Motivational Enhancement Therapy Manual

be a wise decision since, as we saw, your liver tests were elevated way above normal when you entered the hospital. Your drinking was negatively affecting your liver and could have led to permanent damage. This is common for individuals with moderate to severe alcohol problems and, as we saw, you seem to fit in this group. We also saw that with abstinence during your time in the hospital your liver tests basically returned to normal. This is very encouraging and indicates that if you remain off alcohol, your health will continue to improve or, at least, not deteriorate further. You also indicated in the tests that one of your most difficult situations with respect to drinking is when you find yourself at home with nothing to do and feeling lonely. This appears to be the problem you ran into last weekend in which you said you had a strong urge to have a drink. You also express some difficulty turning down drinks when you're around some of your old buddies. Based on your discussion here, it certainly sounds like you are committed to staying off alcohol. In fact, since discharge you have been doing extremely well. At this point then, it may be helpful for us to talk about what you feel you need to do or need to continue doing in order to maintain the important change you've already made.

Although it is not necessary to complete the plan for change by the end of the first session, some plan elements should be completed in order to give closure to the first session.

In the second and subsequent sessions, the therapist should complete the plan for change, if it has not been done already. The majority of these sessions will be spent reviewing progress as discussed above, reinforcing the client's change and modifying the plan for change as needed.

The first two sessions of MET are scheduled to occur within a week of each other. Feedback and spouse involvement are scheduled during these sessions. If significant others cannot come in during these sessions, they can be invited to later sessions.

The final two sessions are times when clients can check in and reflect on their progress and problems. If they have lost momentum or have encountered serious problems, this is the time to reflect, empathize, summarize, and offer advice. Followthrough on the plans and modifying plans would be a major focus of these sessions. In Project MATCH, as with the other therapies, ME therapists have available up to two emergency sessions to use if there are crises for the client. These would be used similarly to those in the outpatient condition.

Appendix B: Motivational Enhancement Therapy in the Aftercare Setting

Integrating Experiences with Motivational Enhancement Therapy in the aftercare
MET Aftercare setting have been quite positive. Many patients view the support for
With Inpatient taking personal responsibility for their aftercare plan to be quite helpful.

Programing Although this message may be somewhat at variance with the

information given during the inpatient stay, clarification of the MET
philosophy and perspective can be an important first step to engaging
the patient. The focus on discharge and life after hospitalization is
critical for the aftercare patient. Focus not only on the plans for
sobriety, which may have been heavily influenced by inpatient staff
and other patients, but also on plans for establishing routines and
goals postdischarge. Several key issues can arise in this context.

The Most aftercare patients will have a postdischarge plan that is devel
Prepackaged oped during the hospital program. At times, these plans are rather
Plan standardized, depending on the type of inpatient program, and can
include AA, group therapy, or disulfiram. They often include messages
about employment, relationships, leisure, exercise, and a variety of
other activities or life situations. Exploring this plan is a critical first
step in assisting clients in developing their own unique plan to which
they can commit. It is important to explore which elements the clients
really believe will work and will fit with their unique situation. Be
careful to have clients be as specific as possible in discussing the plan,.
Elicit the details of the plan and how it will work.
In some cases, the discharge plan may not be well formulated or may
change as the client leaves the hospital. It is important to check with
the client about how the plans are developing. From one week to the
next, the client's plan can undergo substantial revisions. This would
be particularly true during the time between the final two MET
sessions.

Should the prepackaged discharge plan serve as the action plan of
Motivational Enhancement Therapy? In each case, the MET therapist
works with the client to answer this question. In the aftercare condi
tion, the therapists help the clients evaluate prehospital problems, the
feedback, and the hospital discharge plan to develop a unique action
plan. This plan can include all or part of the prepackaged plan if the
motivation elicited during the first sessions focuses on these elements.
However, as clients consider their particular situation and address
personal issues and situations, the MET action plan can be quite
different from the prepackaged plan.

Disulfiram Some clients will be discharged from the hospital on disulfiram, which
must be taken regularly. There are several important considerations
about disulfiram and ME therapy. Disulfiram can be a very helpful
aid in promoting sobriety in clients who are impulsive and may need
some built-in delays and deterrents to drinking. However, clients can
see disulfiram as the sole cause of their sobriety. This can undermine

self-motivation and self-efficacy. If clients are planning to use disulfiram as part of their postdischarge plans, it is important to explore how the disulfiram will help and what role it will play in sobriety. It is also helpful to elicit self-motivational statements that make clients the agents in the use of disulfiram. It is their decision to take disulfiram and their evaluation of the need for disulfiram that will help them to follow through with the prescription that makes disulfiram work. Ownership of the disulfiram plan and daily commitment to the prescription can certainly be a valuable part of the MET action plan and promote successful sobriety. Do not be afraid to include disulfiram in the plan, but only include it if the client endorses it and has a personal commitment to it. Often, disulfiram is the decision of the doctor and not the client. In this case, it is important not to undermine or sabotage the inpatient prescription but not to endorse or push it if the client does not demonstrate any commitment to the disulfiram. Focus your attention on other behaviors and ideas that can engage the client's interest and commitment.

Alcoholics It will be difficult, if not impossible, for any client to complete an

Anonymous inpatient stay without having a prescription to attend AA or to

participate in the 12-Step recovery process.

AA involvement is often a major element in the discharge plan prepared in the hospital and part of the hospital regimen. Thus, in the aftercare condition, it would be impossible to simply ignore AA involvement. However, because of the overlap with other treatment conditions, you need to be careful not to become an independent promoter of AA involvement. In the MET condition, it seems best to handle AA involvement the same as other aspects of the client's plan. Therapists do not originate or promote any one measure or method of achieving sobriety. Therapists do help indicated by the client or the feedback information. Specifically, this approach would mean that AA involvement is exam ined if it is proposed by the client or has been a part of the client's experience. In this examination, the therapist explores the specifics, uses reflective listening, elicits motivational statements, and summarizes the client's plans and commitment with regard to AA involvement and 12-Step work. Some clients may simply be reflecting a party line, others may be convinced of the value of meetings, and still others may be committed to working with a sponsor and completing each of the 12 Steps of recovery. Understanding the client's level of under standing and commitment is the first step. If any level of AA involvement is included as an integral part of the action plan postdischarge, it needs to be monitored and examined as the therapist would do with any other method or measure decided by the client.

Motivational Enhancement Therapy attempts to identify motivations and maximize the client's commitment to a personal, individual plan I of action. For clients who identify AA as a viable part of their plan, the

task of MET is to enhance the personal motivation and commitment to follow through with that part of the plan. From this perspective, there is no conflict between AA involvement and MET. In fact, they can be quite compatible, particularly in the aftercare condition where the social support and philosophy of AA, if freely chosen by the client, can provide substantial assistance in achieving the goal of sobriety.

Feedback

Even after an inpatient stay, clients appear genuinely interested in
the results and can gain information, insight, and motivation from the
specific feedback given to them about their condition. Several cautions
need to be heeded in giving feedback in the aftercare condition that
may differ from the outpatient condition.

At times, the feedback on liver functioning and neuropsychological
functioning will appear to be nonproblematic. This can be interpreted
by a client as a sign that there are no problems or no damage. It is
important to remember that the tests given provide only gross indica
tors and are not designed to assess subtle signs of damage or dysfunc
tion. In other words, these tests do not give the client a clean bill of
health and, if negative, need to be contrasted with the significance of
the problem that needed hospital treatment. Having few indicators of
damage can also be reframed to convey the message that the client is
fortunate to not yet be showing gross symptoms. This message can be
used to increase motivation for sobriety, since sobriety can ensure
protection from any further alcohol-related damage.

Clients may be quite interested in having additional information and
explanation of their physical condition. Since they are coming from a
hospital setting, they may address the therapist as one who is well
versed in medical conditions and problems. It is important for thera
pists to clarify specific issues, to acknowledge when they do not know
an answer, and to obtain an answer for the next session or refer clients
to the physician in charge of their case in the hospital. Issues of
credibility and accuracy of information are important considerations
in the feedback process.

Ambivalence and Attribution ME therapists in aftercare settings should not be surprised to find ambivalence about drinking, and particularly about abstinence, among their clients. Many individuals who enter hospital treatment are motivated by external pressures or by current problems or concerns at the time of the hospitalization. The hospital stay can be a time of respite and even one of eroding motivation as the pressures or
concerns recede. Therefore, it is critical not to assume motivation for sobriety postdischarge. Often, clients are motivated not to go back to the hospital, never to get to that prehospital state again, and not to have as many problems that drove them to drink. If you listen carefully, you will hear that these are not motivations about drinking but about the problems drinking caused.

In exploring the drinking problem, it is often helpful to get a clear understanding of what led to the prehospital pattern of drinking and the reason for hospitalization. It would be important to continue to connect psychosocial problems with drinking whenever this can clearly be done. Understanding how the postdischarge plan will address both drinking and other lifestyle, relationship, and employment issues can be a fruitful avenue of discussion. Listen carefully for what abstinence from drinking will mean for this client and what it will entail. Many of these clients have been living in alcohol-saturated environments. In fact, this may be part of the reason for hospitalization. Discharge from the protected setting of the hospital will severely test plans and ideas about abstinence. Even a firmly motivated stance during the first session in the hospital can be shaken to the founda-tions at the second session after the client is discharged. The first few weeks can be quite volatile with respect to motivations about sobriety and plans for using certain coping measures to ensure sobriety.

Aftercare ME therapists need to be aware of these issues, probe for the ambivalence, and listen carefully to the client. Using reflective listen ing, supportive and empathic statements, and accurate, sensitive feedback will be particularly needed to handle the ambivalence of the aftercare client.

The hospital setting provides a safe environment for helping clients initiate an alcohol-free existence. The restricted setting, however, can have a deleterious effect on client attributions of success. Since access to alcohol cues is quite limited during detox and hospital stays, clients have to attribute some of their successful abstinence to external control. Part of the task of the aftercare ME therapist is to assist the client in retributing the success to internal causes. After all, the client chooses to enter and stay in the hospital and must choose the level of participation in the program as well as the level of commitment to sobriety. Thus, although it is true that the restricted setting is helpful, attribution to personal goals, effort, and achievement is important to increase self-efficacy. Since MET puts the responsibility for sobriety squarely on the client, it would be helpful to explore and assist in the attribution of success to the client rather than the hospital. This is an ongoing process that becomes more salient as the client is discharged and during the later sessions of MET.

Motivational Enhancement Therapy can be an effective aftercare treatment for clients discharged from various types of inpatient treatment. This aftercare approach can enhance the work accomplished by the clients during their inpatient program and can assist them in developing a solid plan for achieving and maintaining sobriety.

Appendix C: Therapist Selection,

Training, and Supervision in

Project MATCH

by Kathleen Carroll, Ph.D.

Specifications of treatment in manuals is intended to define and differentiate psychotherapies, to standardize therapist technique, and to permit replication by other investigators. However, it is essential that manual-guided therapies be implemented by qualified therapists who are trained to perform them effectively. Project MATCH uses extensive procedures to select, train, and monitor therapists in order to promote delivery of study treatments that are specific, discriminable, and delivered at a consistently high level of quality. These include (1) selection of experienced therapists committed to the type of therapy they would be performing, (2) extensive training to help therapists modify their repertoire to meet manual guidelines and to standardize performance across therapists and across sites, and (3) ongoing monitoring and supervision of each therapist's delivery of treatment during the main phase of the study to assure implementation of study treatments at a high and consistent level.

Therapist All MATCH therapist candidates are required to meet the following
Selection selection criteria: (1) completion of a master's degree or above in

counseling, psychology, social work, or a closely related field (some
exceptions to this requirement were made in individual cases), (2) at
least 2 years of clinical experience after completion of degree or
certification, (3) appropriate therapist technique, based on a video
; taped example of a therapy session with an actual client submitted to
the principal investigator at each site and to the Yale Coordinating
Center, and (4) experience in conducting a type of treatment consistent
with the MATCH treatment they would be conducting and experience
treating alcoholics or a closely related clinical population.
These criteria are intended to facilitate (1) selection of appropriate
therapists for the training program, as training is not intended to train
novice therapists, but to familiarize experienced therapists with man-ual-guided therapy, and (2) implementation of MATCH treatments by experienced and credible therapists. For example, therapists selected for the Cognitive-Behavioral Coping Skills Therapy (CB) are experienced in cognitive and behavioral techniques; thus, the CB therapists are predominantly doctoral or masters-level psychologists. Therapists for the Twelve-Step Facilitation Program are predominantly individuals who have gone through 12-step recovery themselves, have been abstinent for several years, and are typically masters-level or certified alcoholism counselors. Therapists selected for the recently developed Motivation Enhancement Therapy (MET) have worked extensively with alcoholics and typically have experience in systems theory, family therapy, and motivational counseling.

Therapist Training, supervision, and certification of therapists was centralized
Training at the Yale Coordinating Center to facilitate consistency of treatment
delivery across sites. Each therapist came to New Haven for a 3-day
intensive training seminar, which included background and rationale
for Project MATCH, extensive review of the treatment manual, review
of taped examples of MATCH sessions, and practice exercises. Each
therapist then returned to their clinical site and was assigned a
minimum of two training cases, which were conducted following the
MATCH protocol (e.g., weekly individual sessions, a maximum of two
emergency and two conjoint sessions, truncated sessions for patients
who arrived for a treatment session intoxicated).

All sessions from training cases were videotaped and sent to the Coordinating Center for review of the therapists' (1) adherence to manual guidelines, (2) level of skillfulness in treatment delivery, (3) appropriate structure and focus, (4) empathy and facilitation of the therapeutic alliance, and (5) nonverbal behavior. Yale Coordinating
Center supervisors review all training sessions and provide weekly individual supervision to each therapist via telephone. Supplemental onsite supervision is delivered weekly by the project coordinator at '
each Clinical Research Unit.

Therapists were certified by the Yale Coordinating Center supervisors following successful completion of training cases. Therapists whose performance on initial cases was inadequate were assigned additional training cases until their performance improved. The average number of training cases was three, and therapists completed an average of 26 supervised sessions before certification.

Ongoing Monitoring

To monitor implementation of Project MATCH treatments, facilitate
consistency of treatment quality and delivery across sites, and prevent
therapist "drift" during the main phase of the study, all sessions are
videotaped and sent to the Coordinating Center, where a proportion
of each subject's sessions (one-third of all sessions for Cognitive
Behavioral and Twelve-Step Facilitation, one half of all MET sessions) are reviewed by the supervisors. Telephone supervision is provided on a monthly basis by the Coordinating Center supervisors and supplemented with weekly onsite group supervision at each Clinical Research Unit.

All sessions viewed are rated for therapist skillfulness, adherence to manual guidelines, and delivery of manual-specified active ingredients unique to each approach. These ratings are sent monthly to the project coordinators at each site to alert local supervisors to therapist drift. Therapists whose performance deviates in quality or adherence to the manual are "redlined" by the Coordinating Center, and the frequency of sessions monitored and supervision is increased until the therapist's performance returns to acceptable levels.