Motivational Enhancement

Therapy
Kristiana Siste
Divisi Psikiatri Adiksi
FKUI/RSCM

Definition
Motivational Enhancement Therapy (MET)

adalah intervensi yang bersifat sistematik

untuk melakukan perubahan
Didisain untuk membuat proses lebih cepat,
dan perubahan dari internal
Strategi dari terapi ini bukan mencoba untuk
menuntun dan mengarahkan pasien sampai
kemudian pulih namun membangun motivasi
agar klien dapat menggunakan
kemampuannya untuk berubah
Pasien mengubah dirinya sendiri.

 Terapi didahului dengan evaluasi yang intensif selama

berlangsung 7-8 jam.

MET terdiri dari 4 tahap :
Minggu 1 fokus pada (eksplorasi masalah)
(1) melakukan evaluasi terkait masalah (keparahan, gejala
yang ada, rencana selanjutnya)
(2) Mengembangkan motivasi klien untuk memulai atau
melanjutkan perubahan
Minggu 2 fokus pada proses mengembangkan motivasi,
menuju komitmen
Pada minggu 6 dan 12, terapis melakukan monitoring
dan memperkuat progress.
Terapi selesai dalam waktu 90 hari.
Sekali seminggu, tidak lebih dari 2 jam (sudah tidak
efektif).

Stages of change

Motivational Support:
Precontemplation
Klien belum mau berubah
Klien mungkin tidak bersedia atau merasa

tidak mampu berubah

Klien butuh untuk ditingkatkan
kesadarannya sebelum ia menyadari
bahwa ia perlu berubah

Motivational Conflict:
Contemplation
Ambivalensi: berubah atau tidak berubah
Example: I know Id feel better if I quit

smoking marijuana, but Ill lose a bunch of

friends if I do and I wont have fun anymore.
Example: I feel good about setting a quit
date, but Im not sure I have the guts to
follow through with it.
Klien menyadari ada alasan untuk berubah
Klien sudah membuka pintu untuk berubah

Motivational Support Needed:

Contemplation
Bantu klien untuk mengakhiri

ambivalensinya dan memilih untuk berubah

Bantu klien dengan timbangan pro dan
kontra
Bantu klien untuk membangun rasa
percaya diri untuk berubah

Motivational Conflict:
Preparation
Clients may be fully ready to change but be

unsure of the best way to go about it

Where do I go?
What do I do?
How do I find resources to help?

Motivational Support Needed:

Preparation
Bantu klien mengidentifikasi strategi

perubahan dan pilih yang sesuai dengan

keadaannya (harus detil, rinci)
Bantu untuk membuat perencanaan untuk
berubah dan mengevaluasi kemampuan
untuk berubah (sesuai dengan terms
pasien)
Evaluasi ketrampilan pasien (kalau
mengalami kemajuan, jangan lupa untuk
diapresiasi)

Motivational Conflict:
Action
A client may be doing all the right things

but still sometimes feel a strong desire to

use substances
Example: Staying off cocaine for the past 3

weeks really makes me feel good, but part of

me wants to celebrate by getting high.
Motivation will naturally wax and wane over

time
For example: Is all this really worth it?

Client is actively taking steps to change

Motivational Support Needed:

Action
Bantu klien untuk memilih strategi untuk

berubah
Bantu klien menjalani strategi tersebut dan
bantu ia untuk mempelajari bagaimana
mencegah relaps
Normalisasi ambivalensi
Afirmasi untuk keberhasilan

Motivational Conflict:
Maintenance / Rumatan
Clients in maintenance need to make a lot

of hard decisions about lifestyle

Example: I know I cant play football with

my old using buddies anymore, but I really

miss it.
Example: I just cant be around my brother
when hes high, but its really hard to say no
to him.

Motivational Support Needed:

Maintenance
Bantu klien mengembangkan ketrampilan

baru, bersosialisasi dan beraktivitas untuk

memperkuat pemulihan
Bantu dan dukung klien dalam
mempertahankan koping (skills/ketrampilan:
say no, kalo temen kamu ngajak merokok.
Adain roleplay. Misal:bilang, bentar ya ke
belakang dulu, terus kabur. Bisa juga bilang,
maaf, lagi puasa or something. Kasih real
skills yang langsung aplikatif.) yang baik dan
mengembangkan tujuan hidup

Motivational Conflict:
Relapse
Motivational conflicts may

vary
Relapse leads to regression to
an earlier stage of change
Clients may typically wonder:
Do I want to try again or

not?
Am I capable of maintaining
recovery?

Motivational Support Needed:

Relapse
Bantu untuk segera pulih
Bantu untuk meningkatkan rasa

percaya diri untuk bisa berubah

Bantu untuk menjalani proses
pemulihan
Recovery is not a straight, predictable

path!

Kontemplasi merupakan fase yang paling

kritis.
Bantu klien dalam 2 isu dibawah ini:
1.Seberapa besar masalah ketergantungan

itu menurut klien

2.Bagaimana masalah tersebut
mempengaruhi klien (positif dan negatif)

UJIAN KYK GINI NIH

Basic principles
Express empathy: hindari komunikasi yang

menggambarkan superior/inferior, harus suportif,

jangan agresif dan reflective listening (mendngarkan
dengan sesekali merespon, bisa dengan anggukan
atau berkata sesuatu).
Develop discrepancy: bantu klien melihat
kesenjangan saat ini klien berada dimana dengan
apa yang klien inginkan (misalnya pasien ingin kuliah
tepat waktu, tapi pasien selalu bolos. Ada kesenjangan
antara keinginan dengan apa yang dikerjakannya).
Avoid argumentation: sikap agresif kita yang
menyerang masalah klien dapat membuat mereka
resisten.

Roll with resistance: Pasien pasif-agresif

(setuju dengan saran, tapi tidak

dilakukan)Ambivalensi adalah normal dan
harus dieksplorasi secara terbuka. Solusi harus
berasal dari klien. Tapi misalnya pasien selalu
bilang gabisa2, evaluasi lagi motivasinya.
Jangan2 masih prekontemplasi.
Support self-efficacy : Self-efficacy adalah
kepercayaan diri klien bahwa ia dapat
melakukan tugas tertentu. Contoh supporting
efficacy pasien misalnya dengan pujian /
flattery/ appreciation.

Practical strategies
Phase 1: Building motivation for change
Phase 2: Strengthening commitment to

change
Phase 3: Follow-through strategy
(maintenance).

Phase 1: Building motivation for

change
Elaborasi pernyataan yang memotivasi
Pernyataan:
Masalah terkait dengan penggunaan Napza
Ekspresi kebutuhan, keinginan atau kesediaan

untuk berubah
Contoh:
Tell me a little about your addiction. What do you

like about it? Whats positive about drugs for you?

And whats the other side? What are your worries
about them?
What have other people told you about your
addiction? What are other people worried about?
What makes you think that perhaps you need to
make a change in your addiction?

 Gunakan reflective listening, dengan menanyakan

contoh atau by What else?,

Apabila pembicaraan sudah buntu maka kaitkan
dengan masalah relasi, hukum, finansial, kesehatan
Apabila terapis mengalami kesulitan dalam
menimbulkan perhatian dari klien maka dapat
digunakan strategi berikut: (paradox)
This program is one that requires a fair amount of

motivation from people, and frankly, Im not sure from

what youve told me so far that youre motivated enough
to carry through with it. Do you think we should go
ahead?
Im not sure how much you are interested in changing, or
even in taking a careful look at your addiction. It sounds
like you might be happier just going on as before.

 Mendengarkan dengan empatik

Berikan pertanyaan
Berikan umpan balik personal
Afirmasi
Menangani resistensi :
Simple reflection
Reflection with amplification
Double-sided reflection.
Shifting focus

Reframing adalah strategi dimana terapis

mengundang klien untuk melihat persepsinya

dalam bentuk yang berbeda dan lebih terorganisir.
Makna baru dapat diberikan pada saat reframing ini
.

Drinking as a protective function. You dont want to

impose additional stress on your family by openly

sharing concerns or difficulties in your life [give
examples]. As a result, you carry all this yourself and
absorb tension and stress by drinking, as a way of
trying not to burden your family. The implication here
is that the problem drinker has inner strength or
reserve, is concerned about the family, and could
discover other ways to deal with these issues besides
drinking.

Summarizing: berguna untuk mengulang

dan menyimpulkan pernyataan yang

bersifat motivational dari klien.

Phase 2: Strengthening
Commitment To Change
Kenali kesiapan klien untuk berubah
Klien berhenti untuk menolak
Klien mulai sedikit bertanya
Klien mulai tenang
Klien mulai membuat penyataan yang

bersifat motivational untuk berubah (I guess

I need to do something about my drinking
If I wanted to change my drinking, what
could I do?).
Klien mulai berimajinasi bagaimana hidupnya
setelah ada perubahan

Mendiskusikan rencana: berubah dari

membangun motivasi menuju negosiasi

rencana untuk berubah
What do you make of all this? What are you

thinking youll do about it?

I wonder what youre thinking about your drinking
at this point.
Now that youre this far, I wonder what you might
do about these concerns.
Komunikasikan pilihan
Its up to you what you do about this.
No one can decide this for you.

Konsekuensi dari aksi dan tidak aksi

Infomasi dan nasehat:

Do alcohol problems run in families?
How does drinking damage the brain?
Whats a safe level of drinking?
If I quit drinking, will these problems

improve?
Could my sleep problems be due to my
drinking?

Perkuat abstinensia
Bekerja dengan resistensi: refleksi atau

reframing
Buat worksheet
Buat rencana aksi secara spesifik

Minta klien untuk berkomitmen

Libatkan orang terdekat (Significant Other)

Phase 3: Follow through

Strategies
Reviewing Progress

Diskusikan rencana yang sudah dibuat dan

hal-hal yang sudah dilakukan

Renewing Motivation
Tanyakan pada klien hal terpenting apa yang

menjadi alasan baginya untuk berubah

Redoing Commitment
Tingkatkan rasa percaya diri klien

Types of Change Talk

DARN-C
Desire
Ability
Reasons
Need
Commitment

Source: Amrhein, P. C., Miller, W. R., Yahne, C. E., Palmer, M., & Fulcher, L. (2003). Client
commitment language during motivational interviewing predicts drug use outcomes. Journal of
Consulting & Clinical Psychology. 71(5), 862878.

DARN-C: Desire
Statements clients make about preference

for change:
I would like to
I wish
I really want to

DARN-C: Ability
Statements clients make about self-

efficacy:
I think I could
I can
I am able to

DARN-C: Reasons
Statements clients make that are specific

reasons, or arguments for change:

I know I would feel better if I
I would get along better with my husband if

I
I would worry less about _______ if I

DARN-C: Need
Statements clients make about feeling an

obligation to change:
I should
I really need to
I have to

DARN-C: Commitment
Two levels of commitment statements:
Intention or low-level commitment

statements
High-level commitment statements

DARN-C: Commitment
(continued)
Intention or low-level commitment

statements:
I hope to
I plan to
I will try to.

DARN-C: Commitment
(continued)
High-level commitment statements:
I will
I am going to
I promised my husband I would...

Ways of Evoking Change

Talk
1. Gunakan pertanyaan terbuka : What
would you like your life to be like 5 years
from now?
2. Lakukan elaborasi : How would that
look? or Say more about that.
3. Tanyakan contoh: How might you do
that? or Can you give me some
examples?

Source: Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to
change addictive behavior. New York: Guilford Press.

Ways of Evoking Change Talk

(continued)
4. Tanyakan masa lalu: When in the past
have you made a successful change?
5. Tanyakan ke depannya: How will you
know whether you are successful with this
change?
6. Tanyakan hal yang ekstrim: What would
be the best result you could imagine if you
made a change?

Ways of Evoking Change Talk

(continued)
7. Gunakan readiness ruler: What would it
take to go from a 4 to an 8?
8. Pertimbangkan pros and cons (decisional
balance): What do you like about what is
happening in your life now?
9. Eksplorasi tujuan dan nilai : Tell me what
is most important to you in life.
10. Berada pada pihak klien : Perhaps your
drug use is too important for you to give
up.

Responding to Change Talk:

EARS
Explore
Affirm
Reflect
Summarize

Responding to Change Talk:

Explore
Tanyakan pertanyaan yang menuntun:
Tell me more about how you see that.
What else?
What do you think would happen if _____?
Can you give me some examples?

Biarkan klien dapat mengekspresikan

pikiran positif untuk berubah

Responding to Change Talk:

Affirm
Express agreement, appreciation, or

encouragement and reinforce change talk in

any way:
I think its great that
Wowyouve come a long way
I think you could really make that work
Thats a very insightful statement

Responding to Change Talk:

Reflect
Refleksi terhadap pernyataan positif

tentang perubahan dapat membuat klien

mendengar pernyataan itu dari perspektif
yang berbeda

Responding to Change Talk:

Summarize
Create bouquet summaries that pull

together incidents of change talk

Readiness Ruler
Developed by Stephen Rollnick
Multi-purpose tool

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people

to change addictive behavior. New York: Guilford Press.

Using the Ruler: Be

Specific!
On a scale of 1 to 10, where 1 is not at all

ready and 10 is very ready, how ready are

you to start talking about abstinence?
NOT
How ready do you feel to change?

Using the Ruler: Ask for

Elaboration
Tell me why you chose that number.
Im curious; why did you rate your

readiness at 6 rather than at 5 or 7?

Wowyou rated your readiness at 9! Tell
me more about why you think youre so
ready for this change.

Using the Ruler: Look Toward the

Future

What could happen that would move you

to a higher number?
What do you think it would take for you to
feel more ready for this change?

Using the Ruler: Tailor

Intervention
Not ready (0 to 3): Express concern, offer

information, provide support, follow up

Unsure (4 to 7): Explore positive and
negative aspects of making the change
Ready (8 to 10): Help plan action, identify
resources, convey hope

Using the Ruler: Track Readiness Over

Time
Last month you rated your readiness for

this change at 4. Today you rated it 9.

Whats helped change your thinking?
Last month you rated your readiness for
this change at 8. Today you rated it 5.
Whats happened to decrease your
readiness?

Using the Ruler: Tracking

Importance or Confidence
Importance: On a scale of 1 to 10 how

important is it that you make this change?

Confidence: On a scale of 1 to 10 how
confident are you that you can make this
change?

Using the Ruler To Assess

Importance or Confidence
Be specific:
How important to you is your relationship

with your husband? NOT how important

to you are relationships?
How confident do you feel about saying no
to offers of cocaine? NOT How confident are
you that you can maintain abstinence over
the long term?

Thank You