The preceding sections outlined the basic flow of MET from Phase 1 through Phase 3.  This section will address issues involved in the planning and conduct of the MET sessions.

The Initial Session

Preparing for the First Session

In Project CRAFT, for which this manual was originally developed, treatment was preceded by an extensive battery of assessment instruments, some of which were used as the basis for personal feedback in the first session.  It is not necessary to use these particular instruments.  The general intent is to  provide the client with objective feedback regarding his or her drug use and related problems.

When you contact the client to make your first appointment, stress the importance of bringing along to this session his/her CSO.  If not already identified, this typically would be the spouse, a family member, or a close friend, who can be supportive through the treatment process.  The critical criteria are that the CSO is considered to be an "important person" to the client, and that the CSO ordinarily spends a significant amount of time with the client. If no such person is initially identified, explore further during the first session whether an CSO can be designated.

Also explain that the client must come to this session clean and sober, that a breath test will be administered, and that any significant alcohol in the breath or other evidence of drug impairment will require rescheduling.  All MET sessions are preceded by a breath alcohol test, to ensure sobriety. The client's BAC must be no higher than .05 (50 mg%) in order to proceed. 

Otherwise, the session must be rescheduled.  If there is disagreement as to whether a client is impaired by other drugs at the time of interview, it is acceptable to request an additional urine sample.

Presenting the Rationale and Limits of Treatment

Begin by explaining the nature of this approach.  Here is an example of what you might say: Before we begin, let me just explain a little about how we will be working together.  You have  already  spent  several  hours  completing  the  questionnaires  that  we  need,  and  we appreciate the time you put into that process.  We'll make good use of that information today.

I should also explain right up front that I'm not going to be changing you.  I hope that I can help you think about your present situation and consider what, if anything, you might want to do, but if there is any changing to be done here, you will be the one who does it. 

Nobody can tell you what to do, nobody can make you change.  I'll be giving you a lot of information about yourself, and maybe some advice, but what you do with all of that is completely up to you.  I couldn't change you if I wanted to.  The only person who can decide whether and how you change is you.  How does that sound to you?

After we have worked together for a few sessions you should have a better sense of what you want to do.  If you decide that you would like to make some changes and want some consultation with that, I may be able to help, and we could work together for up to a total of 12 sessions.  If you need other kinds of help or support, I'll refer you.  Do you have any questions about what we'll be doing?

After this introduction, start the first session with a brief structuring of the first session and, if applicable, the CSO's role in this process (refer to the section on "Involving a Significant Other"). Tell the client (and CSO) that you will be giving them feedback from the pretreatment questionnaires and interviews, but first you want to understand better how they see the client's situation. 

Then proceed with strategies for "Eliciting Self-Motivational Statements."  Use reflection ("Listening with Empathy")  as your  primary response  during this early phase.  Other strategies described under "Affirming the Client," "Handling Resistance," and "Reframing" are also quite appropriate here.  [See the "Motivational Interviewing" videotape by Dr. Miller, demonstrating this early phase of MET.]

When you sense that you have elicited the major themes of concern from the client (and CSO), offer a summary statement (see "Summarizing").  If this seems acceptable to the client (and CSO), indicate that the next step is for you to provide feedback from the client's initial assessment. Give the client a copy of the Personal Feedback Report (PFR), and review it step by step (see "Presenting Personal Feedback"). 

Again, you should use reflection, affirmation, reframing, and procedures for handling resistance, as described earlier.  You might not complete this feedback process in the first session.   If not, explain that you will continue the feedback in your next session, and take back the client's copy of the PFR for use in your second session, indicating that you will give it back to keep after you have completed reviewing the feedback next week.

Whenever you do complete the feedback process, ask for the client's (and CSO's) overall response.  One possible query would be:

I've given you quite a bit of information here, and at this point I wonder what you make of all this, and what you're thinking.

Both the feedback and this query will often elicit self-motivational statements that can be reflected, and used as a bridge to the next phase of MET.

After obtaining the client's (and CSO's) responses to the feedback, offer one more summary, including both the concerns raised in the first "eliciting" process, and the information provided during the  feedback  (see  "Summarizing"). 

This is the transition point to the second phase of MET: consolidating commitment to change.  (Again, you will not usually get this far in the first session, and this process is continued in subsequent sessions.)

Using cues from the client and CSO [see "Recognizing Change Readiness"], begin eliciting thoughts, ideas, and plans for what might be done to address the problem [see "Discussing a Plan"].

During  this  phase,  also  use  procedures  outlined  under "Communicating  Free  Choice"  and "Information and Advice."  Specifically elicit from the client (and CSO) what are perceived to be the possible benefits of action, and the likely negative consequences of inaction [see "Consequences of Action"]. 

These can be written down in the form of a balance sheet (reasons to continue as before versus  reasons  to  make a  change)  and given to  the  client.  The basic client-centered stance of reflection, questioning, affirming, reframing, and dealing with resistance indirectly, is to be maintained throughout this and all MET sessions.

This phase proceeds toward the confirmation of a plan for change, and you should seek to obtain whatever commitment you can in this regard [see "Asking for Commitment"].  It can be helpful to write down the client's goals and planned steps for change on the Change Plan Worksheet. 

If appropriate, this plan can be signed by the client [and CSO].  Be careful, however, not to press prematurely for a commitment.  If a plan is signed before commitment is firm, a client may drop out of treatment rather than "go back on" the agreement.

Ending the First Session

Always  end  the  first  session  by  summarizing  what  has  transpired.  The content of this summary will depend upon how far you have proceeded.  In some cases, progress will be slow, and you may spend most of the first session presenting feedback and dealing with concerns or resistance. In other cases, the client will be well along toward determination, and you may be into Phase II (strengthening commitment) strategies by the end of the first session. 

The speed with which this session proceeds will depend upon the client's current stage of change.  Where possible, it is desirable to elicit some client self-motivational statements about change within the first session, and to take some steps toward discussing a plan for change (even if tentative and incomplete). 

Also discuss what the client will do and what changes will be made (if any) between the first and second sessions.  Don't hesitate to move toward commitment to change in the first session if this seems appropriate. 

On the other hand, don't feel pressed to do so.  Premature commitment is ephemeral, and pressuring a client toward change before he or she is ready will evoke resistance and undermine the MET process.

At the end of the first session, it is acceptable to provide the client with a copy of suitable reading material.  If feedback has been completed, also give the client the Personal Feedback Report and a copy of "Understanding Your Personal Feedback Report."

The Follow-up Note

After the first session, prepare a handwritten note to be mailed to the client.  This is not to be a "form letter," but rather a personalized message in your own handwriting.  [If your handwriting is illegible, make other arrangements, but the note should be handwritten, not typed.]
 
There are several elements which can be included in this note, and which are personalized to the individual:

1.  A "joining message" ["I was glad to see you" or "I felt happy for you and your wife after we spoke today," etc.]

2.  Affirmations of the client (and SO)

3.  A reflection of the seriousness of the problem

4.  A brief summary of highlights of the first session, especially self-motivational statements that emerged

5.  A statement of optimism and hope

6.  A reminder of the next session.

Be mindful, of course, of the central importance of protecting client confidentiality in sending this letter.  Here is an example of what such a note might say:

Dear Mr. Robertson:
This is just a note to say that I'm glad you came in today.  I agree with you that there are  some  serious concerns for you to deal with, and I appreciate how openly you are exploring them.  You are already seeing some ways in which you might make a healthy change, and your wife seems very caring and willing to help.  I think that together you will be able to find a way through these problems.  I look forward to seeing you again on Tuesday the 24th at 2:00.

Place a photocopy of this note in the client's clinical file.

Missed Appointments

When a client misses a scheduled appointment, respond immediately.  First try to reach the client by telephone, and when you do, cover these basic points:

1. Clarify the reasons for the missed appointment

2. Affirm the client - reinforce for having come

3. Express your eagerness to see the client again, and encouragement to continue

4. Briefly mention serious concerns that emerged, and your appreciation (as appropriate) that the client is exploring these

5. Express your optimism about the prospects for change, and for benefit to the client and CSO

6. Ask whether there are any questions that you can answer for the client

7. Reschedule the appointment

If no reasonable explanation is offered for the missed appointment (e.g., illness, transportation breakdown),  explore  with  the client whether the missed appointment might reflect any of the following:

* uncertainty about whether or not there is a need for treatment (e.g., "I don't really have that much of a problem)

* ambivalence about making a change

*  frustration  or  anger  about  having  to  participate  in treatment  (particularly with clients coerced into entering the program)

Handle such concerns in a manner consistent with MET (e.g., with reflective listening, reframing). Indicate that it is not surprising, in the beginning phase of consultation, for a person to express their reluctance (frustration, anger, etc.) by not showing up for appointments, being late, and so on. Encouraging the client to voice these concerns directly may help to reduce their expression in future missed appointments. 

Use Phase I strategies to handle any resistance that is encountered.  Affirm the client for being willing to discuss concerns.  Then summarize what you have discussed, add your own optimism about the prospects for positive change, and obtain a recommitment to treatment.  It may be useful to elicit some self-motivational statements from the client in this regard.
Reschedule the appointment.

In all cases, unless you regard it a confidentiality risk or a duplication of the telephone contact that might offend the client, also send a personal, individualized handwritten note with these essential points.  This should be done within two days of the missed appointment. 

Research indicates that a prompt note and telephone call of this kind significantly increases the likelihood that the client will return (Nirenberg, Sobell & Sobell, 1980; Panepinto & Higgins, 1969).  Place a copy of this note in the clinical file.

This procedure should be used when any of the four appointments is missed.  At least three attempts (new appointments) should be made to reschedule a missed session.

Follow-Through MET Sessions

The second session may be scheduled during the same week as Session 1, and in general should not be more than a week later.  It should begin with a brief summary of what transpired during the first session.  Then proceed with the MET process, picking up where you left off. 

Continue with the client's personal feedback from assessment, if this was not completed during the first session, and give the client the PFR and a copy of "Understanding your Personal Feedback Report" to take home. Proceed toward Phase II strategies and commitment to change, if this was not completed in the first session.  If a firm commitment was obtained in the first session, then proceed with follow-through procedures.

Begin each session with a discussion of what has transpired since the last session, and a review of what has been accomplished in previous sessions.   Specific use is made in each session of the follow-through strategies outlined earlier: (1) reviewing progress; (2) renewing motivation, and (3) redoing commitment.  Complete each session with a summary of where the client is at present (e.g., the client's reasons for concern, the main themes of the feedback, the plan that has been negotiated - see "Recapitulation"), eliciting the client's perceptions of what steps should be taken next. 

The plan for change (if previously negotiated) can be reviewed, revised, and (if previously written down) rewritten.

During follow-through sessions, be careful not to assume that ambivalence has been resolved, and that commitment is firm.  It is safer to assume that the client is still ambivalent, and to continue using  the  motivation-building  strategies  of  Phase  I,  as  well  as  the  commitment-strengthening strategies of Phase II.

There should be a clear sense of continuity of care.  MET sessions should be presented as progressive consultations, and as continuous with subsequent treatment and (research) follow-up sessions.  The initial sessions build motivation and strengthen commitment, and subsequent sessions
(including the research follow-ups) serve as periodic check-ups of progress toward change.

It  can  be  helpful  during follow-through sessions to discuss specific situations that have occurred since the last session.  Two kinds of situations can be explored:

1. Situations in which the client used drugs

2. Situations in which the client didn't use drugs.

Drug Use Situations.  If the client used since the last session, discuss how it occurred. Remember to remain empathic, and to avoid a judgmental tone or stance.  During the MET phase of treatment, use this discussion to renew motivation, eliciting from the client further self-motivational statements by asking for the clients thoughts, feelings, reactions, and realizations.  Key questions can be used to redo commitment (e.g., "So what does this mean for the future?"  "I wonder what you will need to do differently next time?"
 
Non-use Situations.  Clients may also find it helpful and rewarding to review situations in which they might have used previously, or in which they were tempted to use, but did not do so. Reinforce self-efficacy by asking the client to clarify what he/she did to cope successfully in these situations.  Encourage the client for small steps, little successes, even minor progress.

Transition or Referral

When a clear change plan develops, the next step is to determine what, if any, additional treatment or consultation the client would like to have in support of change.  If you are personally able to provide some or all of the desired treatment, proceed [up to a total of 12 sessions, including the MET sessions].  If not, help the client to identify the appropriate treatment resources and make the referral.

Whenever possible, make the referral call personally from your office while the client is present, and make a specific appointment for the client.

Termination

Formal termination of the MET phase is generally accomplished by a final recapitulation of the client's situation and progress through the MET sessions.  Your final summary should include these elements:

1. Reviewing the most important factors motivating the client for change, and reconfirming these self-motivational themes.

2. Summarizing the commitments and changes that have been made thus far.

3. Affirming and reinforcing the client (and CSO) for commitments and changes that have been made.

4. Exploring additional areas for change that the client wants to accomplish in the future.

5.  Eliciting  self-motivational  statements  for  the  maintenance  of  change,  and  for further changes.

6. Supporting client self-efficacy, emphasizing the client's ability to change.

7. Dealing with any special problems that are evident (see below).

8. Reminding the client of the follow-up interview(s), emphasizing that these are an important part of the overall program and can be helpful in maintaining change.

To consolidate motivation, it may be useful to ask the client (and CSO) what would be the worst things that could happen if he/she went back to using as before.  Help the client look to the immediate future, to anticipate upcoming events or potential obstacles that could contribute to relapse.

Time and Session Limits

In Project CRAFT, a total of twelve sessions may be provided, as a combination of MET and further indicated treatment. Up to two additional emergency sessions may be provided, at your discretion. 

All sessions, including any emergency sessions, must be completed within three months of the date of the first session.  After that date, you may no longer see the client for any session.

Telephone Consultation

Some clients and their CSOs will contact you by telephone between sessions, for additional consultation. This is acceptable, and all such contacts should be carefully documented in the client's file.  An attempt should be made to keep such contacts brief, rather than providing additional sessions by telephone.

Early in a telephone contact, you should comment positively on the client's openness and willingness to contact you. Reflect and explore any expressions of uncertainty and ambivalence that are expressed with regard to goals or strategies discussed in a previous session. 

It can be helpful to normalize ambivalence and concerns; for example:  "What you're feeling is not at all unusual.  It's really quite common, especially in these early stages.  Of course you're feeling confused.  You're still quite attached to the drugs you've been using, and you're thinking about changing a pattern that has developed over many years.  Give yourself some time." 

Also reinforce any self-motivational statements and indications of willingness to change.  Reassurance can also be in order during these brief contacts; e.g., that people really do make changes in their drug problems, often with a few consultations.

Crisis Intervention

In certain circumstances, you may be contacted by the client or CSO in a condition of crisis. As described earlier, it is permissible to offer up to two special emergency sessions with the client
(and CSO) within the 12-week treatment period.

If at any time, in your opinion, the immediate welfare and safety of the client or another person is in jeopardy (e.g., impending relapse, client is acutely suicidal or violent), you should intervene immediately and appropriately for the protection of those involved, with appropriate consultation from your supervisor. 

This may include your own immediate crisis intervention as well as appropriate referral.  If a client's urgent needs require more additional treatment than you can provide, referral should be arranged.