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
• Terapi didahului dengan evaluasi
yang intensif selama berlangsung 7-8
jam.
• MET terdiri dari 4 tahap :
• Minggu 1 fokus pada
(1) melakukan evaluasi terkait masalah
adiksi (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.
Stages of change
Motivational Support: Motivational Support Needed:
Precontemplation Contemplation
• Klien belum mau berubah • Bantu klien untuk mengakhiri
• Klien mungkin tidak bersedia atau ambivalensinya dan memilih untuk
merasa tidak mampu berubah
berubah
• Klien butuh untuk ditingkatkan
kesadarannya sebelum ia menyadari • Bantu klien dengan “timbangan pro
bahwa ia perlu berubah dan kontra”
• Bantu klien untuk membangun rasa
percaya diri untuk berubah
Motivational Conflict:
Contemplation
• Ambivalensi: berubah atau tidak
berubah
– Example: “I know I’d feel better if I
quit smoking marijuana, but I’ll lose
a bunch of friends if I do and I won’t Motivational Conflict: Preparation
have fun anymore.”
– Example: “I feel good about setting a  Clients may be fully ready to change
quit date, but I’m not sure I have the but be unsure of the best way to go
guts to follow through with it.”
about it
• Klien menyadari ada alasan untuk
berubah  Where do I go?
• Klien sudah membuka pintu untuk  What do I do?
berubah  How do I find resources to help?
Motivational Support Needed:
Preparation
• Bantu klien mengidentifikasi strategi
perubahan dan pilih yang sesuai dengan
keadaannya
• Bantu untuk membuat perencanaan
untuk berubah dan mengevaluasi
kemampuan untuk berubah
• Evaluasi ketrampilan pasien
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
• Bntu klien menjalani strategi tersebut
dan bantu ia untuk mempelajari
bagaimana mencegah relaps
• Normalisasi ambivalensi
• Afirmasi untuk keberhasilan
Motivational Conflict: Maintenance
• Clients in maintenance need to make
a lot of hard decisions about lifestyle
– Example: “I know I can’t play
football with my old using buddies
anymore, but I really miss it.”
– Example: “I just can’t be around my
brother when he’s high, but it’s
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 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)
 Basic principles
• Express empathy: hindari • Roll with resistance:
komunikasi yang Ambivalensi adalah normal
menggambarkan dan harus dieksplorasi secara
superior/inferior, harus terbuka. Solusi harus berasal
suportif, jangan agresif dan dari klien
reflective listening • Support self-efficacy : Self-
• Develop discrepancy: bantu efficacy adalah kepercayaan
klien melihat kesenjangan saat diri klien bahwa ia dapat
ini klien berada dimana melakukan tugas tertentu
dengan apa yang klien
inginkan
• Avoid argumentation: sikap
agresif kita yang menyerang
masalah klien dapat membuat
mereka  resisten
 Practical strategies
• Phase 1: Building motivation for change
• Phase 2: Strengthening commitment to
change
• Phase 3: Follow-through strategy
 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? What’s
positive about drugs for you? And
what’s 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, I’m not sure
from what you’ve told me so far that
you’re motivated enough to carry
through with it. Do you think we
should go ahead?
– I’m 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
• Drinking as a protective function. “You
• Menangani resistensi :
– Simple reflection
– Reflection with amplification
– Double-sided reflection.
– Shifting focus
• Summarizing: berguna untuk mengulang dan menyimpulkan pernyataan
yang bersifat motivational dari klien.
• 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 .
don’t 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.
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 you’ll do about it?
– I wonder what you’re thinking about
your drinking at this point.
– Now that you’re this far, I wonder
what you might do about these
concerns.
• Komunikasikan pilihan
– It’s 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?
– What’s 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), 862–
878.
DARN-C: Desire DARN-C: Reasons
• Statements clients make about • Statements clients make that are
preference for change: specific reasons, or arguments for
– I would like to…
change:
– I know I would feel better if I…
– I wish…
– I would get along better with my
– I really want to…
husband if I…
– I would worry less about _______ if
I…

DARN-C: Ability DARN-C: Need

• Statements clients make about self- • Statements clients make about
efficacy: feeling an obligation to change:
– I think I could… – I should…
– I can… – I really need to…
– I am able to… – I have to…
 DARN-C: Commitment
• Two levels of • Intention or low-level
commitment statements: commitment statements:
– Intention or low-level – I hope to…
commitment statements – I plan to…
– High-level commitment – I will try to….
statements
• 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?”
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?”
Source: Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive
behavior. New York: Guilford Press.
6. Tanyakan hal yang ekstrim: “What
would be the best result you could
imagine if you made a change?”
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: Responding to Change Talk:
Explore Reflect
• Tanyakan pertanyaan yang • Refleksi terhadap pernyataan positif
menuntun: tentang perubahan dapat membuat
– Tell me more about how you see klien mendengar pernyataan itu dari
that. perspektif yang berbeda
– What else?
– What do you think would happen if
_____?
– Can you give me some examples? Responding to Change Talk:
• Biarkan klien dapat mengekspresikan Summarize
pikiran positif untuk berubah
• Create “bouquet” summaries that
pull together incidents of change talk
Responding to Change Talk:
Affirm
• Express agreement, appreciation,
or encouragement and reinforce
change talk in any way:
– I think it’s great that…
– Wow—you’ve come a long way
– I think you could really make that
work
– That’s a very insightful statement
 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.”
• “I’m curious; why did you rate your
readiness at 6 rather than at 5 or 7?”
• “Wow—you rated your readiness at
9! Tell me more about why you think
you’re 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 Using the Ruler To Assess
Readiness Over Time Importance or Confidence
• “Last month you rated your • Be specific:
readiness for this change at 4. – “How important to you is your
Today you rated it 9. What’s relationship with your
helped change your thinking?” husband?” NOT “…how
• “Last month you rated your important to you are
relationships?”
readiness for this change at 8.
Today you rated it 5. What’s – “How confident do you feel
about saying ‘no’ to offers of
happened to decrease your cocaine?” NOT “How confident
readiness?” are you that you can maintain
abstinence over the long term?”
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?”