Upload
dr-dawnelise-snipes-allceus-unlimited-counselor-training
View
178
Download
0
Embed Size (px)
Citation preview
Session 13Screening and Motivational
EnhancementInstructor: Dr. Dawn-Elise Snipes PhD, LPC-
MHSP, NCC
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 Identify what actions to take in each of the sessions Explore strategies for increasing motivation and “rolling with
resistance” Discuss who is appropriate for MET Discuss ways to use MET with patients with co-occurring disorders
Objectives
4 session protocol De-emphasis on labels 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
MET Unique Characteristics
Argue with clients Impose diagnostic labels Tell clients what they “must” do Seek to “break down” denial through direct
confrontation Imply client’s powerlessness
Motivational Enhancement Therapists Do NOT
Precontemplation Contemplation Preparation Action Maintenance
Stages of Change
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 Argumentation◦ No attempt is made to have the client accept or “admit” a problem
Basic Principles: EE-DD-AA-RR-SS
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
Control◦ Self-efficacy◦ Hope and Faith
Commitment◦ Courage and Discipline
Challenge
Hardiness
CBT vs. MICognitive Behavioral Motivational Enhancement Assumes client is
motivated Identify and modify
maladaptive cognitions
Prescribes change strategies
Builds client motivation
Explores and reflects client perception without correcting
Elicits change strategies from the client
Nondirective vs. METNondirective MET Client determines
content and direction Avoids injecting
counselor’s advice and feedback
Empathy is used noncontingently
Directs client toward motivation
Offers advice and feedback
Empathic reflection used selectively to reinforce certain points
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?
What you’ve noticed about how 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?
Building Motivation
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?
More Motivational Questions
Decisional Balance
Consequences of Action or Inaction
Benefits/ Good Things
Consequences/ Fears
Keep Drinking
Stop Drinking
Drinking is really important to you. Tell me about that. What is it about drinking that you really need to hang
onto? Information and Advice
◦ Do alcohol problems run in your family?◦ What do you think it means to be “addicted” or an
“alcoholic”◦ If I quit drinking, will __(problems)__improve?
Still More Motivational Questions
Information and Advice cont…◦ What’s a safe level of drinking?
0 --is the greatest amount someone with a history of drinking problems can safely drink. Safest for anyone
1—Largest amount in an hour 2 – Greatest amount in a day that won’t increase health risk 3 – Greatest amount in a day that won’t increase risk of
impairment 14 – Greatest amount in a week
More Questions
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.
Empathy
Benefits◦ Strengthening the working relationship, ◦ Enhancing a sense of self-responsibility and empowerment◦ Reinforcing effort and self-motivational statements◦ Supporting client self-esteem
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.
Affirmation
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
Examples of Resistance
Arguing, disagreeing, challenging
Judging, criticizing, blaming
Warning of negative consequences.
Seeking to persuade with logic or evidence.
Ineffective Responses to Resistance
Interpreting or analyzing the “reasons” for resistance.
Confronting with authority
Using sarcasm or incredulity
More Ineffectiveness
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
◦ 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
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
More Effective Responses
Rolling with resistance◦ There is a paradoxical element in this, which often will bring
the client back to a balanced or opposite perspective. ◦ This is useful with clients who present in a highly
oppositional manner and seem to reject every idea C: But I can’t quit drinking. I mean, all of my friends drink! T: It may very well be that when we’re through, you’ll decide
that it’s worth it to keep on drinking. It may be too difficult to make a change. That will be up to you.
More Responses…
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
Reframing
Incorporate them throughout the assessment or session
Summarize both motivational statements and statements of reluctance—Fair and Balanced
Summarizing
Signs◦ Client stops resisting and raising objections◦ Client asks fewer questions◦ Client appears more settled, peaceful◦ Client makes motivational statements indicating
willingness to change◦
Recognizing Change Readiness
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
Have clients identify how they think each modifiable factor should be addressed
Discussing a Plan cont…
Provide a rationale for why it might be a safe choice Nobody can guarantee a safe level of drinking I want to tell you, however, that I am concerned about the
possibility of your continued use because◦ Medications◦ Mental or Physical Health Conditions◦ Strong external consequences (jail)◦ Prior history of severe consequences of use
Deal with resistance through◦ Reflection◦ Juxtaposition/contrasting wants
Abstinence
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…
Change Plan Worksheet
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)
Asking for Commitment
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
Role of the SO
Emphasis is placed on positive attempts to deal with the problem
Negative experiences—stress, family disorganization, employment difficulties—should be reframed as normative in families with an alcohol problem.
The counselor might compare the SO’s experiences to the stress experienced by families confronted with other disorders such as heart disease, diabetes, and depression
The SO can discuss the risks and costs of continued drinking There is a danger of overwhelming or alienating clients if the
counselor and SO both present negative feedback
The SO cont…
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
◦ Write a sample note
The Follow Up Note
First follow-up session 1-2 weeks after initial session Sessions 3 and 4 are at weeks 6 and 12 Actions
◦ Review progress and problems◦ Renew motivation
Review most important reasons for change)◦ Redoing commitment (Reinforce self-efficacy)
Control Commitment Challenge
Follow Through Strategies
Discussed during 4th session◦ 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
Termination
Treatment Dissatisfaction◦ Affirm expression of concern◦ Explore reasons for concern
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
Missed Appointments (no good explanation)◦ Explore uncertainty about whether or not treatment is
needed (e.g., “I don’t really have that much of a problem”)◦ Discuss ambivalence about making a change◦ Empathize with frustration or anger about having to
participate in treatment In either case of a missed appointment, send a
handwritten note summarizing the phone call and the new appointment
Special Problems cont…
Contacts should be kept brief Elicit, do not prescribe, change strategies Elicit information about what is happening Reflect and affirm progress Normalize feelings of ambivalence
Telephone Consultation
Can it be effectively used with co-occurring?◦ Stages of change◦ Self-motivational statements◦ Strengths and solutions focused planning◦ 12-week course
Characteristics of appropriate patients◦ Cognitive development◦ Level of impairment◦ Amount of social support◦ Co-Occurring issues◦ Other?
MET and Co-Occurring
MET is a 4 session evidence based practice It 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
Summary