Motivational Enhancement Therapy: Description of Counseling Approach
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William R. Miller
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1. OVERVIEW, DESCRIPTION, AND RATIONALE
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1.1 General Description of Approach
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Motivational Enhancement Therapy (MET) seeks to evoke from clients their own
motivation for change and to consolidate a personal decision and plan for change.
The approach is largely client centered, although planned and directed.
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1.2 Goals and Objectives of Approach
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As applied to drug abuse, MET seeks to alter the harmful use of drugs. Because
each client sets his or her own goals, no absolute goal is imposed through MET,
although counselors may advise specific goals such as complete abstention. A broader
range of life goals may be explored as well.
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1.3 Theoretical Rationale/Mechanism
of Action
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MET is based on principles of cognitive and social psychology. The counselor
seeks to develop a discrepancy in the client's perceptions between current behavior
and significant personal goals. Consistent with Bem's self-perception theory,
emphasis is placed on eliciting from clients self-motivational statements of
desire for and commitment to change. The working assumption is that intrinsic
motivation is a necessary and often sufficient factor in instigating change.
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1.4 Agent of Change
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The client is the agent of change, with assistance from the counselor.
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1.5 Conception of Drug Abuse/Addiction,
Causative Factors
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Drug problems are viewed as behaviors under at least partial voluntary control
of the client, which are subject to normal principles of behavior change. Drugs
of abuse are assumed to offer inherent motivating properties to the drug abuser,
which by definition have overridden competing motivations. The task in MET is
to elicit and strengthen competing motivations.
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2. CONTRAST TO OTHER COUNSELING APPROACHES
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2.1 Most Similar Counseling Approaches
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MET bears many similarities to Rogerian client-centered counseling but is directive
rather than nondirective. There are also certain similarities to cognitive therapy
and reality therapy.
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2.2 Most Dissimilar Counseling
Approaches
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MET is strikingly dissimilar from counseling approaches designed to oppose
denial and break down defenses through direct confrontation. Furthermore, MET
differs from behavioral approaches in that no direct advice or skill training
is provided.
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3. FORMAT
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3.1 Modalities of Treatment
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MET is typically conducted as individual counseling, though family members
may also be present and engaged. Group MET is conceivable but untested.
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3.2 Ideal Treatment Setting
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MET has been tested and found effective in both outpatient and inpatient settings.
There is no necessary or ideal setting.
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3.3 Duration of Treatment
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MET is typically brief, limited to two to four sessions that each last 1 hour.
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3.4 Compatibility With Other
Treatments
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MET can be a suitable prelude to other treatment approaches designed to enhance
treatment response. It has been shown to increase client compliance in subsequent
alcoholism treatment and thereby to improve outcome.
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3.5 Role of Self-Help Programs
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MET does not formally involve any self-help group, although participation in
such groups may be part of a client's chosen change plan. MET is wholly compatible
with a 12-step approach.
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4. COUNSELOR CHARACTERISTICS AND TRAINING
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4.1 Educational Requirements
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MET has been effectively administered by prebachelor's-level university students
working as supervised paraprofessional counselors. Education level may not be
a critical determinant of effectiveness in using MET.
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4.2 Training, Credentials, and
Experience Required
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Specific training in MET is important. A skillful MET practitioner makes the
process look easy and natural, but in fact the component skills require substantial
practice and shaping.
Initial intensive training of 2 to 3 days with subsequent supervised experience
in MET is recommended. Training initially focuses on the rationale for MET and
the establishment of sound reflective listening skills without which other aspects
of MET cannot be implemented effectively. Once these skills are in place, training
proceeds to other strategies for enhancing motivation and strengthening commitment
to change. Counselors new to this approach are unlikely to implement it successfully,
based on a single workshop, without ongoing supervision.
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4.3 Counselor's Recovery Status
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The counselor's recovery status is largely irrelevant in MET. Some research
has found that counselors in early recovery tend to overidentify with clients
and have difficulty in separating their own issues and advice from the counseling
process. This would be a particular hindrance in MET.
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4.4 Ideal Personal Characteristics
of Counselor
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MET requires a high level of therapeutic empathy as defined by Carl Rogers
(as opposed to empathy in the sense of having had similar experiences). High
interpersonal warmth and congruence are also desirable. Counselors who cannot
suspend their own needs, perceptions, and advice are ill suited to MET.
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4.5 Counselor's Behaviors Prescribed
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Common counselor behaviors in MET include asking open-ended questions, reflective
listening, reframing, and supporting. A key strategy is developing discrepancy
by eliciting the client's own verbal expression of problems, concerns, reasons
for change, and optimism regarding change. Counselors are instructed to "roll
with" resistance rather than confronting it directly. Emphasis is also given
to supporting client self-efficacy, the perception that change is possible and
can be accomplished by the client. Assessment findings are often used as personal
feedback to instill client motivation.
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4.6 Counselor's Behaviors Proscribed
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Most important is for the counselor to avoid what is termed the confrontation/denial
trap, in which the counselor is placed in the position of defending the presence
of a problem and the need for change, while the client argues that there is
no problem or need for change. Argumentation is generally proscribed. The counselor
also avoids taking on an "expert" role, which implies that the counselor will
impart the solution to the client. Relatedly, counselors are encouraged to avoid
"closed" (short answer) questions and specifically to avoid asking three questions
in a row. Diagnostic labeling as problem drinker or alcoholic, for example,
is specifically avoided.
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4.7 Recommended Supervision
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Direct observation of sessions is vital to effective supervision with MET.
Counselors are least able to observe or convey the very behaviors they most
need to change. In advance of or during supervision, supervisors should review
videotape or audiotape of sessions. It is particularly helpful for the supervisor
and those supervised to use a structured observation sheet in following the
sessions, coding the content of counselor and client responses as a means of
attending to process rather than being caught up in content. Specific workshops
for trainers of motivational interviewing are offered periodically.
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5. CLIENT-COUNSELOR RELATIONSHIP
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5.1 What Is the Counselor's Role?
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The counselor's primary role is to elicit and consolidate the client's intrinsic
motivations for change. This facilitator role may include minor aspects as educator
and collaborator. The expert/adviser role is deemphasized. When personal assessment
feedback is provided as part of MET, the counselor temporarily assumes the role
of educator.
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5.2 Who Talks More?
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The client should do more than half of the talking, except during a period
of personal assessment feedback when the counselor has a substantial explanatory
role.
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5.3 How Directive Is the Counselor?
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MET sessions are client centered but directive. There is a specific objective
that the counselor pursues through systematic strategies. When MET is successfully
conducted, however, the client does not feel directed, coerced, or advised.
Direction is typically accomplished through open-ended questions and selective
reflection of client material rather than through more overtly confrontational
strategies and advice giving. To use a metaphor, the client and counselor are
working a jigsaw puzzle together. Rather than putting the pieces in place while
the client watches, the counselor helps to construct the frame, then puts pieces
on the table for the client to place.
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5.4 Therapeutic Alliance
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The rapid establishment of a working therapeutic alliance is an important aspect
of MET. The basic conditions of client-centered therapy provide a strong foundation,
with particular emphasis on the strategies of open-ended questions and reflective
listening. Such supportive and motivation-building strategies are employed until
resistance abates and the client shows indication of being ready to discuss
change.
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6. TARGET POPULATIONS
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6.1 Clients Best Suited for This Counseling
Approach
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Research to date has found MET to be effective with a broad range of severity
of alcohol problems. No unique markers of differential response have been identified.
Court-mandated clients appear to respond as favorably as those who are self-referred.
One study has shown MET to be differentially effective (relative to a behavioral
approach) with clients in the earliest stages of change (i.e., most unmotivated).
MET has been evaluated well with problem drinkers, but its results are less
studied with other drug problems. Two studies have reported positive results
with marijuana and heroin users. The basic therapeutic style would remain the
same regardless of target drug, but specific content (e.g., assessment feedback)
may vary.
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6.2 Clients Poorly Suited for This Counseling
Approach
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MET may be insufficiently directive for clients who desire clear direction
and advice. Research to date has identified no client characteristics that predict
poorer response to MET than to alternative approaches. Brief counseling in general
may be less effective as a stand-alone treatment with more severely impaired
clients.
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7. ASSESSMENT
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MET commonly includes a structured assessment of use, consequences, addiction,
biomedical sequelae, family history, and other risk factors. A variety
of specific instruments could be used to assess these dimensions. Instruments
that are sensitive to early stages of impairment are particularly desirable.
A common sequence is to conduct a brief motivational interview to prepare the
client for assessment. This is followed by structured assessment including the
above dimensions. A third session then provides the client with personal feedback
regarding the findings from assessment in relation to norms.
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8. SESSION FORMAT AND CONTENT
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8.1 Format for a Typical Session
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The content of an MET session depends on the client's stage of motivation.
Prochaska and colleagues (1992) have described four stages of readiness:
- Precontemplation, in which the individual is not considering change.
- Contemplation, in which the individual is ambivalent, weighing the pros
and cons of change.
- Determination or preparation, where the balance tips in favor of change
and the individual begins considering options.
- Action, which involves the individual taking specific steps to accomplish
change.
With precontemplators, the counselor explores perceived positive and negative
aspects of use. Open-ended questions are used to elicit client expression, and
reflective paraphrase is used to reinforce key points of motivation. During
a session following structured assessment, most of the time is devoted to explaining
feedback to the client. Later in MET, attention is devoted to developing and
consolidating a change plan.
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8.2 Several Typical Session Topics
or Themes
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The theme of the session is typically determined by the counselor, but specific
content within the theme is provided by the client. Examples of common themes
include:
- Good and not-so-good things about use.
- A typical day involving use.
- Reasons to quit or change.
- Ideas about how change might occur.
Sessions commonly begin with open-ended questions and end with a summary reflection.
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8.3 Session Structure
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Sessions are rather structured, although in presentation they are flexible
and client centered.
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8.4 Strategies for Dealing With
Common Clinical Problems
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Resistance of all types is met by a reflective "rolling with" strategy, rather
than direct confrontation or opposition. For example, client minimization or
rationalization might be met with various forms of reflective listening, such
as double-sided reflection, where both sides of ambivalence are captured. The
counselor might also agree with the client's point but then reframe it. Standard
program rules (e.g., regarding coming to sessions under the influence) may,
of course, still be enforced.
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8.5 Strategies for Dealing With
Denial, Resistance, or Poor Motivation
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The central characteristic of MET is as follows: Resistance and poor motivation
are not regarded as client characteristics but rather as cognitions and behaviors
subject to interpersonal influence. Research demonstrates that a counselor can
drive resistance levels up and down dramatically according to his or her personal
counseling style. A respectful, reflective approach is used throughout MET with
minimal advice or direction. The goal is still confrontation in the sense of
bringing the client face to face with a difficult reality and thereby initiating
change. Common strategies for decreasing resistance behaviors include variations
on reflective listening (e.g., amplified reflection, in which the counselor
takes the client's resistance a step further), reframing or giving a new meaning
to what the client has said, and selective agreement. Many of these take the
form of the counselor giving voice to the client's resistance, seeking to elicit
the client's own verbalizations of the need for change.
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8.6 Strategies for Dealing With
Crises
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Crises often offer particularly good windows of opportunity for motivation.
Rapid availability of the MET counselor is desirable. Beyond the taking of immediate
actions necessary to ensure safety, counseling strategies remain largely the
same.
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8.7 Counselor's Response to Slips
and Relapses
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Occurrences of renewed use are queried through open-ended questions and are
explored through reflective listening. Judgmental responses are carefully avoided.
The client's own perceptions of the slip or relapse are explored, and renewed
attention is given to the change plan and to what if anything may have been
faulty in the prior plan.
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9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT
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Significant others (SOs) may be involved in MET sessions and can be useful
sources of motivational material and change plans. The counselor must ensure
that the SO does not behave in a manner that elicits resistance and inhibits
motivation for change. The SO's primary role is to offer his or her own observations
and perceptions, with focus remaining on eliciting the client's intrinsic motivation.
The counselor may also employ MET strategies to strengthen the SO's own motivation
for change and elicit plans for behavior change. SO involvement can also make
reasons for change more salient for the client. The implicit goal remains to
instigate change in the client.
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REFERENCE
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Prochaska, J.O.; DiClemente, C.C.; and Norcross, J.C. In search of how people
change: Applications to addictive behaviors. Am Psychol 47:1102-1114,
1992.
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AUTHOR
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William R. Miller, Ph.D.
Regents Professor of Psychology and Psychiatry
Center on Alcoholism, Substance
Abuse, and Addictions (CASAA)
University of New Mexico
Albuquerque, NM 87131
University of New Mexico
Albuquerque, NM 87131
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