There are a number of ways that substance abuse clients let treatment providers know they are not ready to change. Some simply state that they do not have a problem and are not interested in treatment. Others say that they only want to be in treatment to fulfill a legal mandate. Often, clients let counselors know that they have mixed feelings about recovery through their actions. While they espouse a commitment to recovery, sometimes vehemently, their actions say something different. They show up late for group, fail to comply with their treatment plan, violate program rules, decrease self-help group attendance, or submit positive urine samples.

Lack of motivation is one of the biggest challenges facing treatment providers. Research has shown that a majority of clients who enter treatment for substance abuse problems do not complete it (Shaffer & Robbins, 1995). How counselors respond to low motivation or a mixed commitment to recovery is therefore a critical issue in need of more attention.

Historically, many programs have viewed low motivation as evidence that the client had not "hit bottom." This view holds that the client has not yet experienced enough consequences associated with their substance use to make a commitment to recovery. The client may be told that they are "not ready" for treatment and should return when they are able to make a stronger commitment. A lack of commitment, particularly in residential programs, may be viewed as having a negative impact on other clients who are more committed to recovery.

Stages of change

William Miller and colleagues (Miller & Rollnick, 1991; Miller et al., 1992, 1995; Miller, 2000) have developed a model that is based on an alternative view of motivation. Their treatment model known as Motivational Enhancement Therapy (MET), or its shorter version known as Motivational Interviewing (MI), draws upon the "stage of change" model developed by Prochaska and colleagues (Prochaska & DiClemente, 1986; Prochaska, DiClemente, & Norcross, 1992). This model suggests that there are five stages that describe clients' readiness for change: pre-contemplation, contemplation, preparation for change, action, and change maintenance. During pre-contemplation, the client has no awareness of the consequences of his or her addiction and no thoughts about making changes. At the contemplation stage the client begins to recognize some consequences associated with addiction and begins to consider whether a change is necessary. The preparation for change stage is characterized by the client considering various strategies to make changes in his or her substance use. In the action stage one begins to make the changes that are planned, and in the change maintenance stage strategies are developed to maintain the gains.

This view of a continuum of change contrasts with previous dichotomous notions that clients are or are not ready for change - either they have hit bottom or they have not. On the other hand, the MET perspective sees clients as transitioning through several different stages of readiness to change. The goal is to help clients move along the continuum from pre-contemplation toward action.

After reviewing the research showing that MET is effective, several strategies are described for using MET at the beginning of treatment, particularly with clients who are resistant. Finally, it is suggested that MET can be an effective intervention when clients prematurely drop out of treatment or are discharged due to various rule violations.

Facilitating stage-change

There are a number of fundamental principles that are used throughout MET to help clients transition through the stages of change. In addition, some strategies described by Shaffer and Robins (1995) are specific interventions for each stage of change. Therefore, before describing their prescriptive use of MET, the overall philosophy and specific techniques will be briefly described.

A substantial part of the MET approach draws on the Client Centered model of counseling developed by Carl Rogers and his colleagues (Miller & Rollnick, 1991). Many of the techniques of Client Centered counseling have become standard skills that students learn in counselor training programs (e.g., empathy, open questions, reflective listening, affirmations, summary statements). The philosophy of the model emphasizes a tone of respect, a non-confrontational stance, personal growth through increased self-awareness, and a view that some clients can often change using their own untapped resources.

In developing MET, Miller and colleagues (Miller & Rollnick, 1991; Miller et. al., 1992; Miller et. al., 1995; Miller, 2000) expanded on the basic principles of Client Centered Therapy in several respects. First, they developed the concept of "rolling with resistance." This refers to a stance of acknowledging the client's arguments to not make changes, rather than confronting the client's resistance. From their perspective, confronting resistance or denial only fuels resistance and puts the client in a position of arguing with the counselor against the need for change. Hence, the client stays stuck in a pre-contemplation stage. In contrast, use of MET skills such as reflection or open questions allows for an honest self-examination about the client's motivation to continue substance use. Once the counselor acknowledges this part of the client's experience, it opens the door to examine negative aspects of substance use. Exploration of the client's motivation to use substances as well as his or her reasons to stop or change is the technique known as exploring ambivalence. This examination of ambivalence is key to helping clients move along the stages of change continuum from the pre-contemplation stage into the contemplation stage, and ultimately toward the action stage.

From the MET perspective, it is the ambivalence, not denial, that is the core issue in addiction treatment (Shaffer & Robbins, 1995). The client invariably presents an internal struggle pulling them toward use of substances and simultaneously pulling them toward sobriety. Gently helping the client move into their ambivalence and share it with the counselor is a vital but difficult MET skill. It requires skills that go beyond standard Client Centered counseling.

Miller and colleagues (Miller & Rollnick, 1991; Miller et al., 1992; Miller et al., 1995; Miller, 2000) have developed a number of more directive or strategic types of interventions that help counselors guide clients into ambivalence. In addition to the aforementioned technique of rolling with resistance, counselors "heighten discrepancies" by pointing out how the client's use of substances conflict with his or her goals or values. Counselors also provide objective, non-judgmental "feedback" about the consequences of the client's substance use. The content of the feedback can come from structured questionnaires or worksheets that the client completes before the session or from material in the counseling session itself. It is important to try to keep the feedback factual and avoid arguing with the client if he or she disputes the feedback. An important MET principle to keep in mind is that the responsibility for making changes is always with the client. "Eliciting self-motivating statements" is a technique where the counselor asks open questions that help the client examine reasons or advantages of making changes. A second way to implement this technique is to highlight those statements that the client makes that reflect motivation to change. The counselor waits for opportunities to reflect these self-motivating statements and then follows up with open-ended questions about the content of the statements. Finally, counselors use "double-sided reflections," which summarize the client's stated reasons for wanting to continue substance use and reasons for wanting to decrease or stop.

Once the ambivalence is tipped in favor of a desire to make changes, the counselor uses other directive or strategic interventions to help the client proceed into the preparation for change and action stages. Discussion of "change planning" helps the client develop a plan for changes that are relative to his or her substance use. Although the development of changing goals is collaborative, it is important that the motivation come primarily from the client rather than the counselor. If the client espouses a goal that appears to be unrealistic, the counselor can then provide objective feedback about the potential challenges involved in achieving such a goal.

The client's strategies for achieving goals should draw on his or her own ideas, strengths, and resources. The counselor reinforces and affirms the client's "self-efficacy," the belief that one can make the changes that he or she wants to make. It is important for the counselor to avoid prescribing a pre-determined method of achieving the identified goals. However, it can be helpful for the counselor to give the client advice on how to achieve goals if the client asks for it or the counselor checks with the client to find out whether he or she is interested in suggestions.

Shaffer and Robbins (1995) present a model of MET that provides additional guidance about using MET more prescriptively during different stages of change. While they adhere to the strategies described above, they also add some additional considerations that are worth noting. First, when the client is in the action stage, they more aggressively point out the need to focus on strategies for change. Because the client is ready for change, he or she may be receptive to cognitive behavioral interventions for substance use as well as psychoeducation about a variety of other strategies for change. Shaffer and Robbins (1995) point out that people who are successful in dealing with substance abuse problems make observable changes in their lives. They change their social networks, enter treatment programs, join self-help or spiritual groups, and engage in growth-oriented activities such as meditation or psychotherapy. Because of the need for action, it can be a mistake during the action stage for the counselor to be too passive and focus primarily on ambivalence or reflective strategies. Such an approach would constitute an empathic failure because the counselor would not be responding to the needs of the client. Instead, advice, psychoeducation, and reinforcing client's self-efficacy are preferred interventions.

In contrast, a focus on change activities during precontemplation or contemplation is usually not advisable because the client experiences it as external coercion to change. Hence, the therapeutic relationship is damaged and the client's internal motivation to change is not elicited. During precontemplation and contemplation stages, preferred strategies include working with ambivalence, providing feedback, and an open exploration about the role of substance use in the client's life.

The description of MET techniques presented is not intended to suggest a rigid implementation of their use. Rather, it is intended to identify basic skills, the overall tone and purpose of MET, and general considerations about how to use different techniques most effectively. The application of Motivational Enhancement Therapy is always primarily based on the specific situation that each client presents.

Research on MET

MET has enjoyed increasing empirical validation as an effective intervention for alcohol and drug problems (Brown & Miller, 1993; Project MATCH Research Group, 1997, 1998; Martino et al., 2000; Saunders et al., 1995; Sellman et al., 2001). Some of these studies have examined the use of one or two MET sessions before more intensive treatment (Brown & Miller, 1993; Martino et al., 2000; Saunders et al., 1995). Others have examined the use of a four session MET model as a brief stand-alone treatment (Project MATCH Research Group, 1997, 1998; Sellman et al., 2001).

The studies that examined MET as a preparation for more intensive treatment found that clients who received the MET counseling had better engagement in treatment and better outcomes at follow-up than clients who did not receive MET counseling. As a stand-alone treatment for mild to moderate alcohol problems, MET was found to help clients significantly decrease their use of alcohol. In the Project MATCH study, four sessions of MET had outcomes that were equal to 12 cognitive behavioral sessions and 12 twelve-step facilitation sessions. Yet, the overall conclusion of MATCH was one that no therapy was significantly better than the other.

The research studies on MET have resulted in the development of structured treatment manuals to guide counselors in its use. One was developed for the Project MATCH study (Miller et al., 1992) of alcohol dependence and the other was developed for the National Institute of Drug Abuse (NIDA) study that is using MET in outpatient drug treatment (Carroll et al., 2000; Obert & Farentinos, 2000). The Project MATCH manual is available by contacting the National Institute on Alcohol Abuse and Alcoholism and the NIDA manual is currently being studied. Because of space limitations, the specifics of the manuals will not be reviewed here. However, the goal of the manuals is to provide direction for counselors in how to use MET and there are specific issues to focus on in each session. With more emphasis being placed on outcomes in substance abuse treatment, it is likely that the field will see more treatment manuals being used as a way to ensure quality and consistency in the delivery of services.

Using MET to prepare clients for treatment

There are several ways that substance abuse programs can use MET to prepare clients for treatment. One is to integrate MET principles into the intake interview at the beginning of treatment. Another is to provide several sessions to clients who are highly ambivalent about treatment or who are in a pre-contemplative stage. These sessions can be implemented at the treatment facility or by outside therapists not affiliated with the program. It is an opportunity for the therapist to increase motivation among those clients who would otherwise be vulnerable to premature termination. It also provides clients with insights about their substance abuse issues that help them engage in productive therapeutic work earlier.

Clients who do not succeed in treatment

An issue that the MET literature has not addressed is how to use MET for clients who refuse to enter treatment after the initial intake, prematurely drop out, or are asked to leave because they do not meet the program's expectations. These are clients that programs have typically labeled as "not ready" for treatment or are not yet "hitting bottom."

An alternative to waiting for them to hit bottom is to interview a client using MET methods. In most cases, the use of a therapist not associated with the program is indicated because it provides a more neutral perspective. It would be difficult for staff that has been presenting a structured model of treatment to the client to suddenly step back and take on an objective MET stance. Also, it may be difficult for the client to view the therapist as non-judgmental if the client left the program with an overall negative experience of it.

There are several ways that MET sessions can be helpful to a client who prematurely terminates treatment. First, the therapist can apply MET strategies to help the client examine his or her experience in treatment.

For example, the concept of ambivalence can be used to help clients examine the benefits derived from treatment as well as the disappointments. The "double-sided" exploration of the treatment experience can help counteract the tendency to devalue the entire program and discount benefits the client may have experienced despite the premature termination. Reflection of self-efficacy and self-motivating statements are essential.

Second, MET sessions after termination can help the client re-examine his or her motivation for sobriety, as well as the challenges faced in attempting to establish and maintain a recovery program. Part of this discussion should include the difficulties faced in the treatment program, other options available to the client, and what the client might do differently if a decision is made to re-enter the treatment program.

Providing hope

One of the biggest tragedies in the addictions field is the sense of failure many clients feel when they do not succeed in a program. That sense of failure is sometimes fueled by counselors' views that the client has not hit bottom or is not ready for treatment. The result is that the client gives up on their attempts to establish sobriety and regresses away from the action stage to the contemplation or pre-contemplation stage. MET interventions can be invaluable as a means of reenergizing motivation for change and hope for recovery.

Douglas L. Polcin, EdD, MFT, is a licensed therapist and consultant specializing in Motivational Enhancement Therapy in Concord, California. He is also a research psychologist in substance abuse at the Haight Ashbury Free Clinic in San Francisco, where he is a Co-Investigator of a National Study of MET. Dr. Polcin teaches courses in substance abuse treatment at the University of California, Berkeley program in Alcohol and Drug Abuse Studies and Dominican University of California. He can be reached via e-mail at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
    Brown, J.M. & Miller, W.R. (1993). Impact of motivational interviewing on participation and outcome in residential alcoholism treatment. Psychology of Addictive Behaviors, 7, 211-218.
    Carroll, K.M., Farentinos, C., Ball, S.A., Crits-Christoph, P., Libby, B., Morgenstern, J., Obert, J, Polcin, D., & Woody, G. (2000). CTN: Motivational Enhancement Treatment to Improve Treatment Engagement and Outcome in Individuals Seeking Treatment for Substance Abuse. New Haven, CT: Yale University.
    Martino, S., Carroll, K.M., O'Malley, S.S., Rounsaville, B.J. (2000). Motivational interviewing with psychiatrically ill substance abusing clients. American Journal of Addiction, 9(1), 88-91.
    Miller, W.R. (2000). Rediscovering fire: Small interventions, large effects. Psychology of addictive behaviors, 14(1), 6-18.
    Miller, W.R. & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.
    Miller, W.R., Zweben, A., DiClemente, C.C., & Rycharik, R.G. (1992). Motivational enhancement therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence (NIAAA Project MATCH Monograph, Vol. 2; DHHS Publication No. ADM 92-1894). Washington D.C.: U.S. Government Printing Office.
    Miller, W.R., Brown, J.M., Simpson, T.L., Handmaker, N.S., Bien, T.H., Luckie, L.F., Montgomery, H.A., Hester, R.K. & Tonigan, J.S. (1995). What works? A methodological analysis of the alcohol treatment outcome literature. In R.K. Hester and W.R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives. Boston, MA: Allyn & Bacon.
    Obert, J.L. & Farentinos, C.F. (2000). Motivational Enhancement Therapy (MET) to Improve Treatment Engagement and Outcome in Subjects Seeking Treatment for Substance Abuse. Washington D.C.: Clinical Trials Network, NIDA.
    Prochaska, J.O. & DiClemente, C.C. (1986). Toward a comprehensive model of change. In: W.R. Miller and N. Heather (Eds.), Treating Addictive Disorders: Processes of Change (pp. 3-27). Applied Clinical Psychology Series, New York, NY: Plenum Press.
    Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114.
    Project MATCH Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment outcomes. Journal of Studies on Alcohol, 58, 7-29.
    Project MATCH Research Group. (1998). Matching alcoholism treatments to client heterogeneity: Projects MATCH 3-year drinking outcomes, Alcohol: Clinical & Experimental Research, 22(6), 1300-1311.
    Saunders, B., Wilkinson, C. & Phillips, M. (1995). The impact of a brief motivational intervention with opiate users attending a methadone program. Addiction, 90, 415-424.
    Sellman, J.D., Sullivan, P.F., Dore, G.M., Adamson, S.J. & MacEwan, I. (2001). A randomized controlled trial of motivational enhancement therapy (MET) for mild to moderate alcohol dependence. Journal of Studies on Alcohol, 62(3), 389-396.
    Shaffer, H.J. & Robbins, M. (1995). Psychotherapy for addictive behavior: A stage change approach to meaning making. In A.M. Washton (Ed.), Psychotherapy and Substance Abuse: A Practitioner's Handbook. New York: Guilford Press.

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