MOTIVATIONAL ENHANCEMENT THERAPY

Presented By Dr. Sheba Singh VIMHANS

Identifying Information

Name Age Sex Educational Qualification Occupation Marital Status SES

: Mr. A (Ankit) : 29 years : Male : 12th std : Unemployed : single : MSES

Informants
Self, Mother, Elder brother. The information is adequate and reliable

Presenting Complaints

Excessive use of alcohol and cigarette Anger Low mood Lack of interest in doing anything Death wishes Decreased sleep Poor self care From the last 8 years Slashed his arms and forehead with a blade .a week ago

Onset - Insidious Course continuous Duration 8 years

HISTORY OF PRESENT ILLNESS

The patient was apparently well till the year 2003 when he started indulging in excessive alcohol use, excessive smoking and gambling. Patients mother and elder brother reported that he got into bad company when he was studying in 10th class and that is when he started drinking, smoking and gambling. The patient himself reported that his use of alcohol increased gradually; initially he used to drink around 60ml to 120ml of whiskey a day with his friends, it increased to 240ml-300ml per day within two years, presently he consumes around 500ml-750ml of alcohol everyday (He consumes 300ml-400ml of alcohol when he is out with his friends within 2-3 hours and later in the evening drinks 100-250ml of whiskey alone at home).

The patient also reported that he started smoking when he was in 10th standard. Some friends had asked him to try a cigarette; he gradually started liking it. In the beginning he used to smoke 1 cigarette a day then increased it to 2-3 within some days, then to 78 per day and presently he smokes around 2030 cigarettes per day. The client also reports that he increased the amount of intake of alcohol and number of cigarettes in a day because he felt that he was not getting the high which he used to, with the same amount.

The patient while talking about his bad habits told that increase in his alcohol intake and cigarette smoking happened when the girl he liked in school got married around 8 years back.. He also reported that although this was his one- sided affair, he felt very sad and lonely and started taking excessive alcohol to forget about the whole thing. He, however, said that he has forgotten the girl now. According to him, a reason for his increased intake of alcohol presently, is to induce sleep when he suffers from restlessness and sleeplessness at night. The patient reported that twice in the last 8 years, he also tried to induce sleep by slashing his forehead and arms with a blade (he believes that by doing so he can relax his nerves) but when he did not succeed in that he indulged in consumption of alcohol again. These episodes of slashing his forehead and arms have happened twice in last 2 years i.e. first episode happened one and a half years ago and the second a week back from when the patient reported at VIMHANS.

The patient reported that his friends had pushed him to gambling also but for the last 2 years he has stopped doing it. He stopped gambling because he was in debt. He had started borrowing money from his friends for gambling. The patients brother reported that earlier the patient used to spend his pocket money for gambling and alcohol, used to take money from his father for one reason or the other and even then if he wanted more money he used to borrow from his friends. The brother further reported that gradually the amount borrowed by him reached in lacs and it had to be paid back by him as his father is not alive( he died 3 years back). The brother reported that he has a family to support and it is very difficult for him to pay back his brothers debts.

The mother of the patient reported that to save him from bad company and to refrain him from his bad habits she tried sending the patient to their relatives place, out of their home town, for work. She tried this thrice in the last 4 years but every time he returns back home after 3-4 months. The patient and his mother reported that the relatives with whom he would stay used to complain about his excessive drinking and used to send him back home. The brother also told that they tried starting a business for him and made him sit at the shop but they found that he was not interested in working there and had again started borrowing money from people for gambling and drinking.

The brother of the patient reported that sometimes the patient also feels that he should get rid of his bad habits and he tries and stops drinking and cigarette smoking for even four month but is unable to resist his temptations and again gets into these bad habits. The patient himself reported that in the last 8 years he attempted many times to abstain from drinking and smoking but is unable to refrain from them for long. According to him he wants to quit these things because he wants to get into some business, get married and settle in life. He says, When I leave drinking I feel like having it again after a few days but with a promise to myself (which I am never able to keep) that I will have only 2 pegs or 120ml of whiskey. On being asked about what happens to him during the time when he is not consuming alcohol any does he again turns to alcohol he reported raat mein neend nahin aati, hath kanpte rehte hain, sar mien dard hota hai. On being further probed he said, bure-bure sapne aate hain aur palken jhapakti rahti hain.

According to the patients mother and brother he keeps low mood and is lethargic which could be seen in his behaviors like not talking to anybody and keeping himself in his room. The mother reported that the patient is lethargic to such an extent that he does not come out from his room till 2 in the afternoon and doesnt take bath for many days which vary from 3 15 days. She said that she keeps on telling him to get up and take bath but he doesnt listen to him. When asked about why he behaves in this manner the patient replied, kuch karne ka ya kahin bahar jane ka man nahin karta. Kya karoon bahar ja kar, phir vohi dost mil jayenge aur mein unse milna nahin chahta ghar par bhi kissi se baat karne ka man nahin karta.

The brother reported that the patient also has anger outbursts sometimes between the episodes of drinking heavily. These anger outbursts are manifested in the form of banging his head on the table or breaking glasses. In one of his fits of anger he even broke the television. On being asked about this behavior he replied, Mujhe bahut bura lagta hai, meri buri adaton ki vajah se meri mummy aur bhai bahut pareshaan rehte hain. Meri vajah se hi papa bhi pareshaaan rehte the. Inhin baton se gussa aa jata hai aur mein aisi harkaten karne lagta hoon. Kabhi kabhi lagta hai jeevan mein kuch nahin rakha hai, mujhe mar jana chahiye .

The patient came to VIMHANS with his mother and brother and told the therapist that he wants to get rid of his problems and wants to get well.

Negative History

No h/o head injury or fever No h/o of patient complaining that his own thoughts are being spoken aloud, thought being accessible to others, or thoughts being inserted in her mind No h/o suggestive of voices, running commentary on patients behavior or discussing patient among themselves. No h/o showing odd body postures No h/o suggestive of any false fixed unshakeable belief No h/o pervasive anxiety, excessive irrational fear No h/o repetitive washing, checking, recurrent mental image, form of ideas or impulses to act

Family History

The patient is the youngest child in the order of birth. Presently he is staying with his mother and elder brother who is married and has 3 daughters. He is a businessman. The patients father expired 3 years back due to kidney failure. The patient has guilt that his father died worrying about him. According to the mother of the patient, their home atmosphere is not healthy as her daughter-in-law indulges in very abusive language and frequent fights with her and the patient. The fights are mostly regarding the bad behavior and habits of the client.

Personal History

Birth and Early Development FTND No history of pre or post natal complications was reported. All developmental milestones were reported to be achieved on time. School History At school the patient was a good student till 10th std. He used to mingle with other classmates and his teachers appreciated him. But his academic performance deteriorated so much after he gradually increased his intake of alcohol and cigarette that he could not study after his 12th std.

Premorbid History

Premorbidly Mr. A was a person who trusted others. He was a very social person and had a group of friends with whom he used to mingle. He used to feel responsible towards his studies. He was a good student and was the monitor of the class. He had friends in his class with whom he maintained good relationship. He used to have girl friends also, one of whom he liked very much and wanted to marry later. He maintained a good rapport with the teachers and his teachers also appreciated him for his hard work and good academic results. He used to feel good on his achievements and used to have a feeling of improving on his failures. He used to be quite worried about body building. Even now one of the reasons behind leaving all the bad habits is that he wants his body to be fit. He is also a very emotional person. He used care a lot for the girl in her class whom he liked very much and wanted to marry despite knowing that she does not care for him. He also used to care for his mother and used to support her emotionally whenever she was tense or worried. As for his leisure activities he used to enjoy watching movies and hanging around with friends.

Mental Status Examination

General Appearance Mr. A was shabbily dressed in a t-shirt and trouser when he came for interview. Most of the time he was looking down and blinking his eyes while talking. Rapport could be established and he told about his problem elaborately. Reaction time Normal Psychomotor activity Normal Speech The patients speech was normal in tone, tempo and volume

Affect Subjective Abhi mein theek hoon par mujhe apni kharab aadaten chodni hain Objective Depressed Range Normal Congruity Mood congruent Communicability communicable Lability Reactivity

Thought Stream Normal Form No FTD could be elicited Possession Thought Content - Bura lagta hai, meri buri adaton ki vajah se meri mummy aur bhai bahut pareshaan rehte hain. Meri vajah se hi papa bhi pareshaaan rehte the. Inhin baton se gussa aa jata hai aur mein aisi harkaten karne lagta hoon. Kabhi kabhi lagta hai jeevan mein kuch nahin rakha hai main marna chahta hoon. (Hopelessness)

Cognitive Status Orientation The patient was oriented towards time, place and person. Attention and Concentration Adequate, Memory His immediate memory is intact as she scored 6 on Digit span test (forward) and scored 4 on DST (backward). His recent and remote memory is intact. Intelligence _ Adequate, as he was able to answer simple general knowledge questions. Abstraction Intact, as he was able to tell the differences and similarities and the meanings of the proverbs which were asked. Judgment His social judgment is impaired as he is not active socially, does not go out or meet people. His personal and test judgments are intact. Insight- III

Diagnostic Impression Substance dependence, Depression with cluster B traits.

MOTIVATIONAL ENHANCEMENT THERAPY (MET)

Motivational Enhancement Therapy (MET) is a systematic intervention approach which evokes change. employs motivational strategies to mobilize the clients own change resources.

FEATURES OF MET (Miller & Rollnick, 1995)

Motivation to change is elicited from the counselee It is brief in duration Direct persuasion is avoided Readiness to change is seen as fluctuating The counseling relationship is like a partnership than expert/recipient roles.

STAGES OF CHANGE

Prochaska & Diclemente (1982,1984,1985,1986) have described a transtheoretical model of how people change addictive behavior. In a transtheoretical perspective, individuals move through a series of stages of change as they progress in modifying problem behaviors.

STAGES OF CHANGE

Precontemplation: not yet considering it Contemplation: beginning to consider the consequences of a problem and reasons for changing the behavior Determination: decision made to change Action: implements methods for change Maintenance: practice, practice, practice Relapse: important to begin cycle again

STAGES OF CHANGE

Maintenance

Pre-contemplation

Action

Contemplation

Determination to stop

PRINCIPLES OF MET
1.

Express Empathy Understand the client and his concerns Respect his choice and selfdirection Acceptance and support leads to change

PRINCIPLES OF MET (cont.)

2. Things to avoid
Being

judgmental Ordering or commanding Warning or threatening Giving advice or providing solution

PRINCIPLES OF MET (cont.)

Arguing

or persuading Moralizing Disagreeing or criticizing Ridiculing Interpreting or analyzing Reassuring or sympathizing

PRINCIPLES OF MET (cont.)

3. Open Ended Questions - These encourage further elaboration. For example: Ask How has your drinking changed over time? Instead of Has your drinking changed over time?

PRINCIPLES OF MET (cont.)

4.

Reflective Listening In reflective listening the therapist

Shows her client that she is really listening to him Checks by reflecting whether she has understood what the client is saying

PRINCIPLES OF MET (cont.)

Gives

feedback on the clients statements making him realize his own reasons for change
feedback which is in the form of statements rather than questions

Gives

PRINCIPLES OF MET (cont.)

Reflective listening examples: C: I worry sometimes that I may be drinking too much for my own good. T: You have been drinking quite a bit. OR C: I dont really feel like its that much. I can drink a lot and not feel it. T: More than most people.

PRINCIPLES OF MET (cont.)

5. Resistance It is reflected during sessions as Arguing Interrupting Denying Ignoring

PRINCIPLES OF MET (cont.)

There are a number of reasons for resistance e.g. the client is pushed into treatment by relatives, or he doesn't believe in her ability to change etc.

PRINCIPLES OF MET (cont.)

Rolling with resistance (Miller and Rollnick,1991)

Non-confrontational

method for dealing with resistant clients. Ambivalence is explored openly Involves reflective listening techniques

PRINCIPLES OF MET (cont.)

For example following statement of the client can be responded by the therapist in a number of ways, listed as under:

I dont see why my drinking is such a problem. All my friends drink as much as I do.

PRINCIPLES OF MET (cont.)

Simple Reflection Acknowledge the client's resistance by reflecting: You cannot see how your drinking can be a problem when your friends don't seem to have any problem.

PRINCIPLES OF MET (cont.)

Amplified Reflection Exaggerate the statement without being sarcastic.

If your friends have no problem with their drinking then there is nothing for you to worry about.

PRINCIPLES OF MET (cont.)

Double-sided Reflection Try to show the client both sides of his ambivalence.

I can see how this must be confusing for you. On the one hand you have come in because you are concerned about drinking and how it affects you, and on the other hand, it seems like you are not drinking any more than your friends do.

PRINCIPLES OF MET (cont.)

6.

Reframing It is a way of acknowledging what the client has said and, at the same time, drawing his attention to a different meaning or interpretation that is likely to support. Reframing the clients explanation of tolerance is also important.

PRINCIPLES OF MET (cont.)

Summarizing

It helps in accumulating the points made by the client and also showing him that the therapist was listening to him. Summaries can be used to:

PRINCIPLES OF MET (cont.)

highlight

the point where the client seemed blocked make the client go through his own stated reasons for change show the client his ambivalence by linking the good and less good things close a discussion.

PRINCIPLES OF MET (cont.)

For example: On the one hand you have said that you like drinking because it takes you in the fantasy world while on the other hand, you are loosing your job because of this. So it sounds like you are torn two ways.

MOTIVATIONAL STRATEGIES
1. EXPLORING THE GOOD THINGS AND THE LESS GOOD THINGS This strategy aims to let the client explore his thoughts and feelings about his drinking. The four key aspects of this strategy are:

MOTIVATIONAL STRATEGIES (cont.)

The good things Begin with the good things as it helps in building a rapport with the client. For example:

What are some of the good things about your drinking? OR What do you like about drinking?

MOTIVATIONAL STRATEGIES (cont.)

The less good things Avoid using phrases like bad things or problems. A phrase like less good things would help in encouraging an open discussion with the client. Begin with open-ended question like:

What are some of the less good things about your drinking? OR What are the things you dont like so much about your use of drinking?

MOTIVATIONAL STRATEGIES (cont.)

After exploring the less good things probe how they are affecting him, like: How does this affect you? OR What dont you like about it?

The therapist can further ask him to give her an example.

MOTIVATIONAL STRATEGIES (cont.)

Exploring

concerns Focus on the less good aspects which are of concern to the client. For example:

How do you feel about that? OR Is that a problem or concern for you in any way?

MOTIVATIONAL STRATEGIES (cont.)

Summarizing Summarize the clients good things and less good things in his own words. The aim is to make the client realize that his concerns and worries outweigh the good things about continuing to use alcohol.

MOTIVATIONAL STRATEGIES (cont.)

2. LIFE SATISFACTION Ask the client about his past hopes and future aspirations. This can often create an uncomfortable discrepancy for the client which is actually a powerful motivating force for change.

MOTIVATIONAL STRATEGIES (cont.)

Looking Back Ask questions like: When you were (18 or 16) what sorts of things did you think that you would be doing now?

How does that differ from what is happening now? How do you feel about that?

MOTIVATIONAL STRATEGIES (cont.)

Looking forward Similarly, with regard to the future: How would you like things to be different in the future?

What stopping you doing what you would like to?

MOTIVATIONAL STRATEGIES (cont.)

3. Self vs. User This approach allows the client to consider the discrepancy between himself as a person versus himself as a substance user. Following questions might be asked:

MOTIVATIONAL STRATEGIES (cont.)

Tell me..how would you describe the things you like about yourself? Summarize and then ask: And how would you describe yourself as a drinker? Summarize and then ask: How would these things fit together?

MOTIVATIONAL STRATEGIES (cont.)

4. Helping with decision making After the client feels the need for change, the next step is to take decision regarding it. Miller & Rollnick(1991) have suggested the following signs which show that the client is ready for this stage:

MOTIVATIONAL STRATEGIES (cont.)

decreased resistance fewer questions about the problem more questions about change talking about how life would be after a change

MOTIVATIONAL STRATEGIES (cont.)

This stage includes reviewing: clients own perception of the problem what still remains attractive about the problem for him restating the clients comments about intending to change stating your own assessment of the situation.

MOTIVATIONAL STRATEGIES (cont.)

After this summary, which brings together many reasons for change, following questions are asked: where does this leave you now? what does this mean about your drinking?

Dont take over from here, or push hard for action.

Providing Information for PreContemplators

Providing information about the drug useful for clients who are not concerned about their drug or alcohol use. It can help to provoke thinking about change to correct misconceptions about risks associated with use

In the beginning the client is asked, what he knows about the risks associated with their substance use. It may acquaint the therapist with the clients knowledge of the hazards related to the substance any misinformation about the substance

This may be asked in the following manner: Would you be interested in knowing more about the effects of alcohol on the body?

These questions are asked to Increase the clients perception of the risks and problems associated with his drug/alcohol use

After providing the information the therapist may ask the client: I wonder how is it relevant for you?