Motivational Interviewing, Enhancement & Stages of Change | CBT Skills

Hey there everybody, and welcome to today's video on motivational enhancement therapy. I'm your host, Dr. Donnellice Snipes. In this presentation, we're going to compare and contrast motivational enhancement therapy with other approaches to therapy like cognitive, behavioral and non directive therapy. We'll briefly review the frames approach, describe the stages of change, define the eeddaa, RRS, and ORS strategies, and explore other strategies for increasing motivation. Now, last week we talked about motivational interviewing, which is a technique that is used within motivational enhancement therapy. Motivational enhancement therapy is a four to six session brief intervention. Typically it's used with people in earlier stages of readiness for change and it may have a significant gap between sessions. So unlike traditional therapy that meets every week, oftentimes the person will come in for their first session and then it'll be six weeks before they return for their second session in met. This gives them a period where they can reflect on what was talked about and observe for themselves the the reality of whether their behaviors are causing problems in their life or not when they come back is often when the clinician and the person will start working together to create a meaningful plan for change. Characteristics unique to MET include emphasis on personal choice regarding future behavior and that is very similar to motivational interviewing. Or we are making sure the person understands we're not forcing them to do anything. We are helping them evaluate what's going on and decide whether it's important for them to make a change in order to fully achieve their rich and meaningful life. Objective evaluation is focused on eliciting the person's own concerns, not my concerns, not the significant other's concerns or but what is the client's concern about change and about not changing. Resistance is an interpersonal behavior pattern indicating either a failure to accurately empathize so we may not be connecting with the person and understanding their connection to the behavior or their fears about change. Resistance can also represent a sense of threat or disempowerment. And again, if we're asking somebody to do something and they're being resistant, that tells us that we have failed to identify or address whatever is causing their sense of anxiety, their sense of threat. Or maybe we're posing it in a way where they feel disempowered, where they feel like they're being told to do something. Resistance in MET is met with reflection and curiosity. Not just in the initial session, but every session thereafter. If the person is not achieving their goals, you know, that's not necessarily resistance against something we're saying. If they say I am going to do xyz and they come back the next week or six weeks later and they haven't yet done xyz. They're resisting themselves, they're resisting change. It's not. Not personal. It is a. It's behavioral. So we want to be curious about. I'm wondering why, even though you've stated that there are all these reasons for change that you feel outweigh the benefits of staying the same, you're still not doing it. So I'm wondering if it's a skill gap, if it is a time thing, what is it that is holding you back? What are the reasons you give yourself for not engaging in this behavior? And let's take a look at what that might mean. Ineffective responses to resistance, arguing, disagreeing, or challenging. We don't want to lecture people. They've been lectured enough by most others. So it's important that we provide a empathic safe environment for them to explore what their thoughts and perceptions about the problem are. Yeah, we might not agree, but it's not our place. We are in motivational enhancement. We are helping the person try to figure out what they believe. We don't want to judge, criticize, or blame. Whether it's blaming the person or blaming other people, that's number one, it's not our place. And number two, it creates a negative emotional motivational environment. We don't want to judge somebody for the decisions they're making. We want to again, explore with curiosity. If they're doing this, for example, drug use, if they're doing this, what function is it serving? Let me get curious and understand how, how this is in some way helping the person. If they are clinically depressed and they're not following through on their treatment plan, instead of judging them as being, quote, unmotivated or resistant or whatever term you want to use, exploring why is this person making these plans and not following through. Maybe they're making the plans in session with you because they feel pressure to do so. They feel like they're expected to do so and they don't intend on following through because it's just overwhelming. Or maybe when they're in session with you, they get this charge of motivation and as soon as they walk out, they start getting overwhelmed and they can't put one foot in front of the other and implement it. So you need to break the goals into much smaller chunks and maybe not have as many things that the person is doing. Instead of trying to address exercise, nutrition and thinking styles or whatever you're addressing, pick one, let's focus on your main cognitive distortion or let's focus on your inner critic right now. So you may need to help people figure out how to break these goals down to, to be more manageable. Because when people are depressed or in early recovery, they don't have a lot of energy getting up, getting showered, activities of daily living, you know, that takes most of what they've got. So expecting them to do 15 assignments, and I'm exaggerating here, but you can see how that would be overwhelming. We don't want to warn people of negative consequences. They know the negative consequences. They've been living with them. It's not something that's a surprise to them. So warning them of it is very condescending and paternalistic and will really disrupt the rapport with the client. Don't seek to persuade them with logic or evidence. We don't want to say, well, this, let me tell you why you need to do this. They don't want to hear that they've already had other people most likely tell them why they need to do it, but they haven't been motivated to do it. So they have most of the objective or logical information. What we need to get down to is the emotional and motivational aspects. Why is it, even though you know it's probably a good thing for you, why is it that you are having difficulty getting motivated to make a change? We don't want to interpret or analyze their reasons for resistance. We want to be very careful about saying, well, you're doing this because you're being resistant, because you're angry at so and so and you want to prove that they can't push you around or whatever, you know, when possible, instead of focusing on why they're not doing something, focus on what would motivate you to do something else instead. If you don't want to go to meetings, instead of analyzing the resistance to going to meetings or self help groups, say, all right, that's not something you want to do. What could you do instead? We want to avoid confronting with authority because that takes their power away and we don't want to use their condition and address it with sarcasm or incredulity. Like, I don't understand how in the world you wouldn't want to get better. Leave that alone. They've already heard that. So again, from, especially from a trauma informed perspective, we want to make sure that we are helping people feel safe and empowered. And we do that by providing them with respect, not judgment, with power, not, you know, pushiness. I don't know what the opposite of that is, and we really want to make sure that we create an environment that's safe. We respond to their needs, we empathize, we validate what they're saying so they can hear what they're saying and help them come to the decision. Motivational enhancement therapists do not argue. We don't impose diagnostic labels. Now, that can be a little bit tricky if you've got to do billing. But in general, motivational enhancement therapists want to meet the person where they are. If they want to use person first language or they don't want to diagnosis, that's fine. We're not going to force one on them. If they, on the other hand, want, want to use a term like alcoholic or addict, then we will meet them where they are with that diagnostic label. We want to avoid telling people what they must do or seek to break down denial through direct confrontation. This has been what they've been trying for 80 years before motivational enhancement therapy and motivational interviewing really came about. And we realized, hey, breaking people down really doesn't work because a lot of times there's a function of that behavior and that behavior is protective in some way or lack of change represents a bigger issue. So confronting them implies that they are doing whatever they're doing willfully and they are intentionally being depressed, they're intentionally being anxious, and that is just so not the case. Frames and oars. Now these are some mnemonics that they came up with for motivational enhancement therapy. And it's important to be aware of these particular mnemonics just because they do come up a lot and they're often abbreviated. So, so frames represents feedback. We want to, if we're doing an assessment, provide feedback about what the assessment says. Just very objective feedback about what you observe based on your knowledge. Now remember, we don't want to come in like the authoritarian and tell them, well, I can see that you need to enter a recovery program because of all these things we, we want to say. I can see that, you know, you're drinking a six pack every night. I can see that you're struggling with problems in your relationships. You're struggling with your sleep, you're struggling with your ulcers. You know, objective feedback about what you're seeing. Provide objective feedback if it's appropriate. You know, sometimes people want to know. They think, well, everybody's doing it. It's perfectly normal to come home and, and, you know, drink 12 beers. And we want to normalize that behavior. If the person presents false information, inaccurate information, we do want to correct it. You know, would you be surprised to know that that's actually not true? Don't push the issue, don't lecture them. But if there is a inaccuracy that comes up, we do want to, you know, give them the accurate information. They can do with it what they will once they've got feedback about what's going on in the city with them, or when they come back the second, third, fourth session, we're going to talk about what progress have you made. And as a therapist, I'm going to hear what they say and I'm going to paraphrase providing feedback about, you know, how awesome it is that the positive steps they made and, you know, those sorts of things. So we're just providing a summary of what we as clinicians see. That's the feedback. We're going to place the responsibility for change directly on the person's shoulders. It's your responsibility to decide whether or not you are going to change. I'm not going to do it for you. I'm not going to force you to do it now. I always struggle with advice because in counseling graduate school, we're taught you don't give advice. However, advice is part of frame. So you got to know the word. What we mean by advice is, you know, providing information about. For example, I've had other clients that I've worked with that have struggled with something similar and this has worked for them. Just giving them information that, you know, what might happen if they make this particular change. You're not telling them to make it, you're just providing information. M stands for menu of options. At this point, the person is saying, all right, well, I'll consider making a change maybe, but what might I have to do? And so we can start offering a menu of options. Individual therapy, group therapy, journaling, self help groups, whatever is appropriate for that person's particular condition and allow them to start to explore. And generally in motivational enhancement therapy, that's all they're going to do between session one and session two is think about what you've talked about and start exploring the menu of options and maybe even dipping their toe in and trying a few of these things out. Empathy is so important in every session. Empathize and remember safety and empowerment. Safety and empowerment. We want to empathize with how scary it is to come to treatment, to make yourself vulnerable, to be potentially vulnerable to criticism. They don't know what they're walking into. We want to empathize with how overwhelming it might be to even think about change, let alone make A change and how exhausting their current condition is, but how exhausting change is. You know, see, there's a lot of things we can empathize with. We really need to take time to put ourselves in the shoes of the people that we're working with and go, okay, you know, what is it like to be them right now? And what would it be like to be them going through the treatment process, in what ways is that going to impact them? What's that going to feel like? And provide support. And we can provide intellectual support or telling them about different research or information that they may need. We can provide emotional support. We want to make sure that they have social support. They not only in that one hour that they're in session or however long your program is, but also in the other 23 hours of the day, where can they find support? Because sometimes people need support in the wee hours in the morning, and where can they get support at 2am in terms of method for providing feedback and getting information and giving advice and all this stuff, the method of doing that is ors use open ended questions. Instead of are you happy right now? Which is a yes or no question, have the person describe what would it be like to not be using or not be depressed? Or what are you hoping that our interaction today can provide? So ask them basically long questions, essay questions. A stands for affirmations. We want to affirm as often as possible when people are engaging, when people are being open and willing to listen. We want to affirm how scary it can be to think about change. We want to affirm their courage, their determination, their abilities. Anytime they make a positive step forward, either in behavior or attitude, we want to make sure to highlight that with affirmations. Use R stands for using reflective listening. And reflective listening is really important because it enables you to bounce back what they said. So they say something and that's positive or motivational, when you say it back to them, when you reflect it back to them, they not only hear you saying it, but they hear themselves saying it too. So it has double power. Another technique I've found helpful with reflective listening can be having a whiteboard where you just jot down notes that a person is saying. So they can see it. And when you see it, unlike when you say it and it just kind of disappears when you see it, it sits there and you can come back and ponder it a little bit more. And summaries are used very frequently in motivational enhancement to keep coming back to what we're talking about, to keep highlighting the reasons for change to keep highlighting ways to cope with apprehensions and fears about change. Motivation needs to be enhanced and maintained in all stages of change. So MET can be used for people in action or maintenance, but it can also be used for people in pre contemplation. Contemplation or preparation. Now, remember, we talked about this last week in motivational interviewing. But pre contemplation, the person is either reluctant to change. Maybe they've tried before and it hasn't worked out. So they're like, I don't know that it'll do any good. They may be resistant to change because they're afraid to make the change, or they may be not willing to. To think about change because they just. They don't even know how. They don't know where to begin, so they have a skill gap. Pre contemplation is when the person says, you know what? I really don't have a problem that I need help with, so please go away now. Contemplation is when the person acknowledges, yeah, this is not the best. This could be a problem. At that point, they're still often not ready to engage other people. They're thinking, okay, I will acknowledge that I've got a problem, but I got it. I've got it under control. I really don't need to do anything about it yet. Now, a lot of times people will be referred to counseling when they're in these early stages of readiness for change. So what we want to do is help them identify the problem and figure out what steps they can take that might help them feel, again, safer, more empowered, and maybe even open to considering the possibilities. Now, EED D A A R R S S. I'm not sure who came up with that, but EE stands for Express Empathy. We want to use reflective listening and accurate empathy with people when we're talking to them, which means not just reflecting back what they said when, but the underlying message that you're getting with it. For example, they may say, I don't have a problem with my drinking. And it could indicate, you know, depending on how they say it, it could indicate that they are feeling frustrated and judged by other people. So they're not willing to even examine whether they've got a problem or they're afraid that you are going to start labeling them. DD stands for Develop discrepancy. Highlight a discrepancy between where they are and where they want to be. Have them talk about what does a rich and meaningful life look like to you and what would need to change in order to be living that rich and meaningful life. Once they really define that, then say, okay, now, based on your current situation, is that helping you move toward your rich and meaningful life? Raise people's awareness of their personal consequences of their use or their condition to precipitate a crisis. Increasing motivation for change. Now, we want to be really careful how we do this, because if we push too hard or if we try too hard to raise their awareness, they're going to feel lectured at. And remember, that's one of the things we don't do. We don't lecture, we don't judge. We just want to ask them questions like, has it had any impact on your work, on your health, on your sleep, on your energy levels? And they can answer however they see fit, but this starts kind of bringing stuff to the forefront without telling them what the problems may be. It's much more powerful if the motivation comes from within. Avoid arguing. No attempt is made to have the person accept or admit that they've got a problem. This is where we aren't putting labels on people. What we're doing is just saying, where are you? You were referred to counseling or you came in here for a reason. So tell me about what that reason is and tell me what your perception of the situation is. Roll with resistance. Help people develop new ways of viewing problems in ways that are invited, not imposed. So maybe they're seeing substance use as a way to relax. And as a clinician, we may see that it's causing them lots of other problems. We're not going to lecture them on all the problems it's causing and how bad it is for their health. What we want to do is then start asking questions. If they say, this is what I do to relax. So I hear that you've got a really stressful life going right now. Tell me about what's causing some of the stress in your life and tell me about, you know, has your drinking impacted that at all? We can do the same thing with depression. Some people, especially people with persistent depressive disorder, may not recognize that the, even the low grade persistent depression in between the major depressive episodes, even that low grade depression is really keeping them from living the life they want. So we want to ask them, how is your current condition keeping you from living the life you want? Ambivalence is viewed as normal, not pathological, and is explored openly. People are doing what they're doing because it's the best way they know how to survive. Until now, the best tools they could based on the tools they have. So ambivalence Makes sense. If they try to change and they fail, that can be disempowering and devastating. If they start to try to change, it may be overwhelming and at least they know what to expect here. There are a lot of reasons why people might not want to change and, and they may have just as many reasons why they do want to change. And that's okay. We want to validate both sides. Solutions are evoked from the person rather than provided by the therapist. Instead of saying, okay, I hear you're having problems with your sleeping, instead of saying these are the six things you're going to do, we want to say, what do you think might help you improve your sleep? What do you think is contributing to your sleep problems? Evoke those statements. That way the person feels empowered and they're learning how to problem solve along the way. Support self efficacy. People will not try to change unless they believe there is hope for success. We need to make sure that they recognize that if they try to change, we will support them, we will help them along the way. In order to move towards that rich and meaningful life, we want to inspire hope as well as motivation. One method of doing this is called hardiness. And hardiness is comprised of commitment, control and challenge. So remember, we've already defined, worked with them to identify what a rich and meaningful life looks like for them. In that rich and meaningful life, there are people, things, experiences that are important in their life and we want them to look at that and say, okay, of those things that are important, which ones are going well right now? Of the things that I'm committed to in my life, which ones are going well right now and which ones are not? And you know, and of the things that are not going well, are there any aspects that are going well? And we want to build on that. Instead of saying, well, your life is a shambles, we want to help people recognize that there are parts of their life that are going at least somewhat okay, and we can build on that. Control helps them develop self efficacy. Recognizing the aspects of, of the things that are going well that they can continue to nurture, that they can control to a certain extent. And the aspects of the things that are not going well that they may be able to address and turn around, they may not be able to address everything. So it's important to recognize that, you know, not everything can be fixed or cured or whatever, but what can you do? So for example, if their diabetes is out of control, their A1C is way high, they can't eliminate diabetes even if they wanted to so that's not something. If they want to be healthy and disease free, well, that's not going to happen. However, they can be empowered to more effectively manage their diabetes and you can start talking about ways to do that with depression. You know, some people do have genetic predisposition to depression with any of the types of depression. So they may not be able to get rid of that genetic predisposition. They may not be able to complete completely eradicate things. But there are a lot of things that they can do to improve their mood and their energy and their all that stuff as well as prevent flare ups or relapses of major depressive disorder and challenge. Helping people recognize that making these challenges, it ain't easy. However, it's not undoable. It is something that they can accomplish and helping them recognize things that they used to perceive as barriers or obstacles to living a rich and meaningful life, well, it may not be easy to change them. But if they view it as a challenge, something that they've got to figure out how to work around what's going to work for them, then it can help enhance motivation. Now I said earlier we were going to compare and contrast motivational enhancement to other types of therapy. Cognitive behavioral therapy, one of my favorites versus motivational enhancement. CBT assumes that the person is already motivated. So there's a difference right there. It seeks to identify and modify maladaptive cognitions or thoughts and it prescribes change strategies. So you can see how this is much more clinician directed than met, which MET builds motivation. It doesn't assume that it exists, explores and reflects the person's perception of without correcting their cognitions. If they think that everybody always does this, then we may explore where did you get that idea? Where did you get that knowledge from? And reflect it back to them. And it elicits change strategies from within the person. Instead of prescribing things, instead of me telling, telling you what to do, me giving you things that may quote fix you, I'm going to say what do you think is causing your problems and what do you think is going to work for you? So I'm starting with what you might be motivated to do and working within your understanding of your current situation. Non directive therapies, the person determines their direction. This is more like humanistic therapies. The therapist avoids injecting their advice and feedback and provides non contingent empathy. So empathy is there all the time for however you feel. And the person is just provided a very open, safe place to explore their feelings and it can go in A bunch of different directions. Motivational enhancement, on the other hand, directs the person toward motivation. We're identifying an issue and trying to enhance motivation. Now, that issue may be somewhat different and you want to arrive at mutually agreeable goals. For example, I talked before about a client that I had that was on felony probation, and in order to get off probation, he had to remain substance free for the duration. But he had no desire to stop using that particular substance forever. Instead of setting that as a goal, which wasn't his goal, I said, what are you motivated to do? And his motivation was to get off probation. With eating disorders. People with eating disorders are terrified of gaining weight. They may not want to comply with eating protocols and treatment because of that fear. So having weight gain as a goal may be completely counterproductive. Having staying out of the hospital as a goal, well, that's something different because most people with eating disorders will tell you that they really, really don't want to go to the hospital where they'll probably be force fed. Motivational enhancement offers advice and feedback and empathic reflection is used selectively to reinforce certain points. And I'm going to explain that in a minute. Questions that can help build motivation how has your using or your condition changed over time? So using is self explanatory. Are they using more? Are they developing tolerance? When we're talking about a condition, let's use anxiety this time. How has your anxiety changed over time? And most of the time, if things are left unchecked, depression, anxiety, ocd, things like that often get a lot worse. So examining how it's changed over time and what's contributed to that change, what things do you think could be problems or might become problems as a result of your use or your condition? What have others said about your use or your condition and what are they worried about? What types of things do they tell you that they worry about? If you continue in this particular path, what makes you think that perhaps you need to make a change in your using or your condition? Now, obviously, for talking with somebody with depression, you're going to say, what makes you think that perhaps you need to make a change in your depression or in your current mood? If you're talking about anxiety or you're going to use that, I'm just using the compound statement in order to help you recognize that motivational enhancement therapy can be used for a variety of issues, not just substance use, other motivational questions. Well, and in this case, tolerance is specific to substance use. Do you seem to be able to drink more or use more than other people without showing as much effect. So that's a question you're only going to ask of somebody that you're engaging that has a substance use issue. Memory have you had periods of not remembering what happened or other memory problems either while using or during flare ups of your condition? So when your depression gets really bad or when your anxiety gets really bad, do you have memory problems? And this can also indicate some elements of dissociation, especially with people with PTSD or depression or even personality disorders. Relationships has using or your condition affected your relationships? Generally the answer is yes. An open ended question would be how has using or your condition affected your relationships, if at all? Health Are you aware of any health problems related to use or your condition? For example, people with anxiety may have flare ups of autoimmune conditions as a result of their stress levels or they may develop ulcers as a result of their stress levels. People who use substances obviously may develop certain medical issues as a result of use. Legal have you had any legal issues because of behavior while using or during flare ups of your condition? Now you may be going, how does that apply to mental health? Well, when using you can get DUIs, for example, for legal drugs. And if you're using illegal drugs, you can obviously have legal problems because of possession or use of illegal drugs. With regard to mental illness, some people when they're having a flare up of their anxiety, for example, may get very stressed out and then drink to calm themselves down and get a dui. Or they may get very stressed out and have a raging temper as a result. You know, so we want to look at that. There are potential legal issues that may come up. We also want to look at some civil legal issues like divorce or child custody issues as a result of their mental illness. Financial has using or your condition contributed to money problems? Now we know that financial problems are very common in people with substance use issues, but not always. You know, some people can balance it out. They are high functioning if you will. But people with depression or anxiety or ocd, for example, may have difficulty keeping a job because their symptoms are so severe, which can cause significant financial and housing problems. A motivational technique that can be very, very helpful for people is the decisional balance exercise. And this is one that comes straight out of motivational interviewing. And this is the chart that I talked about last week. On the top you're going to have the benefits or the good things and the consequences or your fears. And then on the left side you have stay the same or change. So you're going to Start out asking, what are the benefits or good things about staying the same? What do you get out of this current situation? And for substances, there's often quite a few things that may go in here. For mental illness, there are usually very few things that go in here, but we still need to explore it. And then what are the benefits or good things about change? What do you think might improve? What are you hopeful about if you change? What do you think could be better? Then you want to go over consequences and fears. What are the consequences if you stay the same? Or what are your fears about what will happen if you stay the same? And examine that physically, what are the benefits? What are the consequences? Affectively, your mood, what are the benefits? What are the consequences? Relationships, finances, what are the benefits? What are the consequences? We want to look at also the consequences and fears of change. If the person starts to change, what are they afraid might happen? Are they afraid they're going to lose friends? Are they afraid they're going to relapse? Are they afraid they're going to find out that they can't do it? What are their fears? Let's just kind of get all that out here on the table so we can talk about it. Other motivational questions for information and advice, ask the person, do these problems run in your family? If so, you know, what impact have these problems had on the family members that have had them? What has worked as far as treatment for people in your family who have had them and what hasn't worked? You know, help me understand a little bit more about the knowns. What do you think it means to have this problem? What do you think it means to have depression? What do you think it means to have people thinking that you drink too much? Notice I didn't say alcoholism. If the person is not embracing alcoholism, then that's not their problem. Yet right now their problem is that people think they drink too much. If you quit using or if you got better, will any of your identified problems improve Empathy Advantages of empathy it's unlikely to evoke resistance from the person. You know, when we empathize with somebody, they actually feel heard and understood. Imagine that. It encourages the person to keep talking and explaining, exploring the topic. If you are start judging or criticizing or offering advice or doing any of that stuff too soon, a lot of times it may shut the person down. Empathy basically keeps that door open. It communicates respect and caring and builds an alliance. It clarifies for the therapist exactly what the person means. When we empathize, we we are going to ask questions so what I'm hearing is that you are feeling very trapped in your current situation and the person will either say exactly or no. That's not quite it. So it helps us paraphrase and understand and get a more clarity on what the person is saying. And it also helps them get more clarity on what they're thinking. And it can be used to reinforce ideas expressed by the client. We want to reflect selectively reinforcing parts of what the person has said and ignoring others. For example, a person may say, I've tried to recover before only to quickly relapse. Okay, we might respond, in the past you've been willing to change and develop some tools that helped for a little while, but they didn't stick. Okay, so you're paraphrasing both things, but you're highlighting the fact that they did develop tools and they had been willing to change. So you're being selectively reflective. People not only hear themselves saying self motivational statements, but also hear you saying that they said it. Affirmation strengthens the working relationship, enhances a sense of self responsibility and empowerment. A can do attitude. If we're constantly, well, not constantly frequently highlighting what they do well. A lot of times people, when they come into treatment, everybody else has been focusing on what they do wrong and they are probably focusing on what they do wrong instead of what they're doing right. So we are providing sort of a breath of fresh air where we are selectively affirming those things that they do well reinforce the positive, the negative will dissipate. We're reinforcing effort and self motivational statements and supporting the person's self esteem. Some examples of affirmation. I appreciate you hanging in there through this feedback, which must be pretty rough for you. So sometimes the feedback, whether it's substance about the impact of their substance use or their depression, or their refusal to take their medication for their bipolar disorder, whatever it is, may be very difficult for the person to hear because they hear other people are angry at them or frustrated with them or worried about them. So we want to affirm the courage it takes to sit there through it and listen to constructive feedback. I mean, think about yourself. How easy is it for you to sit there and listen to constructive feedback? Most of us have difficulty with it. We can take it, but especially if it's presented gently but we don't like it. And if you are already struggling with depression or anxiety or low self esteem or fears of rejection and somebody comes in and starts giving you feedback that is constructive or critical, it can Feel very threatening. 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. So if the person indicates that, okay, maybe I will consider doing something or even just the fact that they showed up, I think it's great that you're strong enough to be willing to consider looking at this problem. Lots of hedges in there, but we are reinforcing the positive behavior of even showing up for session. You really have some good ideas for how you might change. I've never not been able to use that one. We can reflect with amplification. The client may say, I don't think I have a problem. You may respond, so as far as you can see, there really haven't been any problems at all or harm because of your condition. And by emphasizing the extreme words, the person may go, well, you know, there have been a issues, but not a lot. Well, tell me about what those issues were. Double sided reflection is the on one hand. But on the other hand, the client may say, but I can't change whether it's getting over depression, addressing their post traumatic stress, addressing their substance use, whatever it is, I can't change. The therapist may say, on one hand, you don't want to continue feeling this way, but on the other hand, your other attempts to change have failed and you feel hopeless. So putting both of those things out there, we're not saying one is right, one is wrong. We're just saying I see both sides of it. We can also shift focus away from the problematic issue. A lot of times people come in and they are already defensive and amped up. If we shift focus, then we may be able to develop more rapport because they won't feel like they're being forced. The client may say, happiness is just not something I'm capable of. The therapist may say, well, you're getting way ahead of things. Let's just focus on helping you start sleeping a little better. Later on. We can explore what, if anything, we might be able to help you do in terms of addressing your depression. So through the conversation, the person may have identified that one of the problems that they've got right now is sleeping problems. So instead of saying, let's address your depression and help you feel happy, we want to say, okay, well, let's identify one target behavior that you think is a problem and let's help you work on that. This will help the person develop a sense of competence and hope that change is possible. Reframing can motivate the person to deal with the behavior, placing current problems in a more positive frame communicates that the problem is solvable and changeable. It's important to use the person's own views, words, and perceptions about their situation or behaviors. Summarizing is another technique, and it incorporates summary statements throughout the assessment or the session. We want to summarize both motivational statements as well as statements of reluctance. So again, you wanted to change, but you're overwhelmed by everything that has to be done. We want to present both sides. You have hope that change is possible, but you can't figure out which first step to take. So we have the but statements. A lot of times that can help clients feel understood and identify some of those underlying resistances that they may not have identified previously. Discussing a Plan Once a person is ready to start thinking about making changes, we want to ask, or even at the end of the first session, what do you think you need to do now? We've talked about what's going on, other people's perceptions, your perceptions, the impact of your current behaviors. So what do you think you need to do now? You have free choice. It's up to you what you do about this. Nobody can decide for you when to change, whether you need to change. So the ball is in your court. Encourage the person to list all of the things that contribute to their problem. Then identify which ones are modifiable. So what issues are contributing to you not living your most rich and meaningful life right now? What things are holding you back and which ones are modifiable? So if the person comes in and they say, I don't have a problem with drinking or I don't have a problem with anxiety, okay, are you living your rich and meaningful life? And if they say it could be better, okay, what's holding you back? What things are causing problems and how can how are they modifiable? How are they addressable, fixable? Whatever word you want to use. And then ask the person, how should each factor that can be fixed or addressed be addressed? What is your perception? The change plan worksheet usually looks something like this. The person identifies the changes I want to make are, and some people will have them identify all the changes they want to make and then pick one to start with. Other people will say, just identify one change that you want to work on making between now and the next session. The most important reasons I want to make these changes are the steps I will take to make these changes are and we want to do this in session so we can make sure that the person is not making their steps too big so they will fail and that they have a very clear and defined plan. The ways other people can help me with this change I will know the plan is working when some things that could interfere with my plan are and this could be things like the kids getting sick or having to work overtime at my job or going to jail, whatever the case may be. And I can address these issues by so a lot of times when people enter therapy, they maybe even the ones that are motivated the day they enter life happens and their kid gets sick or they get transferred to a different job or something else happens and they get sidetracked from the change process. So we want to help them anticipate these things ahead of time and figure out a preliminary plan for for addressing anything that might be trying to sidetrack or derail them. We want to ask for commitment Reinforce what people perceive to be the likely benefits of making a change as well as the consequences of inaction. Clarify the significant other's role in helping the person to make the change. In motivational enhancement we really want to include support people. Remember the frames S stands for support. Remind the person and the significant other that you will be seeing the person for follow up visits at the very least week six and week 12. The significant other or others provide an alternate point of view during the assessment. If the client will allow a significant other to be there can serve as a supporting function in identifying motivating statements outside of the session can assist in development and implementation of the plan. So you may ask the significant other, what things have you seen that seem to help Jim Bob when he starts feeling really depressed? Or what are the early warning signs that you notice that indicate that Jim Bob is getting ready to have a major depressive episode? So significant others can be very very helpful in the session. It's just important to set ground rules at the beginning of the session that the significant other is not judgmental, does not argue, does not roll their eyes that they are there to be supportive and encourage the person to explore questions for the significant other. Now during the feedback process is when we ask some of these questions and it can be very difficult for the client. What has it been like for you while John has been drinking every night? Or what has it been like for you when John has his major depressive episodes? What have you noticed about John's using or their condition over the past six months? What has discouraged you from trying to help in the past? What is encouraging right now and what do you like most about John? The person when they are not using or in the midst of a flare up of their condition. Emphasis is placed on the positive attempts to deal with the problem. Negative experiences, science, stress, family disorganization, etc. Are reframed as normal. In families with addiction or mental illness, it's important to remember that there's a danger of overwhelming or alienating people. If the counselor and significant other both present negative feedback, the person can feel ganged up on. After the session, provide a follow up note that includes a joining message like it was wonderful meeting you and your wife today. An affirmation of the person and the significant other about how much courage it took and how much energy that you see that they're willing to devote a reflection of the seriousness of the problem A brief summary of the highlights of the first session, especially self motivational statements that the people made a statement of optimism and hope that you believe that change and recovery is possible for them and a reminder of their next session. Follow through strategies Review progress and problems when they attend their six week follow up, renew motivation by reviewing and updating their decisional balance activity. So go over that chart again and ask if any of the concerns about change, for example, have gone away or moved over to a different category. Redo commitment by reinforcing self efficacy identifying what things that they've been able to change and control and improve in their situation and how that fits in and has impacted all of the other things in their life that they're committed to. You know, how is this one positive change? Had ripple positive change effects termination and this is usually after week 12. Review, summarize, affirm and reinforce the commitments and changes that have been made. Explore additional areas for change. Elicit self motivational statements from maintenance. Why do you want to keep doing this? Support self efficacy, emphasizing that the person's ability to change you've got this. You have the ability. Sometimes you may just need a little bit more input from people who have other tools that might be useful and deal with any special problems that have arisen. If the client misses appointments, try to get in touch with them. Assuming you can clarify the reasons for the missed appointment, express appreciation for them coming to the first appointment and your eagerness to see them again. Briefly mention your concern for the person based on the severity of the issues that you discussed. Express your optimism about the prospects for change and reschedule the appointment. If you can't get them on the phone, you may have to send this to them in a letter. Just make sure that you're observing all the HIPAA regulations. If the person is dissatisfied with treatment Affirm their expression of concern. If they say it didn't work or I'm not happy with this or I can't do this. All right, validate and affirm. Explore their reasons for concern. What exactly was it that didn't sit well with you? Help me understand that so I can provide direction and then offer alternatives and place the responsibility for change back on the person. Maybe this strategy didn't work for you. I. Or maybe we just didn't connect well, you know, and this could even result in referring out to a different therapist or a different type of therapy. Motivational enhancement therapy can be effectively used with any person who is medically and psychologically stable. The focus is on eliciting self motivational statements, exploring ambivalence, empowering the person to make positive changes, enlisting the support of significant others, and encouraging continued progress. One of the really cool things about met though, is that it can be done in three, four, six sessions and the spacing between sessions is often further than, you know, what you would normally do. It's not going to be an every week sort of thing, which puts the responsibility and the onus for change on the person and helps them develop a sense of self efficacy because they're not feeling like they've got to come in and check in with you every single week to see if they're doing it right. But you do provide resources for them between sessions, so if they feel like they need assistance, they know where they can get support. That was a brief summary of Motivational Enhancement therapy. If that is something that sounds like an interesting tool, I encourage you to explore it further.