCE  BY HAVING THE CLIENT GENERATE THE PROS AND CONS OF CHANGE OPTIONS.

INFORMATION AND ADVICE

• OFTEN  CLIENTS AND SIGNIFICANT OTHERS (SO) WILL ASK FOR  KEY INFORMATION WHICH MIGHT BE IMPORTANT FOR THEIR DECISION  PROCESS

• THEY  MIGHT ALSO ASK YOU FOR ADVICE• IT IS QUITE  APPROPRIATE  TO PROVIDE  YOUR OWN

VIEWS IN THIS CIRCUMSTANCE WITH QUALIFIERS  AND PERMISSION TO DISAGREE

EMPHASIZING ABSTINENCE

• SUCCESSFUL ABSTINENCE IS A SAFE CHOICE. IF YOU DON’T DRINK  YOU CAN  BE  SURE  THAT YOU WOULDN’T HAVE PROBLEMS  BECAUSE  OF  YOUR DRINKING.

• THERE ARE GOOD REASONS TO TRY A PERIOD OF ABSTINENCE

• NO ONE CAN GUARANTEE A SAFE LEVEL OF DRINKING THAT WILL  CAUSE YOU MORE HARM.

THE CHANGE 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 :• I WILL THAT MY PLAN IS WORKING IF :• SOME THINGS THAT COULD INTERFERE WITH MY PLAN

ARE :

ASKING FOR COMMITMENT

• ASK  WHAT CONCERNS FEARS OR DOUBTS THE CLIENT  MAY  HAVE  THAT MIGHT INTERFERE WITH THE CLIENT CARRYING OUT THE PLAN.

• WHAT  OTHER OBSTACLES MIGHT BE ENCOUNTERED THAT  COULD  DIVERT HIM/HER FROM THE PLAN. HOW COULD ONE DEAL WITH THIS ?

• CLARIFY THE SO’S ROLE IN HELPING THE CLIENT MAKE  THE  DESIRED CHANGE.

• MAKE AN APPOINTMENT FOR FOLLOW UP VISITS  

• DEALING WITH RESISTANCE• RECAPITULATING• INVOLVING A SIGNIFICANT OTHER

PHASE 3 : FOLLOW THROUGH STRATEGIES  

NOW MET FOCUSES  ON  FOLLOW THROUGH. THREE PROCESSES ARE INVOLVED:  • REVIEWING  PROGRESS, • RENEWING MOTIVATION  AND  • REDOING COMMITMENT .  

THE “5AS”THE 5 MAJOR STEPS IN THIS INTERVENTION ARE:• ASK ABOUT SUBSTANCE USE• ADVISE -- ADVISE TO QUIT• ASSESS COMMITMENT AND BARRIERS TO

CHANGE• ASSIST PATIENTS COMMITTED TO CHANGE• ARRANGE -- ARRANGE FOLLOW-UP TO

MONITOR PROGRESS

THE “5RS”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.

THANK YOU !!!