Motivational Enhancement Therapy

Motivational Enhancement Therapy (MET) is a counseling approach that helps individuals resolve their ambivalence about engaging in treatment and stopping their drug use. This approach aims to evoke rapid and internally motivated change, rather than guide the patient stepwise through the recovery process. This therapy consists of an initial assessment battery session, followed by two to four individual treatment sessions with a therapist. In the first treatment session, the therapist provides feedback to the initial assessment, stimulating discussion about personal substance use and eliciting self-motivational statements. Motivational interviewing principles are used to strengthen motivation and build a plan for change. Coping strategies for high-risk situations are suggested and discussed with the patient. In subsequent sessions, the therapist monitors change, reviews cessation strategies being used, and continues to encourage commitment to change or sustained abstinence. Patients sometimes are encouraged to bring a significant other to sessions.

Motivation is a powerful predictor of change in recovery.

In recent years, addiction treatments have shifted away from punitive methods and abstinence protocols toward a focus on motivation and change-based interventions (Miller & Rose, 2009).

One such intervention is Motivational Enhancement Therapy (MET). MET is a behavioral intervention designed to help clients with substance use disorders.

It uses a variety of methods to promote motivation and elicit change (Miller, 1992). This article will describe the history and process of this therapy and discuss some training opportunities.

What Is Motivational Enhancement Therapy?

MET is a short intervention that uses motivational interviewing. But to explain it, let’s start with the beginnings.

A brief history of MET

A team of therapists developed it as part of Project MATCH, a large-scale study of addiction treatments (Miller, 1992). The eight-year study began in 1989 and aimed to match specific alcohol treatments to clients. MET was one of three therapies studied, along with Cognitive-Behavioral Therapy (CBT) and Twelve-Step Facilitation Therapy (TSF).

The researchers designed MET to be a standardized short-term motivational protocol. Initially, it was created to stand in as a control group (Longabaugh & Wirtz, 2001). Indeed, the lack of a true control group is one of the major criticisms of the study (Cutler & Fishbain, 2005). However, the results showed that MET was as effective as CBT and TSF (P.M.R. Group, 1998).

Results from Project MATCH were ultimately inconclusive regarding which treatments were best matched for each variable, but MET showed positive results as a short-term intervention (P.M.R. Group, 1998). It has continued to be used in various settings and studied as an intervention, although now it is generally seen as most effective when combined with other treatments (DiClemente, Corno, Graydon, Wiprovnick, & Knoblach, 2017).

How MET works

MET is a therapy designed to quickly produce internally motivated change (Miller, 1992). Based on motivational psychology, MET uses a combination of assessments, goal setting, and motivational interviewing to move a client from ambivalence about their recovery to a mindset of change.

MET comprises four carefully planned treatment sessions. Prior to treatment, the client completes a battery of assessments lasting 7–8 hours. The sessions can be envisioned as moving through three phases.

Phase one involves building the motivation for change. In this stage, the therapist reviews the assessments by presenting personal information that the client relayed.

Discussion around substance use involves the therapist empathically listening, reflecting back the client’s words and feelings, and attempting to elicit change-based language through open-ended questions. Once the therapist assesses that the client is ready for change, they can move to the next phase.

Phase two is a consolidation of change. This stage begins to move the client toward a plan for change. The plan is not prescriptive but rather created by the client. The therapist uses reinforcing and empowering statements, like “No one can decide this for you” and “It’s up to you what you do about this.” Together, the client and therapist create a change plan worksheet (found in the Medical Management Treatment Manual published by the US National Institute on Alcohol Abuse and Alcoholism).

Phase three consists of follow-through strategies. This could happen as soon as the second session, depending on the client’s initial motivation. The tools used in this phase are reviewing progress, renewing motivation, and redoing commitment.

Key components

There are 5 key components to motivational enhancement therapy:

• Express empathy – therapists seek to build trust and respect with the patient, making sure that each individual knows that the decision to change is ultimately up to him/her. The therapist acts as both a “supportive companion and knowledgeable consultant” in meetings.^[rx]
• Develop discrepancy – Clients attention is enhanced and focused on discrepancies. Raising a clients awareness of personal consequences brings about a motivation for change, allowing the client to willingly discuss options to change “in order to reduce the perceived discrepancy and regain emotional equilibrium”.^[rx]
• Avoid argument – Arguments will be avoided and not engaged in. Therapists use strategies to help clients see true consequences and reduce the “perceived positive aspects” of behaviors, such as drinking alcohol.^[rx]
• Rolling with resistance – As the resistance of some kind will exist. MET encourages that the therapist “roll with” these resistances, “with a goal of shifting clients perceptions”. Rather than therapists providing solutions, they are usually “evoked from the client”.^[rx]
• Support self-efficacy – Self-efficacy is defined as the way people view their own competence and achieve their own goals. Therapists encourage clients to realize they are capable of many things, including having the strength to give up alcohol.^[rx]

The Goal of MET

MET was created specifically for addiction recovery, and the goal is ultimately to increase motivation.

The entire purpose of MET is to move the client into a motivated state for change. After they have reached this state, the therapist and client can then work together to create a plan.

Unlike other forms of rehabilitation, MET does not set out to make abstinence the goal. It is emphasized as a clear option only after the client shows readiness to change.

The therapist may present data that shows the benefit of abstinence and even question the goal of moderation if the client desires that, but MET allows for the client to choose their own recovery goals. This is an important distinction, as many programs for addiction give a diagnosis and state expectations of removing the substance entirely. MET and other motivational therapies focus on autonomy and respect for the client.

Unlike CBT, which assumes that the client is already motivated and therefore does not have strategies to build motivation, MET has direct and clear principles and strategies for building client motivation. Motivational therapies are based on the belief that the client is capable of change and that they have the inner resources necessary to create that change.

MOTIVATIONAL ENHANCEMENT THERAPY GOALS AND PRINCIPLES

The primary goal of MET is to help individuals overcome their ambivalence or resistance to behavior change. MET focuses on increasing intrinsic motivation by raising awareness of a problem, adjusting any self-defeating thoughts regarding the problem, and increasing confidence in one’s ability to change. Instead of identifying a problem and telling a person in therapy what to do about it, the therapist encourages a person in therapy to make self-motivating statements that display a clear understanding of the problem and a resolve to change.

Although MET may be used as a stand-alone treatment, it is more often employed in conjunction with other forms of therapy. This type of therapy can also serve as a form of pretreatment that may increase a person’s motivation to start a more specific form of therapy, such as cognitive behavioral therapy. MET might also be used along with a different form of therapy to reinforce one’s motivation to change.

MET is based on five motivational principles that are designed to guide the therapist’s work with an individual in therapy:

• Express empathy: Therapists create a supportive environment in order to help an individual feel accepted and respected, and they engage in reflective listening rather than direct confrontation. The therapist will listen to what an individual is saying and then reflect it back, with slight but deliberate modifications. The modifications both let the individual know that the therapist has heard and understood and encourage the individual to elaborate.
• Develop discrepancy: In MET, the therapist directs attention toward the discrepancy between an individual’s desired state of being and that individual’s actual state of being. This discrepancy may help aid in recognizing the ways that current behaviors hinder one from achieving goals, and it can also provide a strong incentive for behavior change.
• Avoid argumentation: A therapist will avoid attacking an individual or an individual’s behavior, as this is thought to result in defensiveness and resistance. Other, gentler methods are used to raise awareness of any problems, and any statements regarding a need for change should come from the individual, not the therapist.
• Roll with resistance: Instead of directly confronting any resistance on the part of the individual, the therapist tries to defuse it, often through reflective listening or by simply going along with what an individual is saying. This approach may seem counterintuitive, but it decreases the odds of further defensiveness and may make it more likely that an individual will remain in therapy and benefit from other aspects of the intervention.
• Support self-efficacy: One’s motivation to change typically depends not only on the reasons for modifying behavior but also on the belief that one is able to perform the tasks required for change. One aspect of a therapist’s role is to help individuals become aware of their ability to successfully undertake the actions needed for change.

MET and Stages of Change: 6 Steps for Recovery

The transtheoretical model of the stages of change is incorporated into the MET process. These stages can be a good framework for envisioning the process of addiction recovery.

There are six stages of change, according to the model created by DiClemente and Prochaska (1998):

1. Pre-contemplation
2. Contemplation
3. Determination
4. Action
5. Maintenance
6. Relapse

In MET, the therapists meet the client in whichever stage they are in, and the goal is to assist them in moving through each of these stages. According to this model, the contemplation and determination stages are the most critical (Miller, 1992).

In the contemplation stage, the discussion focuses on the pros and cons of continuing to use the substance. This discussion will, in a non-judgmental way, assess how the client’s life might change, both for the positive and the negative. Tipping the balance toward change will help the client move from contemplation to determination.

In the determination stage, clients firm up their resolve to change. For a client in relapse, this can be fueled by remembering past attempts and how their lives were improving. For clients who are just starting out, developing self-efficacy by celebrating small wins and noticing the positive effects of the change can build confidence and determination.

The ideal path for change is to move from determination to action and eventually (after a few months) into the maintenance stage. For many in recovery, the path is not linear and may require several attempts. The good news is that even those who relapse can return to contemplation and move through the stages again.

MET vs Motivational Interviewing

Motivational interviewing is a theory of counseling developed by William R. Miller and Stephen Rollnick (2012).

It is a structured and goal-directed form of therapy with the overarching aim of enhancing motivation in the client.

Motivational Enhancement Therapy uses motivational interviewing (MI) as its core process. In that way, there is no difference in methodology or treatment focus. The only real difference between MET and MI is the structure.

MET is designed to be brief, lasting only four sessions, and was envisioned as a standalone treatment in situations where the therapist may have limited time with the client. MI on the other hand, is a technique that can be used in many settings and used in combination with other therapies.

“While MI represents a broader therapeutic approach, MET includes specific emphasis on personalized assessment, feedback, and change plans.”

Guydish, Jessup, Tajima, and Manser, 2010, p. 4

Motivational interviewing is widely used to treat substance use, but it can also be used in many other settings and is valuable in any situation where a client is struggling with motivation. MET, on the other hand, has been used only for reducing substance use and was designed with this need in mind.

Because MI is so much more flexible and multifaceted, it is more widely used. MI has decades of research to support its efficacy. Over 300 clinical trials have been published and a number of meta-analyses and reviews (DiClemente et al., 2017).

Motivational interviewing has been shown to be effective not only with reducing substance use but also to manage diabetes, dietary changes, hypertension, and mental illness (DiClemente et al., 2017). A Delphi poll of distinguished therapists ranked MI in the top five theoretical schools of counseling today (Norcross, Pfund, & Prochaska, 2013).

In general, MET falls under the umbrella of motivational therapies. It is considered a brief intervention and has the same efficacy and outcomes as other forms of motivational therapies (DiClemente et al., 2017).

5 Helpful Techniques to Apply

Motivational interviewing has five important techniques that are critical to developing motivation in a client.

These five techniques are also applied in MET.

1. Express empathy

The first and one of the most powerful therapeutic techniques is to express empathy to the client. It is critical to establish a trusting relationship in the MET program quickly because it is short-term.

A good way to foster trust is to show empathy through active listening, reflecting, and validating the client’s experience. The relationship between the therapist and client is not hierarchical or punitive, and the therapist shows respect for the client’s decisions.

MET therapists know that only the client can choose to change their substance use. The goal of therapy is to “compliment rather than denigrate, to build up rather than tear down” (Miller, 1992, p. 7).

2. Develop discrepancy

An important part of the process of moving from the pre-contemplation stage to contemplation is to develop discrepancy. This is the process of realizing the impact that substance use is having on the client’s life. The discrepancy lies between where the client would like to be and the reality of where they are.

It may take time for the client to realize this discrepancy. Once it’s realized, the client may be more willing to discuss change.

3. Avoid argumentation

It is important during the MET process that the client not be put into a defensive posture. Argument and pressure from the therapist may create this and can break down the trust that was established.

Realizing discrepancy can be a sensitive and painful process, and any attempt on the therapist’s side to label or pressure the client may cause them to revert back into pre-contemplation and choose to stay with the substance.

“When MET is done properly, the client and not the therapist voices the arguments for change” (Miller, 1992, p. 8).

4. Roll with resistance

A tenet of motivational interviewing is “rolling with resistance.” This points to the therapist’s ability to avoid challenging the client’s ambivalence.

The client’s uncertainty toward change is seen as part of the process and not viewed as pathological. Rather, the therapist works with the client to keep the momentum going. Resistance is met with reflection, rather than a challenge.

5. Support self-efficacy

The client must believe they have the ability to change if they desire it. This belief in our ability to meet goals is called self-efficacy.

MET works to increase self-efficacy. If the client doesn’t believe they can change, they may meet their discrepancy crisis with defensive coping. This will allow the client to reduce the discomfort brought on by the discrepancy without creating change – an understandable behavior. Building self-efficacy takes time and encouragement, which is created in the later sessions.

Techniques of Motivational Enhancement Therapy

MET is brief and time-limited. It typically lasts four sessions, but in some cases may last as long as six sessions.1

The first session consists of an assessment. The next two to five sessions utilize motivational interviewing strategies to help the client gain greater awareness, build motivation, and develop a plan to change.

Motivational interviewing is a counseling approach that helps people resolve ambivalence and improve motivation to change. It focuses on helping people become more willing, confident, and ready to change.2 Therapists also help clients explore coping strategies and encourage commitment to making a change.

Motivational interviewing approaches to therapy focus on five key motivational principles. During treatment, MET therapists may:

• Express empathy: This strategy involves helping people develop and express empathy for others. The goal is to help them understand how their own behavior affects other people. By gaining this understanding, people may then feel more motivated to change.
• Acknowledge discrepancy: Another key aspect of motivational enhancement therapy is recognizing that there is often a discrepancy between a person’s desired place to be and where they actually are. Being able to acknowledge this disparity between desire and reality can inspire people to take steps to bridge the gap.
• Avoid arguments: MET therapists do not argue with an individual about their behavior or substance use. Argumentation often triggers defensiveness and resistance to change, so gently and optimistically helping people become more aware can make the motivation to change come from within them rather than from someone else.
• Accept resistance: MET therapy recognizes that resistance is common. Instead of fighting it, therapists look for ways to defuse the struggle. The goal is to minimize resistance and allow the individual to stay in treatment and work toward building intrinsic motivation to change.
• Support self-efficacy: In order to make a change, people need to believe that they are capable of achieving their goals. Motivational enhancement therapy helps people improve self-efficacy so that they can recognize their strengths and gain a greater belief in their own capabilities.

Training in Motivational Enhancement Therapy: 2 Options

Because Motivational Enhancement Therapy was designed expressly for Project MATCH, the best way to learn the technique is through their manual, which is freely available online.

Unfortunately, formal training programs for MET do not exist. It is not currently a technique that is widely used, as motivational interviewing is much more broadly applicable. If you learn MI, it is simple to follow and apply the protocol outlined in the Project MATCH manual.

There are, however, many wonderful programs to become trained in MI. A thorough list can be found in our Training in Motivational Interviewing article.

A Take-Home Message

Motivational therapies have been an invaluable addition to the therapist’s toolbox in recent years. This is not surprising because therapists want to elicit change in their clients. For a long time, motivation was overlooked as a critical component of creating change.

Motivational Enhancement Therapy puts the emphasis on increasing the client’s motivation. This is critical in addiction recovery because although the knowledge that change is necessary may be there, motivation can be difficult to access because the draw of the substance is so strong. It’s critical that a client really identifies for themselves how their lives would be positively affected by the change.

Brief interventions like MET have been shown to be just as effective in recovery as other forms of substance use interventions (DiClemente et al., 2017).

This may be surprising, but it is heartening to know that even just four well-structured and targeted sessions with a client can have a lasting impact. MET shows that the techniques of respect, empathy, and compassion can go a long way toward creating health in our clients.