Rationale and The MET approach begins with the assumption that
the responsibility
Basic and capability for change lie within the client. The therapist's
task is
Principle ~ to create a set of conditions that will enhance the client's own
motiva
tion 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 motiva
tion 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:
Express empathy
Develop discrepancy
Avoid argumentation
Roll with resistance
Support self-efficacy
Express The ME therapist seeks to communicate great respect for the
client.
Empathy 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,
only the clients can decide to make a
change in their drinking 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 clini
cal writings, including Bill Wilson's own advice to alcoholics on "work
ing 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.
Develop Motivation for change occurs when
people perceive a discrepancy
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 drinking behavior. In certain cases (e.g., the pre
contemplators in Prochaska and DiClemente's model), it may be nec
essary first to develop such discrepancy by raising clients' awareness
of the personal consequences of their drinking. Such information,
properly presented, can precipitate a crisis (critical mass) of motiva
tion 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. When the
client enters treatment in the later contemplation stage, it takes less
time and effort to move the client along to the point of determination
for change.
Avoid If handled poorly, ambivalence
and discrepancy can resolve into defen
Argumentation sive
coping strategies that reduce the client's discomfort but do not
alter
drinking and related risks. An unrealistic (from the clients'
perspective) attack on their drinking behavior tends to evoke defen
siveness 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
drinking and to begin devaluing the perceived positive aspects of
alcohol. When MET is conducted properly, the client and not the
therapist voices the arguments for change (Miller and Rollnick 1991).
Roll With How the therapist handles client "resistance" is
a crucial and defining
Resistance 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 is described in more detail later.
Support People who are persuaded that
they have a serious problem will still
Self-Efficacy not move toward change unless there is hope for success. Bandura
(1982) has described "self-efficacy" as a critical determinant
of behav-
for change. Self-efficacy is, in essence, the belief that one can perform a particular behavior or
accomplish a particular task. In this case, clients must be persuaded that it
is possible to change their own drinking and thereby reduce related problems.
In everyday language, this might be called hope or optimism, though an overall optimistic nature is not crucial
here. Rather, it is the clients' specific belief that they can
change the
drinking 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 The MET approach differs
dramatically from confrontational treat
From Other ment strategies in which the therapist takes primary
responsibility
Treatment for "breaking down the
client's denial." Miller (1989, p. 75) provided Approaches
these contrasts between
approaches:
Confrontation-of-
Motivational-Interviewing
Denial
Approach Approach
Heavy
emphasis on acceptance Deemphasis
on labels;
of self
as "alcoholic"; acceptance
of "alcoholism"
acceptance
of diagnosis seen as label
seen as unnecessary for
essential
for change change
to occur
Emphasis
on disease of Emphasis
on personal choice
alcoholism
which reduces regarding
future use of alcohol
personal
choice and control and
other drugs
Therapist
presents perceived Therapist
conducts objective
evidence
of alcoholism in an evaluation
but focuses on
attempt
to convince the client eliciting
the client's own
of the
diagnosis concerns
Resistance
seen as "denial," a Resistance
seen as an
trait
characteristic of alcoholics interpersonal
behavior pattern
requiring
confrontation influenced
by the therapist's
behavior
Resistance
is met with Resistance
is met with
argumentation
and correction reflection
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 alcoholic, and
you have to quit drinking") and persuading
the client of the truth. The ME therapist emphasizes the client's
ability to change (self-efficacy) rather than the client's helplessness or
powerlessness over alcohol. As discussed earlier, arguing with the client is
carefully avoided, and strategies for handling resistance are more reflective
than exhortational. The ME therapist, therefore, does not-
Argue with clients.
Impose a diagnostic label on
clients.
Tell clients what they
"must" do.
Seek to "break down"
denial by direct confrontation.
Imply clients'
"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 clients how to change, the ME therapist builds motivation and elicits
ideas as to how change might occur. Thus, the following contrasts apply:
Cognitive-Behavioral Motivational
Enhancement
Approach Approach
Assumes that the client is Employs
specific principles and
motivated; no direct strategies strategies
for building client
for building motivation for motivation
change
Seeks to identify and modify Explores
and reflects client
maladaptive cognitions perceptions
without labeling or
“correcting" them
Prescribes specific coping Elicits
possible change
strategies strategies
from the client and
significant other
Teaches coping behaviors Responsibility
for change
through instruction, modeling, methods
is left with the client;
directed practice, and feedback no
training, modeling, or
practice
Specific problem-solving Natural
problem-solving
strategies are taught processes
are elicited from the
client and significant other
(Miller and Rollnick 1991)
MET, then, is an entirely different strategy from skill training.
It assumes that the key element for lasting change is a motivational shift that
instigates a decision and commitment to change. In the absence of such a shift,
skill training is premature. Once such a shift has occurred, however, people's
ordinary resources and their 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 and Brown 1991).
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). Thus MET is a directive and persuasive
approach, not a nondirective and passive approach.
Nondirective Motivational
Enhancement
Approach Approach
Allows the client to determine Systematically
directs the
the content and direction of client
toward motivation for
counseling change
Avoids injecting the counselor's Offers
the counselor's own
own advice and feedback advice
and feedback where
appropriate
Empathic reflection is used Empathic
reflection is used
noncontingently selectively
to reinforce certain
points
Explores the client's conflicts Seeks
to create and amplify the
and emotions as they are client's
discrepancy in order to
currently enhance
motivation for change
