MET in Addiction Counseling Flashcards

Section 1: Introduction

• Motivational Enhancement Therapy (MET) is a systematic intervention for problem drinkers.
• It's based on motivational psychology to produce rapid, internal motivation for change.
• It mobilizes the client’s own resources instead of step-by-step guidance.
• Treatment involves an extensive assessment battery of 7-8 hours.
• Each session begins with a breath test; a positive result leads to rescheduling.
• MET includes four individualized sessions, ideally with a "significant other" (SO) in the first two sessions.
• Session 1 focuses on:
  • Providing structured feedback from assessments.
  • Addressing problems, consumption levels, symptoms, decisional considerations, and future plans.
  • Building motivation to initiate or continue change.
• Session 2 continues motivation enhancement and commitment consolidation.
• Follow-up sessions at weeks 6 and 12 monitor and encourage progress.
• All therapy is completed within 90 days.
• MET is an effective outpatient treatment requiring fewer therapist-directed sessions.
• It's particularly useful when contact is limited (e.g., general medical practice).
• Research supports MET strategies as effective for change in problem drinkers.

Research Basis for MET

• Research shows surprisingly few outcome differences between intensive and brief alcohol treatment programs.
• One interpretation is that all alcohol treatments are equally ineffective; however, research doesn't support this.
• Significant differences are found in nearly half of clinical trials, with brief treatments often more effective than no intervention.
• An alternative interpretation suggests a common core of effective ingredients, making extensive approaches unnecessary in many cases.
• This leads to a search for critical conditions necessary and sufficient to induce change.
• Miller and Sanchez (in press) described six active elements, 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 elements are consistent with research on what motivates problem drinkers for change.
• Interventions with these elements are effective in initiating treatment and reducing long-term alcohol use and related problems.
• Motivational intervention yields comparable outcomes even when compared with longer, more intensive approaches.
• Accurate empathy is a powerful predictor of therapeutic success, even with other rationales.
• Direct confrontation is predictive of continued client drinking 1 year after treatment.

Stages of Change

• People not considering change are in PRECONTEMPLATION.
• CONTEMPLATION involves considering having a problem and the feasibility/costs of changing.
• DETERMINATION is the decision to take action and change.
• ACTION is when individuals modify the problem behavior, lasting 3-6 months.
• MAINTENANCE is sustained change.
• RELAPSE occurs if efforts fail, beginning another cycle.
• The ideal path is direct from one stage to the next until maintenance.
• Most people with serious problems experience several slips or relapses.
• Most who relapse re-enter contemplation and the change process.
• Several cycles may be needed to learn how to maintain change.
• MET addresses the client's current stage and assists movement toward sustained change.
• The contemplation and determination stages are most critical for the ME therapist.
• The MET therapist helps clients consider two basic issues:
  • How much of a problem is their drinking behavior?
  • The balance of pros and cons of drinking toward change is essential.
• Clients assess the possibility and costs/benefits of changing.
• In the determination stage, clients develop a firm resolve to take action, influenced by past experiences.
• Understanding the cycle of change helps the ME therapist empathize and direct intervention strategies.
• The speed and efficiency of movement through the cycle will vary.
• The task is to assist the individual in moving from one stage to the next as swiftly and effectively as possible.
• MET is grounded in theory and research.
• It's consistent with understanding the stages and processes underlying change in addictive behaviors.
• It draws on motivational principles from experimental and clinical research.
• A motivational approach is supported by clinical trials and has a favorable cost-effectiveness compared to other approaches.

Section 2: Clinical Considerations

• MET assumes responsibility and capability for change lie within the client.
• The therapist creates conditions to enhance the client’s motivation and commitment.
• MET mobilizes the client’s inner resources and natural helping relationships.
• It supports intrinsic motivation for change, leading to initiation, persistence, and compliance.
• Miller and Rollnick (1991) described five basic motivational principles:
  • Express empathy
  • Develop discrepancy
  • Avoid argumentation
  • Roll with resistance
  • Support self-efficacy

Express Empathy

• The ME therapist communicates great respect for the client.
• Communications implying a superior/inferior relationship are avoided.
• The therapist's role is a blend of supportive companion and knowledgeable consultant.
• The client’s freedom of choice and self-direction is respected.
• 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.
• 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 Discrepancy

• Motivation for change occurs when people perceive a 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 behaviour.
• In pre-contemplators, it may be necessary first to develop such discrepancy by raising clients’ awareness of the personal consequences of their drinking.
• Such information, properly presented, can precipitate a crisis of motivation 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 Argumentation

• Ambivalence and discrepancy can resolve into defensive coping strategies if handled poorly.
• An unrealistic attack on their drinking behaviour tends to evoke defensiveness and opposition.
• 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.

Roll with Resistance

• How the therapist handles client “resistance” is a crucial and defining 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.

Support Self-Efficacy

• People who are persuaded that they have a serious problem will still not move toward change unless there is hope for success.
• Bandura (1982) has described “self-efficacy” as a critical determinant of behaviour change.
• Self-efficacy is, in essence, the belief that one can perform a particular behaviour 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.
• Unless this element is present, a discrepancy crisis is likely to resolve into defensive coping to reduce discomfort without changing behaviour.

Differences from Other Treatment Approaches

• The MET approach differs dramatically from confrontational treatment strategies in which the therapist takes primary responsibility for “breaking down the client’s denial.”

• 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”).

• The ME therapist emphasizes the client’s ability to change (self-efficacy) rather than the client’s helplessness or powerlessness over alcohol.

• Arguing with the client is carefully avoided, and strategies for handling resistance are more reflective than extortational.

• 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.”

• MET also differs substantially from cognitive-behavioural 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.

• MET 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.

• 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 behaviour change.

• Thus, MET is a directive and persuasive approach, not a nondirective and passive approach.

Section 3: Practical Strategies

• The MET approach begins with the assumption that the responsibility and capability for change lie within the client.
• The therapist’s task is to create a set of conditions that will enhance the client’s own motivation 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 motivation for change, which will lead the client to initiate, persist in, and comply with behaviour 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

Phase 1: Building Motivation for Change

• Motivational counseling can be divided into two major phases: building motivation for change and strengthening commitment to change (Miller and Rollnick 1991).
• The early phase of MET focuses on developing clients’ motivation to make a change in their drinking.
• Clients will vary widely in their readiness to change.
• This phase may be thought of as tipping the motivational balance (Janis and Mann 1977; Miller 1989; Miller et al. 1988).
• One side of the seesaw favors status quo (i.e., continued drinking as before), whereas the other favors change.
• The former side of the decisional balance is weighed down by perceived positive benefits from drinking and feared consequences of change.
• Weights on the other side consist of perceived benefits of changing one’s drinking and feared consequences of continuing unchanged.
• Your task is to shift the balance in favor of change.

Eliciting Self-Motivational Statements

• Motivational psychology has amply demonstrated that when people are subtly enticed to speak or act in a new way, their beliefs and values tend to shift in that direction.
• This phenomenon has sometimes been described as cognitive dissonance (Festinger 1957).
• Self-perception theory (Bem 1965, 1967, 1972), an alternative account of this phenomenon, might be summarized: “As I hear myself talk, I learn what I believe.”
• That is, the words which come out of a person’s mouth are quite persuasive to that person—more so, perhaps, than words spoken by another.
• If this is so, then the worst persuasion strategy is one that evokes defensive argumentation from the person.
• The positive side of the coin is that the ME therapist seeks to elicit from the client certain kinds of statements that can be considered, within this view, to be self-motivating (Miller 1983).
• These include statements of:
  • Being open to input about drinking.
  • Acknowledging real or potential problems related to drinking
  • Expressing a need, desire, or willingness to change.
• There are several ways to elicit such statements from clients. One is to ask for them directly, via open-ended questions. Some examples:
  • I assume, from the fact that you are here, that you have been having some concerns or difficulties related to your drinking. Tell me about those.
  • Tell me a little about your drinking. What do you like about drinking’? What’s positive about drinking for you? And what’s the other side? What are your worries about drinking?
  • Tell me what you’ve noticed about your drinking. How has it changed over time? What things have you noticed that concern you, that you think could be problems, or might become problems?
  • What have other people told you about your drinking? What are other people worried about? (If a spouse or significant other is present, this can be asked directly.)
  • What makes you think that perhaps you need to make a change in your drink?
• If it bogs down, you can inventory general areas such as:
  • Tolerance—does the client seem to be able to drink more than other people without showing as much effect?
  • Memory—has the client had periods of not remembering what happened while drinking or other memory problems?
  • Relationships—has drinking affected relationships with spouse, family, or friends?
  • Health—is the client aware of any health problems related to using alcohol?
  • Legal—have there been any arrests or other brushes with the law because of behavior while drinking?
  • Financial—has drinking contributed to money problems?
• Information from the pre-treatment assessment (to be used as feedback later) may also suggest some areas to explore.
• If you encounter difficulties in eliciting client concerns, still another strategy is to employ gentle paradox to evoke self-motivational statements.
• In this table-turning approach, you subtly take on the voice of the client’s “resistance,” evoking from the client the opposite side.

Listening with Empathy

• The eliciting strategies just discussed are likely to evoke some initial offerings, but it is also crucial how you respond to clients’ statements.
• The therapeutic skill of accurate empathy (sometimes also called active listening, reflection, or understanding) is an optimal response within MET.
• Acknowledgment of the client’s expressed or implicit feeling state may also be included.
• This way of responding offers a number of advantages:
  • (1) it is unlikely to evoke client resistance,
  • (2) it encourages the client to keep talking and exploring the topic,
  • (3) it communicates respect and caring and builds a working therapeutic alliance,
  • (4) it clarifies for the therapist exactly what the client means, and
  • (5) it can be used to reinforce ideas expressed by the client.
• Optimal reflective listening suspends advice, agreement, disagreement, suggestions, teaching, warning, and questioning in favor of continued exploration of the client’s own processes.

Questioning

• The MET style also includes questioning as an important therapist response.
• Rather than telling clients how they should feel or what to do, the therapist asks clients about their own feelings, ideas, concerns, and plans.
• Elicited information is then responded to with empathic reflection, affirmation, or reframing (see below).

Presenting Personal Feedback

• The first MET session should always include feedback to the client from the