Motivational Enhancement Therapy

Description of the Strategy

Motivational enhancement therapy (MET) was originally developed as one of three treatment methods [Page 380]tested in Project MATCH, a multisite clinical trial funded by the National Institute on Alcohol Abuse and Alcoholism and the largest study ever conducted with psychotherapies for alcohol use disorders. Project MATCH aimed to compare three treatment methods with very different conceptual-theoretical bases. MET was adopted as a treatment focused on increasing clients' intrinsic motivation for change. It was compared with cognitive behavior therapy intended to teach coping skills for relapse prevention and with a 12-step facilitation therapy designed to engage clients in the spiritual program of Alcoholics Anonymous.

MET combines two intervention methods: the clinical style of motivational interviewing and structured personal feedback from pretreatment evaluation. Prior to Project MATCH, this combination had been termed a “drinker's checkup,” in which a comprehensive evaluation was followed by a session in which the client received individual feedback of findings, delivered in an empathic and nonconfrontational counseling style. The drinker's checkup was subsequently adapted for use with various other target concerns, including tobacco smoking, marijuana use, heroin and cocaine use, and marital counseling (a “relationship checkup”).

The clinical style of motivational interviewing (MI) is described in a separate entry in this volume. In essence, MI is a clientcentered yet directive counseling method for helping people to resolve ambivalence and strengthen motivation and commitment to change. The MI counselor avoids arguing for change and instead elicits the client's own desire, reasons, perceived need and self-efficacy for change. Within MI, clients in essence talk themselves into change. In contrast to a deficit reduction view of clients—that they lack knowledge, skills, insight, or motivation that the therapist must install—MI assumes that the necessary motivations for change are already within the client, waiting to be evoked. MI does not, in itself, involve the use of formal pretreatment evaluation or personal feedback for clients. It is the addition of structured assessment feedback that differentiates MET from MI.

Although the treatment that was tested in Project MATCH required a prescribed set of alcohol-related assessment measures, the method of MET is not tied to particular measures. It could include nearly any reliable and valid measure that is pertinent to the target clinical issue. The Project MATCH intervention assessed drinking levels, blood alcohol (intoxication) peaks, ethanol tolerance and dependence levels, negative consequences of drinking, liver function tests, and neuropsychological tests sensitive to alcohol's early effects on cognitive functioning. For smokers, the pertinent dimensions might include carbon monoxide levels, lung capacity, cigarette consumption, and nicotine dependence level. In couples counseling, the checkup component could assess each partner's relationship satisfaction, communication style, sexual satisfaction, mood states, and shared pleasant events. A “spiritual checkup” could be devised using psychometrically sound measures of constructs such as meaning in life, concept of God, values, spiritual practices and experiences, and altruistic love. Other checkup formats are easily imagined for diet and exercise, psychological well-being, physical health, and quality of life.

To be useful in MET, scores from such assessment measures must be interpretable. The client's individual score can be compared with established standards for clinical interpretation (such as cutscores for mild, medium, substantial, or severe dependence) or with norms for general or clinical populations (ideally adjusted for gender and perhaps age). The clinician reviews each finding with the client, explaining the meaning of the measure, the client's own score, and that score's significance relative to norms. With regard to drinking or drug use, for example, we have quantified clients' own levels of use and then compared them with national norms to determine each client's percentile placement (e.g., the percentage of other men or women who use the same amount of the drug, or more). Comparison of self with relevant social norms has a well-established track record in effecting behavior change and is one example of more general processes of self-regulation whereby people adjust their behavior in response to goals and feedback.

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