This therapist manual was prepared in the public domain as part of a treatment development project funded by the National Institute on Drug Abuse (R01-DA08896).  

The author makes no claims or representations regarding the effectiveness of the treatment described herein.  This manual was prepared for standardization of treatment within research programs.  Efficacy studies are underway.

Preface

This is a clinical research guide for therapists in applying Motivational Enhancement Therapy (MET) with  drug abusers.  MET is grounded in the clinical approach known as motivational interviewing  (Miller,  1983;  Miller  &  Rollnick, 1991), and incorporates a "check-up" form of assessment feedback (Miller & Sovereign, 1989; Miller, Sovereign & Krege, 1988). 

This integrated MET approach was delineated in a detailed therapist manual (Miller, Zweben, DiClemente, & Rychtarik, 1992) developed for Project MATCH, a multisite trial of alcoholism treatments funded as a cooperative agreement by the National Institute on Alcohol Abuse and Alcoholism (NIAAA; Project MATCH Research Group, 1993).

This document is an adaptation and extension of the Project MATCH MET therapist manual. Thanks  are  due  to  Drs.  Allen  Zweben,  Carlo  DiClemente,  and  Robert  Rychtarik  for  their collaboration in the preparation of the original MET manual.  The background, clinical approach, and procedures described in that manual are directly applicable in treating clients when the drug of choice is other than alcohol. 

Large portions of the basic text have been adopted and adapted directly from that public domain manual.  New examples have been inserted to illustrate applications with drug abusers, and the entire section on assessment feedback has been changed to reflect drug-focused measures.

This manual was prepared as part of a  treatment development project funded by the National Institute on Drug Abuse (NIDA; R01-DA08896).  Starting with an initial draft, the content of the manual was adjusted and amended based on clinical experience during the two-year study. 

Therapists collaborating in the development of this manual were Robert J. Meyers, Nancy Handmaker, Joseph Miller, Edward Nash, Tracy Simpson, and Carolina Yahne.

This manual was developed specifically to guide the treatment of drug abusers during the second phase of the NIDA treatment development study.  The first phase offered treatment for significant others (e.g., family) who were concerned about the drug use of a loved one who was not seeking treatment.  Phase I interventions sought to engage the drug user in treatment. 

When the Phase I intervention succeeded, the drug user was offered admission to the study, carefully assessed, and given outpatient treatment that began with this MET approach.  Further treatment was then provided, or referral was made to other agencies as appropriate.  Because the significant other (SO) was already involved in the study by participating in Phase I, emphasis was given to the inclusion of the SO in the MET phase.

No claims are made regarding the effectiveness of the treatment procedures described in this manual.  Although the principles of MET are well-grounded in clinical and experimental research, the specific efficacy of MET as outlined in this manual remains to be tested. 

Clinical trials are underway. In the interim, this manual offers a detailed description of MET procedures for use with drug abusers. All  manuals  of this kind should be regarded as "under development," and subject to ongoing improvement based on subsequent research and experience.

Overview

Motivational Enhancement Therapy (MET) is a systematic intervention approach for evoking change.  It is based on principles of motivational psychology, and is designed to produce rapid, internally-motivated change.  This treatment strategy does not attempt to guide and train the client, step by step, through recovery, but instead employs motivational strategies to mobilize the client's own change resources.  

It may be delivered as an intervention in itself, or may be used as a prelude to further treatment.  This manual was prepared for MET offered in an outpatient setting, although its application in residential settings is also feasible.  MET may be particularly useful in situations where contact with clients is limited to one or a few sessions. 

Treatment outcome research strongly supports MET strategies as effective in producing change in problem drinkers.  Although MET has also been used to address other drug problems (Baker & Dixon, 1991; Saunders, Wilkinson & Allsop, 1991; van Bilsen, 1991), outcome studies remain to be done to evaluate its efficacy with drug abuse.

Research Basis for MET

For  over  two  decades, research has pointed to surprisingly few differences in outcome between longer, more intensive treatment programs and shorter, less intensive, even relatively brief alternative approaches in the treatment of alcohol problems (Annis, 1985; Miller & Hester, 1986b; Miller & Rollnick, 1991; U. S. Congress, Office of Technology Assessment, 1983), drug problems (MacKay, McLellan & Alterman, 1992), and mental health problems more generally (Kiesler, 1982).

One interpretation of such findings is that all treatments are equally ineffective.  A larger review of the literature, however, does not support such pessimism.  Significant differences are found, for example, among alcohol treatment modalities in nearly half of clinical trials, and relatively brief treatments have been shown in numerous studies to be more effective than no intervention (Holder, Longabaugh, Miller, & Rubonis, 1991; Miller et al., 1995).

An  alternative  interpretation of this outcome picture is that many treatments contain a common core of ingredients which evoke change, and that additional components of some more extensive approaches may be unnecessary in many cases.  This has led, in the addictions field as elsewhere, to a search for the critical conditions that are necessary and sufficient to induce change (e.g., Orford, 1986). 

Miller and Sanchez (1994) described six elements which they believed to be active ingredients of the relatively brief interventions that have been shown by research to induce change in problem drinkers, summarized by the acronym FRAMES:

FEEDBACK of personal risk or impairment
Emphasis on personal RESPONSIBILITY for change
Clear ADVICE to change
A MENU of alternative change options
Therapist EMPATHY
Facilitation of client SELF-EFFICACY or optimism

These therapeutic elements are consistent with a larger review of research on what motivates change (Miller, 1985; Miller & Rollnick, 1991).

Therapeutic interventions containing some or all of these motivational elements have been demonstrated in over two dozen studies to be effective in initiating treatment, and in reducing long- term alcohol use, alcohol-related problems, and health consequences of drinking (Bien, Miller, & Tonigan, 1993). 

It is noteworthy that in a number of these studies the motivational intervention yielded  comparable  outcomes  even  when  compared  with  longer,  more  intensive  alternative approaches. 

Only one randomized trial to date has attempted to replicate with drug abusers the efficacy of this approach shown to be effective with problem drinkers: Stephens and Roffman (1993) reported motivational interviewing to be effective with marijuana dependent adults.

Further evidence supports the efficacy of the therapeutic style which forms the core of MET. The therapist characteristic of accurate empathy, as defined by Carl Rogers and his students (e.g., Rogers,  1957,  1959;  Truax  & Carkhuff, 1967),  has been shown to be a powerful predictor of therapeutic success, even when treatment is guided by another (e.g., behavioral) rationale (Miller, Taylor & West, 1980; Valle, 1981). 

Miller, Benefield, and Tonigan (1993) reported that the degree to which therapists engaged in direct confrontation (conceptually opposite to an empathic style) was predictive of continued alcohol consumption among problem drinkers one year after treatment.

Stages of Change

The MET approach is further grounded in research on processes of natural recovery. Prochaska and DiClemente (1982, 1984, 1985, 1986) have described a transtheoretical model of how people  change  addictive  behaviors,  with  or  without  formal  treatment.   

In  a  transtheoretical perspective, individuals move through a series of stages of change as they progress in modifying problem behaviors.  This concept of stages is important in understanding change.  Each stage requires certain tasks to be accomplished and certain processes to be used in order to achieve change.  Six separate stages have been identified in this model (Prochaska & DiClemente, 1984, 1986).

Individuals who are not considering change in their problem behavior are described as being in PRECONTEMPLATION. 

The CONTEMPLATION stage entails the person's beginning to consider both the existence of a problem and the feasibility and costs of changing the problem behavior. 

As this individual progresses, he or she moves on to the DETERMINATION stage where the decision is made to take action and change.  Once the individual begins to modify the problem behavior, he or she enters the ACTION stage, which normally continues for 3-6 months. 

After successfully negotiating the action stage, the individual moves to MAINTENANCE or sustained change.  If these efforts fail, a RELAPSE occurs, and the individual begins another cycle.

The ideal path is progress directly from one stage to the next until maintenance is achieved. For most people with serious problems related to drug use, however, the process involves several slips or relapses which represent failed action or maintenance. 

The good news is that most who relapse  go  through  the  cycle again and move back into contemplation and the change process.

Several revolutions through this cycle of change are common before the individual maintains change successfully.

From  a  stages-of-change perspective, the MET approach addresses where the client is currently in the cycle of change, and assists the person to move through the stages toward successful sustained change.  For the ME therapist, the contemplation and determination stages are most critical.

The objective is to help clients consider seriously two basic issues.  The first is how much of a problem their drug use poses for them, and how it is affecting them (both positively and negatively).

Tipping the balance of these pros and cons of drug use toward change is essential for movement from contemplation to determination.  Secondly, the client in contemplation assesses the possibility and the costs/benefits of changing the drug use.  Clients consider whether they will be able to make a change, and how that change will impact their lives.

In the determination stage, clients develop a firm resolve to take action.  That resolve is influenced  by past  experiences  with change attempts.  Individuals who have made unsuccessful attempts to change their drug use in the past need encouragement to decide to go through the cycle again.

Understanding the cycle of change can help the ME therapist to empathize with the client, and can give direction to intervention strategies.  Though individuals move through the cycle of change in their own ways, it is the same cycle. 

The speed and efficiency of movement through the cycle, however, will vary.  The task is to assist the individual in moving from one stage to the next as swiftly and effectively as possible.

There is reason to believe that MET is particularly effective with less motivated clients. Rollnick and his colleagues (Heather, Rollnick, Bell, & Richmond, 1996) in a randomized trial with problem drinkers found that MET was significantly more effective than behavior-change skills training for clients who were in the precontemplation or contemplation stages of change. 

For more motivated clients (already to the action stage when presenting for treatment) the two approaches were equally effective.

In  sum,  MET  is  well-grounded  in theory  and  research  on motivation for change.  It is consistent with an understanding of the stages and processes that underlie change in addictive behaviors. 

It draws on motivational principles that have been derived from both experimental and clinical  research.  This motivational approach is well supported by clinical trials with alcohol problems: its overall effectiveness compares favorably with outcomes of alternative treatments, and when cost-effectiveness is considered, an MET strategy fares well indeed in comparison with other approaches (Holder et al., 1991).