Approaches to Drug Abuse Counseling U.S. Department of Health and Human Services, National Institutes of Health William R. Miller 1. OVERVIEW, DESCRIPTION, AND RATIONALE 1.1 General Description of Approach?
Motivational Enhancement Therapy (MET) seeks to evoke from clients their own motivation for change and to consolidate a personal decision and plan for change. The approach is largely client centered, although planned and directed.
1.2 Goals and Objectives of Approach?
As applied to drug abuse, MET seeks to alter the harmful use of drugs. Because each client sets his or her own goals, no absolute goal is imposed through MET, although counselors may advise specific goals such as complete abstention. A?broader range of life goals may be explored as well.
1.3 Theoretical Rationale/Mechanism of Action?
MET is based on principles of cognitive and social psychology. The counselor seeks to develop a discrepancy in the client’s perceptions between current behavior and significant personal goals. Consistent with Bem’s self-perception theory, emphasis is placed on eliciting from clients self-motivational statements of desire for and commitment to change. The working assumption is that intrinsic motivation is a necessary and often sufficient factor in instigating change.
1.4 Agent of Change?
The client is the agent of change, with assistance from the counselor.
1.5 Conception of Drug Abuse/Addiction, Causative Factors?
Drug problems are viewed as behaviors under at least partial voluntary control of the client, which are subject to normal principles of behavior change. Drugs of abuse are assumed to offer inherent motivating properties to the drug abuser, which by definition have overridden competing motivations. The task in MET is to elicit and strengthen competing motivations.
2. CONTRAST TO OTHER COUNSELING APPROACHES 2.1 Most Similar Counseling Approaches?
MET bears many similarities to Rogerian client-centered counseling but is directive rather than nondirective. There are also certain similarities to cognitive therapy and reality therapy.
2.2 Most Dissimilar Counseling Approaches?
MET is strikingly dissimilar from counseling approaches designed to oppose denial and break down defenses through direct confrontation. Furthermore, MET differs from behavioral approaches in that no direct advice or skill training is provided.
3. FORMAT 3.1 Modalities of Treatment?
MET is typically conducted as individual counseling, though family members may also be present and engaged. Group MET is conceivable but untested.
3.2 Ideal Treatment Setting?
MET has been tested and found effective in both outpatient and inpatient settings. There is no necessary or ideal setting.
3.3 Duration of Treatment?
MET is typically brief, limited to two to four sessions that each last 1 hour.
3.4 Compatibility With Other Treatments?
MET can be a suitable prelude to other treatment approaches designed to enhance treatment response. It has been shown to increase client compliance in subsequent alcoholism treatment and thereby to improve outcome.
3.5 Role of Self-Help Programs?
MET does not formally involve any self-help group, although participation in such groups may be part of a client’s chosen change plan. MET is wholly compatible with a 12-step approach.
4. COUNSELOR CHARACTERISTICS AND TRAINING 4.1 Educational Requirements?
MET has been effectively administered by prebachelor’s-level university students working as supervised paraprofessional counselors. Education level may not be a critical determinant of effectiveness in using MET.
4.2 Training, Credentials, and Experience Required?
Specific training in MET is important. A skillful MET practitioner makes the process look easy and natural, but in fact the component skills require substantial practice and shaping.
Initial intensive training of 2 to 3 days with subsequent supervised experience in MET is recommended. Training initially focuses on the rationale for MET and the establishment of sound reflective listening skills without which other aspects of MET cannot be implemented effectively. Once these skills are in place, training proceeds to other strategies for enhancing motivation and strengthening commitment to change. Counselors new to this approach are unlikely to implement it successfully, based on a single workshop, without ongoing supervision.
4.3 Counselor’s Recovery Status?
The counselor’s recovery status is largely irrelevant in MET. Some research has found that counselors in early recovery tend to overidentify with clients and have difficulty in separating their own issues and advice from the counseling process. This would be a particular hindrance in MET.
4.4 Ideal Personal Characteristics of Counselor?
MET requires a high level of therapeutic empathy as defined by Carl Rogers (as opposed to empathy in the sense of having had similar experiences). High interpersonal warmth and congruence are also desirable. Counselors who cannot suspend their own needs, perceptions, and advice are ill suited to MET.
4.5 Counselor’s Behaviors Prescribed?
Common counselor behaviors in MET include asking open-ended questions, reflective listening, reframing, and supporting. A key strategy is developing discrepancy by eliciting the client’s own verbal expression of problems, concerns, reasons for change, and optimism regarding change. Counselors are instructed to “roll with” resistance rather than confronting it directly. Emphasis is also given to supporting client self-efficacy, the perception that change is possible and can be accomplished by the client. Assessment findings are often used as personal feedback to instill client motivation.
4.6 Counselor’s Behaviors Proscribed?
Most important is for the counselor to avoid what is termed the confrontation/denial trap, in which the counselor is placed in the position of defending the presence of a problem and the need for change, while the client argues that there is no problem or need for change. Argumentation is generally proscribed. The counselor also avoids taking on an “expert” role, which implies that the counselor will impart the solution to the client. Relatedly, counselors are encouraged to avoid “closed” (short answer) questions and specifically to avoid asking three questions in a row. Diagnostic labeling as problem drinker or alcoholic, for example, is specifically avoided.
4.7 Recommended Supervision?
Direct observation of sessions is vital to effective supervision with MET. Counselors are least able to observe or convey the very behaviors they most need to change. In advance of or during supervision, supervisors should review videotape or audiotape of sessions. It is particularly helpful for the supervisor and those supervised to use a structured observation sheet in following the sessions, coding the content of counselor and client responses as a means of attending to process rather than being caught up in content. Specific workshops for trainers of motivational interviewing are offered periodically.
5. CLIENT-COUNSELOR RELATIONSHIP 5.1 What Is the Counselor’s Role??
The counselor’s primary role is to elicit and consolidate the client’s intrinsic motivations for change. This facilitator role may include minor aspects as educator and collaborator. The expert/adviser role is deemphasized. When personal assessment feedback is provided as part of MET, the counselor temporarily assumes the role of educator.
5.2 Who Talks More??
The client should do more than half of the talking, except during a period of personal assessment feedback when the counselor has a substantial explanatory role.
5.3 How Directive Is the Counselor??
MET sessions are client centered but directive. There is a specific objective that the counselor pursues through systematic strategies. When MET is successfully conducted, however, the client does not feel directed, coerced, or advised. Direction is typically accomplished through open-ended questions and selective reflection of client material rather than through more overtly confrontational strategies and advice giving. To use a metaphor, the client and counselor are working a jigsaw puzzle together. Rather than putting the pieces in place while the client watches, the counselor helps to construct the frame, then puts pieces on the table for the client to place.
5.4 Therapeutic Alliance?
The rapid establishment of a working therapeutic alliance is an important aspect of MET. The basic conditions of client-centered therapy provide a strong foundation, with particular emphasis on the strategies of open-ended questions and reflective listening. Such supportive and motivation-building strategies are employed until resistance abates and the client shows indication of being ready to discuss change.
6. TARGET POPULATIONS 6.1 Clients Best Suited for?This?Counseling Approach?
Research to date has found MET to be effective with a broad range of severity of alcohol problems. No unique markers of differential response have been identified. Court-mandated clients appear to respond as favorably as those who are self-referred. One study has shown MET to be differentially effective (relative to a behavioral approach) with clients in the earliest stages of change (i.e., most unmotivated). MET has been evaluated well with problem drinkers, but its results are less studied with other drug problems. Two studies have reported positive results with marijuana and heroin users. The basic therapeutic style would remain the same regardless of target drug, but specific content (e.g., assessment feedback) may vary.
6.2 Clients Poorly Suited for?This?Counseling Approach?
MET may be insufficiently directive for clients who desire clear direction and advice. Research to date has identified no client characteristics that predict poorer response to MET than to alternative approaches. Brief counseling in general may be less effective as a stand-alone treatment with more severely impaired clients.
MET commonly includes a structured assessment of use, consequences, addiction, biomedical sequelae, family history, and other risk factors. A?variety of specific instruments could be used to assess these dimensions. Instruments that are sensitive to early stages of impairment are particularly desirable. A common sequence is to conduct a brief motivational interview to prepare the client for assessment. This is followed by structured assessment including the above dimensions. A third session then provides the client with personal feedback regarding the findings from assessment in relation to norms.
8. SESSION FORMAT AND CONTENT 8.1 Format for a Typical Session?
The content of an MET session depends on the client’s stage of motivation. Prochaska and colleagues (1992) have described four stages of readiness:
- Precontemplation, in which the individual is not considering change.
- Contemplation, in which the individual is ambivalent, weighing the pros and cons of change.
- Determination or preparation, where the balance tips in favor of change and the individual begins considering options.
- Action, which involves the individual taking specific steps to accomplish change.
With precontemplators, the counselor explores perceived positive and negative aspects of use. Open-ended questions are used to elicit client expression, and reflective paraphrase is used to reinforce key points of motivation. During a session following structured assessment, most of the time is devoted to explaining feedback to the client. Later in MET, attention is devoted to developing and consolidating a change plan.
8.2 Several Typical Session Topics or Themes?
The theme of the session is typically determined by the counselor, but specific content within the theme is provided by the client. Examples of common themes include:
- Good and not-so-good things about use.
- A typical day involving use.
- Reasons to quit or change.
- Ideas about how change might occur.
Sessions commonly begin with open-ended questions and end with a summary reflection.
8.3 Session Structure?
Sessions are rather structured, although in presentation they are flexible and client centered.
8.4 Strategies for Dealing With Common Clinical Problems?
Resistance of all types is met by a reflective “rolling with” strategy, rather than direct confrontation or opposition. For example, client minimization or rationalization might be met with various forms of reflective listening, such as double-sided reflection, where both sides of ambivalence are captured. The counselor might also agree with the client’s point but then reframe it. Standard program rules (e.g., regarding coming to sessions under the influence) may, of course, still be enforced.
8.5 Strategies for Dealing With Denial, Resistance, or Poor Motivation?
The central characteristic of MET is as follows: Resistance and poor motivation are not regarded as client characteristics but rather as cognitions and behaviors subject to interpersonal influence. Research demonstrates that a counselor can drive resistance levels up and down dramatically according to his or her personal counseling style. A respectful, reflective approach is used throughout MET with minimal advice or direction. The goal is still confrontation in the sense of bringing the client face to face with a difficult reality and thereby initiating change. Common strategies for decreasing resistance behaviors include variations on reflective listening (e.g., amplified reflection, in which the counselor takes the client’s resistance a step further), reframing or giving a new meaning to what the client has said, and selective agreement. Many of these take the form of the counselor giving voice to the client’s resistance, seeking to elicit the client’s own verbalizations of the need for change.
8.6 Strategies for Dealing With Crises?
Crises often offer particularly good windows of opportunity for motivation. Rapid availability of the MET counselor is desirable. Beyond the taking of immediate actions necessary to ensure safety, counseling strategies remain largely the same.
8.7 Counselor’s Response to Slips and Relapses?
Occurrences of renewed use are queried through open-ended questions and are explored through reflective listening. Judgmental responses are carefully avoided. The client’s own perceptions of the slip or relapse are explored, and renewed attention is given to the change plan and to what if anything may have been faulty in the prior plan.
9. ROLE OF SIGNIFICANT OTHERS IN TREATMENT?
Significant others (SOs) may be involved in MET sessions and can be useful sources of motivational material and change plans. The counselor must ensure that the SO does not behave in a manner that elicits resistance and inhibits motivation for change. The SO’s primary role is to offer his or her own observations and perceptions, with focus remaining on eliciting the client’s intrinsic motivation. The counselor may also employ MET strategies to strengthen the SO’s own motivation for change and elicit plans for behavior change. SO involvement can also make reasons for change more salient for the client. The implicit goal remains to instigate change in the client.
Prochaska, J.O.; DiClemente, C.C.; and Norcross, J.C. In search of how people change: Applications to addictive behaviors. Am Psychol 47:1102-1114, 1992.
William R. Miller, Ph.D.Regents Professor of Psychology and PsychiatryCenter on Alcoholism, SubstanceAbuse, and Addictions (CASAA)University of New MexicoAlbuquerque, NM 87131University of New MexicoAlbuquerque, NM 87131
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