Rationale and Basic Principles

The MET approach begins with the assumption that the responsibility and capability for change lie within the client.  The therapist's task is to create a set of conditions that will enhance the client's own motivation for and commitment to change.  Rather than relying upon therapy sessions as the primary locus of change, the therapist seeks to mobilize the client's inner resources, as well as those inherent in the client's natural helping relationships. 

MET seeks to support intrinsic motivation for change, which will lead the client to initiate, persist in, and comply with behavior change efforts. Miller and Rollnick (1991) have described five basic motivational principles underlying such an approach:

1. Express Empathy
2. Develop Discrepancy
3. Avoid Argumentation
4. Roll with Resistance
5. Support Self-Efficacy

1. Express Empathy

The ME therapist seeks to communicate great respect for the client.  Communications that imply a superior/inferior relationship between therapist and client are avoided.  The therapist's role is a blend of supportive companion and knowledgeable consultant.  The client's freedom of choice and self-direction are respected. 

Indeed, in this view, it is only the client who can decide to change and carry out that choice.  The therapist seeks ways to compliment rather than denigrate, to build up rather than tear down.  Much of MET is listening rather than telling.  Persuasion is gentle, subtle, always with the assumption that change is up to the client. 

The power of such gentle, nonaggressive persuasion has been widely recognized in clinical writings, including Bill Wilson's own advice on "working with others" (Alcoholics Anonymous, 1976). 

Reflective listening (accurate empathy) is a key skill in motivational interviewing.  It communicates an acceptance of clients as they are, while also supporting them in the process of change.

2. Develop Discrepancy

Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be.  The MET approach seeks to enhance and focus the client's attention on such  discrepancies  with  regard  to  drug  use.  In certain cases (e.g., the "precontemplators" in Prochaska and DiClemente's model) it may be necessary first to develop such discrepancy by raising the client's awareness of the adverse personal consequences of his or her drug use. 

Such information, properly presented, can precipitate a crisis (critical mass) of motivation for change.  As a result, the individual may be more willing to enter into a frank discussion of change options, in order to reduce the  perceived  discrepancy  and  regain  emotional  equilibrium. 

In other cases, the client enters treatment in a later "contemplation" stage, and it takes less time and effort to move the client along to the point of determination for change.

3. Avoid Argumentation

If handled poorly, ambivalence and discrepancy can resolve into defensive coping strategies that reduce the client's discomfort but do not alter drug use and related risks.  An unrealistic (from the client's perspective) attack on his or her drug use tends to evoke defensiveness and opposition, and suggests that the therapist does not really understand.

The MET style explicitly avoids direct argumentation, which tends to evoke resistance.  No attempt is made to have the client accept or "admit" a diagnostic label.  The therapist does not seek to prove or convince by force of argument. 

Instead, the therapist employs other strategies to assist the client to see accurately the consequences of drug use, and to begin devaluing the perceived positive aspects of drugs.  When MET is conducted properly, it is the client and not the therapist who voices the arguments for change (Miller & Rollnick, 1991).

4. Roll with Resistance

How the therapist handles client "resistance" is a crucial and defining characteristic of the MET  approach.  MET strategies do not meet resistance head-on, but rather "roll with" the momentum, with a goal of shifting client perceptions in the process. 

New ways of thinking about problems are invited but not imposed.  Ambivalence is viewed as normal, not pathological, and is explored openly. Solutions are usually evoked from the client rather than provided by the therapist. This approach for dealing with resistance will be described in more detail later.

5. Support Self-efficacy

A person who is persuaded that he or she has a serious problem will still not move toward change unless there is hope for success.  Bandura (1982) has described self-efficacy as a critical determinant  of behavior change. 

Self-efficacy is, in essence, the belief that one  can  perform  a particular behavior or accomplish a particular task.  In this case, the client must be persuaded that it is possible to change his or her own drug use and thereby reduce related problems.  In everyday language, this might be called hope or optimism, though it is not an overall optimistic nature that is crucial here. 

Rather, it is the client's specific belief that he or she can change the drug problem. Unless this element is present, a discrepancy crisis is likely to resolve into defensive coping (e.g., rationalization,  denial) to  reduce  discomfort,  without  changing behavior.  This is a natural and understandable protective process.  If one has little hope that things could change, there is little reason to face the problem.

Differences from Other Treatment Approaches

The MET approach differs dramatically from confrontational treatment strategies such as Synanon, in which the therapist takes primary responsibility for "breaking down the client's denial." Miller (1989) described several contrasts between these approaches. 

MET places little emphasis on acceptance of a diagnostic label ("alcoholic," "addict"), whereas confrontational approaches often view such acceptance as a critical condition for change.  MET emphasizes the client's personal choice regarding future drug use, whereas confrontational strategies may minimize the role of personal choice and describe drug abuse as a disease beyond the individual's control.  

Resistance behavior tends  to  be  viewed  as  characterologic  "denial"  by confrontational  therapists,  whereas an MET approach views ambivalence as a normal stage of change.  Consequently an ME therapist meets resistance with reflection rather than argumentation. 

It is noteworthy that this MET style is quite consistent with the original perspectives of Alcoholics Anonymous (1976; cf. Miller & Kurtz, 1994).

A goal of the ME therapist is to evoke from the client statements of problem perception and a need for change (see "Eliciting Self-Motivational Statements").  This is the conceptual opposite of an approach in which the therapist takes responsibility for voicing these perspectives ("You're an addict, and you have to quit using") and persuading the client of their truth. 

The ME therapist emphasizes  the  client's  ability  to  change (self-efficacy) rather than the client's helplessness or powerlessness over drugs.  As discussed earlier, arguing with the client is carefully avoided, and strategies for handling resistance are more reflective than exhortative. 

The ME therapist, therefore, does not:
argue with the client
impose a diagnostic label on the client tell the client what he or she "must" do
seek to "break down" denial by direct confrontation imply a client's "powerlessness"

The MET approach also differs substantially from cognitive-behavioral treatment strategies that prescribe and attempt to teach clients specific coping skills.  No direct skill training is included in the MET approach.  Clients are not taught "how to ..."  Rather the MET strategy relies on the client's own natural change processes and resources. 

Instead of telling the client how to change, the ME therapist builds motivation and elicits ideas from the client as to how change might occur. Whereas skill training strategies implicitly assume readiness to change, MET focuses explicitly on motivation as the key factor in triggering lasting change (Miller & Rollnick, 1991).  In the absence of motivation  and commitment,  skill training is premature. 

Once such a motivational shift has occurred, however, the ordinary resources of the individual and his or her natural relationships may well suffice.  Syme (1988), in fact, has argued that for many individuals a skill training approach may be  inefficacious  precisely  because  it  removes  the  focus  from  what  is  the  key  element  of transformation: a clear and firm decision to change (cf. Miller & Brown, 1991). 

It should be noted, however, that MET is not incompatible with, and could be used as a preparation for a skill training treatment approach.

Finally, it is useful to differentiate MET from nondirective approaches with which it might be confused.  In a strict Rogerian approach, the therapist does not direct treatment, but follows the client's direction wherever it may lead. 

In contrast, MET employs systematic strategies toward specific goals.  The therapist seeks actively to create discrepancy, and to channel it toward behavior change (Miller, 1983). 

The MET counselor offers feedback and advice where appropriate, and uses empathic reflection selectively to reinforce motivation for change. The  increasing  of  conflict (discrepancy) is also a strategic element in MET.  Thus MET is a directive and persuasive method, not a nondirective and passive approach.