National Institute on Alcohol
Abuse and Alcoholism Project MATCH Monograph Series Volume 2
MOTIVATIONAL
A Clinical Research Guide for
This text is posted on the website of the Institute of Addition Awareness
Therapists Treating Individuals
With Alcohol Abuse and Dependence
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as part of a distance learning/homestudy course on Motivational Interviewing
For more information, visit our website at www.CEUInstitute.com
See "Low Cost Internet Courses link"
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William R. Miller, Ph.D.
Allen Zweben, D.S.W.
Carlo C. DiClemente, Ph.D.
Robert G. Rychtarik, Ph.D.
Project MATCH Monograph Series Editor:
Margaret E. Mattson, Ph.D.
U.S.
Department of Health and Human Services
Public Health Service
National Institutes of Health
National Institute on Alcohol Abuse and Alcoholism
6000 Executive Boulevard
Rockville, Maryland 20892-7003
For
sale by the U.S. Government Printing Off-ice
Superintendent of Documents, Mail Stop: SSOP, Washington, DC 20402-9328
Project MATCH is supported by grants under a cooperative agreement funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and implemented by nine clinical research units and a data coordinating center. The project was initiated and is administered by the Treatment Research Branch, NIAAA.
All material appearing in this volume is in the public domain and may be reproduced or copied without permission from the Institute or the authors. Citation of the source is appropriate.
NIH Publication No. 94-3723
Reprinted 1995
The overall effort to design all three manuals in this
series and to
implement the therapies in the Clinical Research Units was coordi
nated by the investigators at Yale University under the leadership of
Drs. Kathleen Carroll and Bruce Rounsaville.
Project MATCH Research Group and Other Contributors
Principal and William Miller, Ph.D.
Coinvestigators Reid Hester, Ph.D.
at the sites Center on Alcoholism, Substance Abuse and Addictions
University
of New Mexico
Albuquerque, NM
Gerard Connors, Ph.D.
Robert Rychtarik, Ph.D.
Research Institute on Alcoholism
Buffalo, NY
Carrie Randall, Ph.D.
Raymond Anton, M.D.
Medical University of South Carolina and Veterans Administration
Medical Center Charleston, SC
Ronald Kadden, Ph.D.
Ned Cooney, Ph.D.
University of Connecticut School of Medicine Farmington, CT
Carlo DiClemente, Ph.D. Joseph Carbonari, Ed.D. , University of
Houston , Houston, TX
Allen Zweben, D.S.W.
University of Wisconsin-Milwaukee
Milwaukee, WI
Richard Longabaugh, Ed.D.
Robert Stout, Ph.D.
Brown University
Providence, RI
Dale Walker, M.D.
Dennis Donovan, Ph.D.
University of Washington and Seattle VA Medical Center
Seattle, WA
Coordinating Thomas Babor, Ph.D.
Center Frances Del Boca, Ph.D.
Principal and University of Connecticut
Coinvestigators Farmington, CT
Kathleen Carroll, Ph.D.
Bruce Rounsaville, M.D.
Yale University
New Haven, CT
NIAAA Staff
John
Allen, Ph.D.
Project Officer for Project MATCH
Chief, Treatment Research Branch
Margaret Mattson, Ph.D.
Staff Collaborator for Project MATCH
Cooperative Lisa Marshall
Education Gallaudet University
Program Washington,
DC
Consultants Larry Muenz, Ph.D.
Gaithersburg, MD
Philip Wirtz, Ph.D.
George Washington
University
Washington, DC
Contractor
Jane K. Myers
President
Janus Associates
Bethesda, MD
Foreword
A major focus of the efforts of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in treatment research is to rigorously test the patient-treatment matching approach to the clinical management of alcoholism. This commitment is particularly reflected in its multisite clinical trial, Project MATCH. This study is the first national, multisite trial of patient-treatment matching and one of the two largest current initiatives of NIAAA. Established under a cooperative agreement that allows direct collaboration between the Institute and the researcher, the project involves nine geographically representative clinical sites and a data coordinating center. Researchers in Project MATCH are among the most senior and experienced treatment scientists in the field. Both public and private treatment facilities, as well as hospital and university outpatient facilities, are represented.
The manuals in this series are the result of the collaborative efforts of the Project MATCH investigators and are used as guides by therapists in the trial. They are presented to the alcohol research community as standardized, well-documented intervention tools for alcoholism treatment research. The final reports of Project MATCH will inform us on the relative efficacy of the interventions being evaluated in the trial and on the types of clients who benefit the most from each of the therapies.
Until the final results from Project MATCH are presented to the community, these interim manuals summarize the consensus of the investigators on reasonable intervention approaches based on present knowledge. We look forward to offering further refinements of these approaches as Project MATCH data are analyzed and published and as the alcohol treatment field advances through the efforts of other ongoing research.
Enoch Gordis, M.D. Director National Institute on Alcohol Abuse
and Alcoholism
This manual for therapists is provided to the public to permit
replication of the treatment procedures employed in Project MATCH, a multisite
clinical trial of patient-treatment matching sponsored by the National
Institute on Alcohol Abuse and Alcoholism (NIAAA). It describes
Motivational Enhancement Therapy (MET), one of three treatment approaches
studied in Project MATCH. Therapist manuals for the other
treatments-Twelve-Step Facilitation Therapy (TSF) and Cognitive-Behavioral
Coping Skills Therapy (CBT)-are available in volumes 1 and 3 of this series,
respectively.
Rationale for Although a number of therapies
have had varying degrees of success,
Patient- no single treatment has been
shown to be effective for all individuals
Treatment diagnosed with alcohol abuse or
dependence. In recent years, interest
in
the field has increasingly focused on patient-treatment matching to
Matching improve outcome. The hypothesis is that more beneficial results
can
be obtained if treatment is prescribed on the basis of individual patient
needs and characteristics as opposed to treating all patients with the
same diagnosis in the same manner.
Many investigators have turned their attention from main effects
evaluations (i.e., studies that ask whether one intervention is more
effective than another) to studies specifically designed to identify
interactions between particular treatments and patient variables.
While treatments may not appear to differ in effectiveness when
applied to a heterogeneous client population, specific treatments may
indeed be more or less effective for specific, clinically meaningful
subgroups.
This
reasoning has led to a new generation of alcoholism treatment
research studies whose design is driven by the objective of finding
effective "matches." Ultimately, the goal of this line of research is
to
provide the clinician with valid and practical rules applicable across a
variety of treatment settings to assign patients to those treatment
regimens particularly suited to them.
Motivational
Enhancement Therapy Manual
Project Project MATCH, a 5-year study,
was initiated by the Treatment
MATCH: Research Branch of NIAAA in 1989.
The details of the design and
implementation of Project
MATCH will be described in full in forth
An Overview coming publications. This section
outlines the major features of the study.
The objective of Project MATCH is to determine if varying subgroups
of alcohol abusing or dependent patients respond differentially to
three treatments: (1) Twelve-Step Facilitation Therapy, (2) Cognitive
Behavioral Coping Skills Therapy, and (3) Motivational Enhancement
Therapy. Each treatment is delivered during a 12-week period by
trained therapists following a standardized protocol.
The project consists of two independent treatment-matching studies,
one with clients recruited at five outpatient settings, the second with
patients receiving aftercare treatment at four sites following an
episode of standard inpatient treatment. Patients are randomly
assigned to one of the three treatment approaches. Each study evalu
ates the interaction effects between selected patient characteristics
and the three treatments.
Each of
the nine study sites is recruiting approximately 150-200
clients. Clients are evaluated at intake and again at 3, 6, 9, 12, and 15
months. Outcome measures for the trial include drinking behavior,
psychological and social function, and consequences of drinking. Anal
yses of a priori hypotheses, as well as exploratory analyses, will show
whether different patient characteristics are associated with differen
tial treatment outcomes in each of the three therapeutic interventions.
Motivational Enhancement Therapy. MET 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 resources.
MET consists of four carefully planned and individualized treatment
sessions. The first two sessions focus on structured feedback from the
initial assessment, future plans, and motivation for change. The final
two sessions at the midpoint and end of treatment provide opportuni
ties for the therapist to reinforce progress, encourage reassessment,
and provide an objective perspective on the process of change.
The manual for this modality begins with an overview of MET and a
description of the general principles to be applied. A special section
discusses how to involve a significant other in MET. Then, specific
guidelines are provided for how to structure the four MET sessions.
Finally, recommendations are made for dealing with special problems
that can arise in conducting MET. Appendix A offers specific instruc
tions for preparing and explaining an individualized client feedback
form. Copies of materials provided to MET clients are also included.
Appendix
B offers guidelines for how to apply the manual-written from the perspective of
outpatient treatment--within a program of aftercare following residential care.
Twelve-Step
Facilitation Approach. This therapy is grounded in the concept of alcoholism as a
spiritual and medical disease. The content of this intervention is consistent
with the 12 Steps of Alcoholics Anonymous (AA), with primary emphasis
given to Steps 1 through 5. In addition to abstinence from alcohol, a major
goal of the treatment is to foster the patient's commitment to participation in
AA. During the course of the program's 12 sessions, patients are actively
encouraged to attend AA meetings and to maintain journals of their AA attendance
and participation. Therapy sessions are highly structured, following a similar
format each week that includes symptoms inquiry, review and reinforcement for
AA participation, introduction and explication of the week's theme, and setting
goals for AA participation for the .next week. Material introduced during
treatment sessions is complemented by reading assignments from AA literature.
Cognitive-Behavioral
Coping Shills Therapy. This therapy is based on the principles of social learning theory
and views drinking behavior as functionally related to major problems in the
person's life. It posits that addressing this broad spectrum of problems will
prove more effective than focusing on drinking alone. Emphasis is placed on
overcoming skill deficits and increasing the person's ability to cope with
high-risk situations that commonly precipitate relapse, including both
interpersonal difficulties and intrapersonal discomfort, such as anger or
depression. The program consists of 12 sessions with the goal of training the
individual to use active behavioral or cognitive coping methods to deal with
problems, rather than relying on alcohol as a maladaptive coping strategy. The
skills also provide a means of obtaining social support critical to the
maintenance of sobriety.
Caveats and Although all three manuals were
developed for a randomized clinical
Critical trial focusing on
patient-treatment matching hypotheses, the sub
stance
of the interventions is equally suitable for other research
Considerations questions and designs. However,
the reader needs to be aware of the
parameters of Project MATCH.
Therapy is delivered in a structured research situation. All three
treatments are manual guided and administered by experienced ther
apists who receive specialized training in one of the three project
interventions. Therapists closely follow the procedures outlined in
their manual, with regular supervision (by observation of videotapes)
from both local and projectwide clinical supervisors.
Motivational Enhancement Therapy Manual
This
manual is written for therapists with similar intensive training and
supervision. A summary of the procedures used to select, train, and supervise
therapists in Project MATCH is provided in appendix C.
There is
an important difference between a therapy textbook and a therapy manual. A
therapy textbook
is a
comprehensive presentation of a particular therapeutic approach, usually
describing a conceptual model, general principles, and a broad range of
applications and examples. It is typically meant to facilitate broad
utilization of a therapeutic approach by a wide range of practitioners in a
variety of settings. A therapy manual, on the other hand, is intended to operationalize and standardize a
treatment approach to be used in a particular context, usually a specific
clinical trial. In writing a therapy manual, the authors must make a number of
specific decisions (e.g., the number and timing of sessions, the content of
each session) that are ordinarily left to clinical judgment in a therapy
textbook.
This
manual is designed to standardize MET as a four-session treatment modality
within the particular context of Project MATCH. All treatments are preceded by
the same extensive assessment battery, requiring approximately 7-8 hours. Abstinence
is the expressed goal of all treatments, and except in unusual situations, all
sessions are videotaped. Each treatment session is preceded by a breath test to
ensure sobriety, and a positive breath alcohol reading results in rescheduling
the session. Therapists are prohibited from mixing MET with other treatment
approaches, and the purity of approach is maintained by local and national
supervisors who review videotapes. All therapy has to be completed within 90
days. A significant other can be invited to participate in up to two sessions.
Other
design requirements of clinical trials are likewise standardized across all
sites, including features such as defined patient eligibility criteria,
randomized assignment of treatment, and guidelines for dealing with patients
who are late or absent for treatment sessions or who show significant clinical
deterioration during the course of the intervention. Guidelines regulate and
document the amount and type of therapy over and above that provided by Project
MATCH that a client receives during the study. Data collection and delivery of
treatment are kept strictly separate, with the former being handled by research
assistants under the supervision of the project coordinators. The three manuals
refer to these Project MATCH-specific procedures with the knowledge that some
readers may wish to follow similar guidelines, while others may choose to
devise new guidelines more appropriate to the requirements of their own
project.
The therapist style and many specific concepts embodied in this manual were drawn from Miller and Rollnick's (1991) Motivational Interviewing. We are grateful to Guilford Press for their permission to publish this specific adaptation. Similar approaches have been more briefly described elsewhere (Edwards and Orford 1977; Miller 1983; van Bilsen and van Emst 1986; Zweben et al. 1983, 1988). The bibliography of this manual provides a range of clinical, videotape, and research resources for further reference.
The general therapeutic principles underlying MET can be applied in many other ways than those delineated here (Miller and Rollnick 1991). Under ordinary circumstances, the number, duration, and distribution of sessions could be flexible. Significant others might be involved in all sessions or none at all. The goals of therapy might be more flexible (Miller 1987), and motivational-counseling procedures could be intermixed with other therapeutic strategies. The specific prescriptions outlined in this manual are imposed for purposes of standardization and separation of treatments in Project MATCH.
The staffs of Project MATCH and NIAAA make no claims or guarantees 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. The final reports of Project MATCH will provide clearer information on the efficacy of this approach relative to others and on the types of clients for whom it may be optimal. In the interim, this manual offers a detailed description of MET procedures as constructed by consensus among the investigators and implemented by the therapists of Project MATCH. All manuals of this kind should be regarded as under development and subject to ongoing improvement based on subsequent research and experience.
The planning and operation of Project MATCH and the products now resulting from it, including this series of manuals, reflect the efforts of many individuals over a period of several years. Their dedication and collegial collaboration have been remarkable and will enrich the field of alcoholism treatment research for years to come.
Margaret E. Mattson, Ph.D.
Project MATCH Staff Collaborator
Project MATCH Monograph Series Editor
Division of Clinical and Prevention
Research
National Institute on Alcohol Abuse and Alcoholism
