Contents

Page

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . iii

Foreword . . . . . . . . . .

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Rationale for Patient-Treatment Matching . . . . . . . . . vii
Project MATCH: An Overview . . . . . . . . . . . . . . . . viii
Caveats and Critical Considerations . . . . . . . . . . . . ix

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Research Basis for MET . . . . . . . . . . . . . . . . . . . 2
Stages of Change . . . . . . . . . . . . . . . . . . . . . . . 4
Clinical Considerations . . . . . . . . . . . . . . . . . . . . 7
Rationale and Basic Principles . . . . . . . . .
Express Empathy . . . . . . . . . . . . . . . . . . . . .
Develop Discrepancy . . . . . . . . . . . . . . . . . . 8
Avoid Argumentation . _ _ _ _ _ . _ _ _ . _
Roll With Resistance . . . . . . . _
Support Self-Efficacy . . . . . . . . . . . . . . . . . . . 8
Differences From Other Treatment Approaches . . . . . . 9
Practical Strategies . . . . . . . . . . . . . . . . . . . . . . 13
Phase 1: Building Motivation for Change . . . . . . . . . . 13
Eliciting Self-Motivational Statements . . . . . . . . . 13
Listening With Empathy . . . . . . . . . . . . . . . . . 16
Presenting Personal Feedback . . . . . . . . . . . . . . 19
Affirming the Client . . . . . . . . . . . . . . . . . . . 21
Handling Resistance . . . . . . . . . . . . . . . . . . . 21
Reframing . . . . . . . . . . . . . . . . . . . . . . . . . 24
Summarizing . . . . . . . . . . . . . . . . . . . . . . . 26
Phase 2: Strengthening Commitment to Change . . . . . . 27
Recognizing Change Readiness . . . . . . . . . . . . . 27
Discussing a Plan . . . . . . . . . . . . . . . . . . . . . 29
Communicating Free Choice . . . . . . . . . . . . . . . 29
Consequences of Action and Inaction . . . . . . . . . . 29
Information and Advice . . . . . . . . . . . . . . . . . . 30
Emphasizing Abstinence . . . . . . . . . . . . . . . . . 31
Dealing With Resistance . . . . . . . . . . . . . . . . . 34
The Change Plan Worksheet . . . . . . . . . . . . . . . 34
Recapitulating . . . . . . . . . . . . . . . . . . . . . . .37

Motivational Enhancement Therapy Manual
Page
Asking for Commitment . . . . . . . . . . . . . . . . . 38
Involving a Significant Other . . . . . . . . . . . . . . . . 39
Goals for Significant Other Involvement . . . . . . . . 40
Explaining the Significant Other's Role . . . . . . . 40
The Significant Other in Phase 1 . . . . . . . . . . . . 41
The Significant Other in Phase 2 . . . . . . . . . . . . 44
Handling SO Disruptiveness . . . . . . . . . . . . . . 45
Phase 3: Followthrough Strategies . . . . . . . . . . . . . 47
Reviewing Progress . . . . . . . . . . . . . . . . . . . 47
Renewing Motivation . . . . . . . . . . . . . . . . . . 47
Redoing Commitment . . . . . . . . . . . . . . . . . . 47
The Structure of MET Sessions . . . . . . . . . . . . . . . 49
The Initial Session . . . . . . . . . . . . . . . . . . . . . . 49
Preparation for the First Session . . . . . . . . . . . . 49
Presenting the Rationale and Limits of Treatment . . 50
Ending the First Session . . . . . . . . . . . . . . . . 52
The Followup Note . . . . . . . . . . . . . . . . . . . 53
Followthrough Sessions . . . . . . . . . . . . . . . . . . . 54
The Second Session . . . . . . . . . . . . . . . . . . . 54
Sessions 3 and 4 . . . . . . . . . . . . . . . . . . . . . 54
Termination . . . . . . . . . . . . . . . . . . . . . . . 55
Dealing With Special Problems . . . . . . . . . . . . . . . 57
Treatment Dissatisfaction . . . . . . . . . . . . . . . . . 57
Missed Appointments . . . . . . . . . . . . . . . . . . . . 58
Telephone Consultation . . . . . . . . . . . . . . . . . . . 59
Crisis Intervention . . . . . . . . . . . . . . . . . . . . . 60
Recommended Reading and Additional Resources . . . 61
Clinical Descriptions . . . . . . . . . . . . . . . . . . . . 61
Demonstration Videotapes . . . . . . . . . . . . . . . . . 62
References . . . . . . . . . . . . . . . : . . . . . . . . . . 62
Appendix A: Assessment Feedback Procedures . . . . . 67
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Alcohol Consumption . . . . . . . . . . . . . . . . . . 67
Alcohol-Related Problems . . . . . . . . . . . . . . . . 68
Alcohol Dependence . . . . . . . . . . . . . . . . . . . 68
Physical Health . . . . . . . . . . . . . . . . . . . . . 68
Neuropsychological Functioning . . . . . . . . . . . . 68
Risk Factors . . . . . . . . . . . . . . . . . . . . . . . 69
Motivation for Change . . . . . . . . . . . . . . . . . 69
Comprehensive Assessment Approaches . . . . . . . . 69
The Project MATCH Assessment Feedback Protocol and
Procedures for Completing the PFR . . . . . . . . . 70
Alcohol Consumption . . . . . . . . . . . . . . . . . . 70
Estimated Blood Alcohol Concentration Peaks . . . . 71
Risk Factors . . . . . . . . .
Problem Severity . . . . . .
Serum Chemistry . . . . . .
Page Neuropsychological Test Results . . . . . . . . . . . . . 75

Interpreting the PFR to Clients . . . . . . . . . . . . . . . 77

Alcohol Consumption . . . . . . . . . . . . . . . . . . . 77

Estimated BAC Peaks . . . . . . . . . . . . . . . . . . 78

Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . 78

Problem Severity . . . . . . . . . . . . . . . . . . . . . 80

Serum Chemistry . . . . . . . . . . . . . . . . . . . . . 80

Neuropsychological Test Results . . . . . . . . . . . . . 82

Assessment Instruments Used in Project MATCH Feedback 83

Form 90 . . . . . . . . . . . . . . . . . . . . . . . . . .83

DRINC 83

MacAndrew Scale . . . . . . . . . . . . . . . . . . . . . 84

Addiction Severity Index . . . . . . . . . . . . . . . . . 84

AUDIT 84

References . . . . . . . . . . . . . . . . . . . . . . . . . . .84

Handouts for Clients . . . . . . . . . . . . . . . . . . . . . . 87

Personal Feedback Report

Understanding Your Personal Feedback Report Alcohol and You

Appendix B: Motivational Enhancement Therapy in the

Aftercare Setting . . . . . . . . . . . . . . . . . . . 109

Scheduling . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Reviewing Progress . . . . . . . . . . . . . . . . . . . . . . 111

Generating Self-Motivational Statements . . . . . . . . . . 112

Providing Personal Feedback . . . . . . . . . . . . . . . . 112

Developing a Plan . . . . . . . . . . . . . . . . . . . . . . . 112

Integrating MET Aftercare With Inpatient Programing . .

115 The Prepackaged Plan . . . . . . . . . . . . . . . . . .

115 Antabuse . . . . . . . . . . . . . . . . . . . . . . . . . 115

Alcoholics Anonymous . . . . . . . . . . . . . . . . . . 116

Feedback . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Ambivalence and Attribution . . . . . . . . . . . . . . . . 117

Appendix C: Therapist Selection, Training, and

Supervision in Project MATCH . . . . . . . . . . . 119

Therapist Selection . . . . . . . . . . . . . . . . . . . . . . 119

Therapist Training . . . . . . . . . . . . . . . . . . . . . . 120

Ongoing Monitoring . . . . . . . . . . . . . . . . . . . . . 120

Overview Motivational Enhancement Therapy (MET) is a systematic interven
tion approach for evoking change in problem drinkers. 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.

Treatment is preceded by an extensive assessment battery (appendix
A) requiring approximately 7-8 hours. Each treatment session is
preceded by a breath test to ensure sobriety, and a positive breath
alcohol reading is cause for rescheduling the session.
As offered in Project MATCH, MET consists of four carefully planned
and individualized treatment sessions. Whenever possible, the client's
spouse or another "significant other" is included in the first two of
these four sessions. The first treatment session (week 1) focuses on (1)
providing structured feedback from the initial assessment regarding
problems associated with drinking, level of consumption and related
symptoms, decisional considerations, and future plans and (2) building
client motivation to initiate or continue change. The second session
(week 2) continues the motivation enhancement process, working
toward consolidating commitment to change. In two followthrough
sessions, at week 6 and week 12, the therapist continues to monitor
and encourage progress. All therapy is completed within 90 days.
MET is not intended to be a minimal or control treatment condition.
MET is, in its own right, an effective outpatient treatment strategy
which, by virtue of its rationale and content, requires fewer therapist
directed sessions than some alternatives. It may, therefore, be partic
ularly useful in situations where contact with problem drinkers is
limited to few or infrequent sessions (e.g., in general medical practice
or in employee assistance programs). Treatment outcome research
strongly supports MET strategies as effective in producing change in
problem drinkers.
The initial presentation of MET in this manual is written from the
perspective of outpatient treatment. These procedures can also be
applied in aftercare, however, and such adaptation is addressed in appendix B.

Research For more than two decades, research has pointed to surprisingly few
Basis for MET differences in outcome between longer, more intensive alcohol treat

ment programs and shorter, less intensive, even relatively brief alter
native approaches (Annis 1985; Miller and Hester 1986b; Miller and
Rollnick 1991; U. S. Congress, Office of Technology Assessment 1983).
One interpretation of such findings is that all alcohol treatments are
equally ineffective. A larger review of the literature, however, does not
support such pessimism. Significant differences among alcohol treat
ment modalities are found in nearly half of clinical trials, and rela
tively brief treatments have been shown in numerous studies to be
more effective than no intervention (Holder et al. 1991).
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 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 (in
press) described six elements which they believed to be active ingre
dients 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 problem drinkers for change (Miller 1985; Miller and Rollnick 1991).

Therapeutic interventions containing some or all of these motivational elements have been demonstrated to be effective in initiating treatment and in reducing long-term alcohol use, alcohol-related problems, and health consequences of drinking. Table 1 summarizes this research. It is noteworthy that, in a number of these studies, the

Table 1. Specific FRAMES components of evaluated brief interventions

Author Feedback Response Advice Menu Empathy Self-Efficacy Outcome

*Anderson and Scott 1992 Yes Yes Yes Yes Yes Yes Brief > No counseling

*Babor and Grant 1991 Yes Yes Yes Manual Yes Yes Brief > No counseling

*Bien 1991 Yes Yes Yes No Yes Yes Brief > No counseling

*Brown and Miller 1992 Yes Yes Yes No Yes Yes Brief > No counseling

*Carpenter et al. 1985 Yes No Yes No No No Brief = Extended counseling

*Chapman and Huygens 1988 Yes Yes Yes Yes No Yes Brief = IPT = OPT treatment

*Chick et al. 1985 Yes Yes Yes No Yes Yes Brief > No counseling

*Chick et al. 1988 No Yes Yes No No No Brief < Extended motiv cnslg

Daniels et al. 1992 Yes No Yes Manual No No Advice + Manual = No advice

Drummond et al. 1992 Yes No Yes No No No Brief = OPT treatment

Edwards et al. 1977 Yes Yes Yes No Yes Yes Brief = OPT/IPT treatment

Elvy et al. 1988 Yes No Yes No No No Brief > No counseling

*Harris and Miller 1990 No Yes Yes Manual Yes Yes Brief = Extended > No treatment

*Heather et al. 1986 Yes Yes Manual Manual No No Manual > No manual

*Heather et al. 1987 Yes Yes Yes Manual No No Brief = No counseling

*Heather et al. 1990 Yes Yes Yes Manual No No Manual > No manual

*Kristenson et al. 1983 Yes Yes Yes No Yes Yes Brief > No counseling

Kuchipudi et al. 1990 Yes No Yes Yes No No Brief = No counseling

Maheswaran et al. 1990 Yes No Yes No No No Brief > No counseling

*Miller and Taylor 1980 No Yes Yes Manual Yes Yes Brief = Behavioral counseling

*Miller et al. 1980 No Yes Yes Manual Yes Yes Brief = Behavioral counseling

*Miller et al. 1981 No Yes Yes Manual Yes Yes Brief = Behavioral counseling

*Miller et al. 1988 Yes Yes Yes Yes Yes Yes Brief > No counseling

*Miller et al. 1991 Yes Yes Yes Yes Yes Yes Brief > No counseling

*Persson and Magnusson 1989 Yes Yes Yes No Yes Yes Brief > No counseling

*Robertson et al. 1986 Yes Yes Yes Yes Yes Yes Brief < Behavioral counseling

*Romelsjo et al. 1989 Yes Yes Yes No Yes Yes Brief = OPT treatment

*Sannibale 1989 Yes Yes Yes No Yes Yes Brief = OPT treatment

*Scott and Anderson 1990 Yes Yes Yes Yes Yes Yes Brief = No counseling

*Skutle and Berg 1987 No Yes Yes Yes+Man Yes Yes Brief = Behavioral counseling

*Wallace et al. 1988 Yes Yes Yes Manual Yes Yes Brief > No counseling
*Zweben et al. 1988 Yes Yes Yes Yes No Yes Brief = Conjoint therapy
` Percent Yes 81 81 100 59 63 69

Source: Bien, Miller, and Tonigan 1992.

NOTE: Components listed are characteristics of the brief intervention in each study.

* Additional information obtained from the study's authors.

Manual = Manual-guided therapy; IPT =Inpatient treatment setting; OPT = Outpatient treatment setting i:

3

Motivational Enhancement Therapy Manual

motivational intervention yielded comparable outcomes even when compared with longer, more intensive alternative approaches.

Further evidence supports the efficacy of the therapeutic style that 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 and Carkhuff 1967), has been shown to be a powerful predictor of therapeutic success with problem drinkers, even when treatment is guided by another (e.g., behavioral) rationale (Miller et al. 1980; Valle 1981). Miller, Benefield, and Tonigan (in press) reported that the degree to which therapists engaged in direct confrontation (conceptually opposite to an empathic style) was predictive of continued client drinking 1 year after treatment.

Stages of The MET approach is further grounded in research on processes of
Change natural recovery. Prochaska and DiClemente (1982, 1984, 1985, 1986)
have described a transtheoretical model of how people change addic
tive 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 were identified in this model
(Prochaska and DiClemente 1984, 1986).

Figure 1. A Stage Model of the Process of Change

Prochaska and DiClemente People who are not considering change in

their problem behavior are described as

PRECONTEMPLATORS. The CONTEM PLATION stage entails individuals' begin

to consider both that they have a

problem and the feasibility and costs of

changing that behavior. As individuals

progress, they move on to the DETERMI

NATION stage, where the decision is made

to take action and change.

Once individuals begin to modify the problem behavior, they

enter the ACTION stage, which normally

continues for 3-6 months.

After success fully negotiating the action stage, individuals move to MAINTENANCE or sustained

If these efforts fail, a RELAPSE occurs, and the individual begins another

Temporary cycle

`''-" "' The ideal path is directly from one stage to

the next until maintenance is achieved. For

most people with serious problems related
to drinking, however, the process involves several slips or relapses
t 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 often needed to learn how to maintain change
successfully.

From a stages-of-change perspective, the MET approach addresses
where the client currently is 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 seriously
consider two basic issues. The first is how much of a problem their
drinking behavior poses for them and how their drinking is affecting
them (both positively and negatively). Tipping the balance of these
pros and cons of drinking toward change is essential for movement
from contemplation to determination. Second, the client in contempla
tion assesses the possibility and the costs/benefits of changing the
problem behavior. Clients consider whether they will be able to make
a change and how that change will affect 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 drinking behavior 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.

In sum, MET is well grounded in theory and research on the successful
resolution of alcohol problems. It is consistent with an understanding
of the stages and processes that underlie change in addictive behav
iors. It draws on motivational principles that have been derived from
both experimental and clinical research. A summary of alcohol treat
ment outcome research reveals that a motivational approach of this
kind is strongly supported by clinical trials: 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).