Followthrough Sessions

The Second The second session is scheduled 1 to 2 weeks after session 1 and should
session 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" (see
appendix A) to take home. Proceed toward Phase 2 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 followthrough procedures.

At the end of the second session, in all cases, offer a closing summary
of the client's reasons for concern, the main themes of the feedback,
and the plan that has been negotiated (see "Recapitulation"). This is
the closing of the second session. If no commitment to change has been
made, indicate that you will see how the client is doing at the followup
in 4 weeks and will continue the discussion at that point. In any event,
remind the client of the third session at week 6. When a spouse or SO
has been involved in the first two sessions, thank the SO for partici
pating in those sessions and explain that the next two sessions will be
with the client alone. If the SO was not involved in both of the initial
sessions, he or she may return for the third session. (The SO's involve
ment is not to exceed two sessions.)

Sessions 3 and 4 Sessions 3 and 4 are to be scheduled for weeks 6 and 12, respectively.
They are important as "booster" sessions to reinforce the motivational
processes begun in the initial sessions. As before, the therapist does
not offer skill training or prescribe a specific course of action. Rather,
the same motivational principles are applied throughout MET. Spe
cific use is made in each session of the followthrough strategies
outlined earlier: (1) reviewing progress, (2) renewing motivation, and
(3) redoing commitment. Sessions 3 and 4 do not include the SO, unless
the SO has not already attended two sessions.
Because several weeks normally lapse between sessions 2 and 3 and
between sessions 3 and 4, you should send the client a handwritten
note or telephone the client a few days before the scheduled appoint
ment. This serves as a reminder and also expresses continued active
interest in your client.

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. Complete each session with a summary of where the client
is at present, eliciting the client's perceptions of what steps should be
taken next. The prior plan for change can be reviewed, revised, and (if previously written down) rewritten.

During these 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 motivationbuilding strategies of Phase 1 as well as the commitment-strengthening strategies of Phase 2.

There should be a clear sense of continuity of care. The four sessions of MET should be presented as progressive consultations and as continuous with the research protocol's schedule of followup sessions. The initial sessions build motivation and strengthen commitment, and subsequent sessions serve as periodic checkups of progress toward change.

It can be helpful during sessions 3 and 4 to discuss specific situations that have occurred since the last session. Two kinds of situations can be explored:

Situations in which the client drank

Situations in which the client did not drink

Drinking Situations

If the client drank since the last session, discuss how it occurred. Remember to remain empathic and to avoid a judgmental tone or stance. Consistent with the MET style, do not prescribe coping strategies for the client. Rather, 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 renew commitment (e.g., "So what does this mean for the future?" "I wonder what you will need to do differently next time?")

Nondrinking Situations

Clients may also find it helpful and rewarding to review situations in which they might have drunk previously or in which they were tempted to drink but did not do so. Reinforce self-efficacy by asking clients to clarify what they did to cope successfully in these situations. Praise clients for small steps, little successes, even minor progress.

Termination Formal termination should be acknowledged and discussed at the end
of the fourth session. This is generally accomplished by a final reca
pitulation of the client's situation and progress through the MET
sessions. Your final summary should include these elements:

Review the most important factors motivating the client for change, and reconfirm these self-motivational themes.

Summarize the commitments and changes that have been made thus far.

Affirm and reinforce the client for commitments and changes that have been made.

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

Elicit self-motivational statements for the maintenance of change and for further changes.

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

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

Remind the client of continuing followup sessions, emphasizing that these are an important part of the overall program and can be helpful in maintaining change.

Review, in session 4, the major points that have come up in the prior three sessions. It may be useful to ask clients about the worst things that could happen if they went back to drinking as before. Help clients look to the immediate future, to anticipate upcoming events or potential obstacles to continued sobriety.

Dealing With Special Problems

Special problems can arise during any treatment. The following are general troubleshooting procedures for handling some of the situations that may arise in delivering therapy in general as well as within a research context.

Treatment Clients may report thinking that the assigned treatment is not going
Dissatisfaction to help or wanting a different treatment.

Under these circumstances,
you should first reinforce clients for being honest about their feelings
(e.g., "I'm glad you expressed your concerns to me right away."). You
should also confirm that clients have the right to quit treatment at any
time, seek help elsewhere, or decide to work on the problem on their
own. In any event, you should explore the client's feelings further (e.g.,
"Whatever you decide is up to you, but it might be helpful for us to talk
about why you're concerned"). Concerns of this kind that arise during
the first session are probably reservations about an approach they
have not yet tried. Typically, in randomized studies of multiple treat
ments, it is appropriate to assure the client that all of the treatments
in the study are expected to succeed equally and that you will be
offering all the help you can. No one can guarantee that any particular
treatment will work, but you can encourage the client to give it a good
try for the planned period and see what happens. You can add that
should the problem continue or worsen, you will discuss other possible
approaches.

If a client expresses reservations after two or three sessions, consider
whether there have been new developments. Have new problems
arisen? Did the plan for change that was previously developed with
the client fail to work, and if so, why? Was it properly implemented?
Was it tried long enough? Is there input or pressure from someone else
for a change in approaches or for discontinuation of treatment? Is the
client discouraged?

If the client's drinking problem has shown improvement but new
problems, not previously identified, have appeared, these new problems
can be discussed, following (and not departing from) the treatment
procedures outlined above. The discussion of new problems and con
cerns, or a review of how prior implementation failed, can set the stage
for continuation in treatment. You can suggest that it may be too early to judge how well this approach will work and that the client should continue for the 12-week duration. After that, if the client still feels a need for additional treatment, he or she could certainly obtain it.

If other parties are concerned about this treatment and are pressuring the client, you can explore this problem by following the treatment guidelines outlined above. It is also permissible for you to telephone the concerned party (with written consent from the client) to discuss the concerns and provide assurances, along the same lines as those outlined above for similar client concerns.

In Project MATCH, a limit of no more than two additional "emergency" sessions may be provided at the therapist's discretion. These must remain consistent with the MET guidelines provided in this manual and can be viewed as an extension or intensification of MET. The SO may be included in these sessions if appropriate, but the SO may never be seen alone. All sessions, including any emergency sessions, must be completed within 12 weeks of the first session. After that date, therapists are no longer permitted to see the client for any session, even if MET has not been completed.

A plan to provide a specific referral and help the client make contact was devised in Project MATCH in case all attempts to keep the client in treatment fail. Additional treatment may not be provided by any project therapist. Referral is made to an outside agency or to a therapist within the same agency who has no involvement in Project MATCH. A good procedure for accomplishing the referral is to telephone the agency or professional while the client is still in your office and make a specific appointment. For Project MATCH, this is discussed with the project coordinator or project director, because it has implications for the client's continuation in the study. In any event, the client is urged to participate in followup interviews as originally planned.

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

Clarify the reasons for the missed appointment.
Affirm the client-reinforce for having come.
Express your eagerness to see the client again.

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

Express your optimism about the prospects for change.

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 treatment is needed (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 by others into entering the program)

Handle such concerns in a manner consistent with MET (e.g., with reflective listening, refraining). Indicate that it is not surprising, in the beginning phase of consultation, for people 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 1 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 as 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 2 days of the missed appointment. Research indicates that a prompt note and telephone call of this kind significantly increase the likelihood that the client will return (Nirenberg et al. 1980; Panepinto and 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. Three attempts (new appointments) should be made to reschedule a missed session.

Telephone Some clients and their SOs will contact you by telephone between
Consultation 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. All telephone contacts must also
comply with the basic procedures of MET. Specific change strategies
should not be prescribed. Rather, your approach emphasizes elicita
tion and reflection.

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 drinking, 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 change their drinking, often with a few consultations.

Crisis The Project MATCH protocol provides guidelines on actions to be
Intervention taken if the therapist is contacted by the client or SO in a condition of

crisis. Others using this manual can adopt these guidelines as needed
for their own protocols. These guidelines permit offering up to two
special emergency sessions with the client (and SO) within the 12
week treatment period.

If at any time, in the therapist's 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), the protocol instructs the
therapist to intervene immediately and appropriately for the protec
tion of those involved, with appropriate consultation from the therapy
program supervisor. This may include your own immediate crisis
intervention as well as appropriate referral. In Project MATCH, the
therapist's involvement in crisis interventions cannot exceed two
sessions above and beyond those prescribed by the treatment condi
tion. If a client's urgent needs require more additional treatment than
this, referral is arranged.

Cases where there appears to be a worsening of the drinking problems,

or evidence of other new and serious difficulties (e.g., suicidal

thoughts, psychotic behavior, violence) are referred to the onsite

Project MATCH study coordinator for further evaluation and consultation. Based on his/her own evaluation and the defined procedures of the study, the coordinator determines what action is warranted and whether the client should be continued in the study. If alternative treatments are warranted, the coordinator is involved in making this determination.