Motivational enhancement therapy

1. Introduction

Version followed: Project MATCH Motivational Enhancement Therapy Manual (Miller, Zweben, DiClemente & Rychtarik; NIAAA Project MATCH Monograph Series Vol. 2, NIH Pub. No. 94-3723, 1992/1994, reprinted 1999), the four-session alcohol version. Gaps (session-by-session logistics, missed appointments, telephone contact, termination) are filled from the CASAA MET with Drug Abusers manual and the Yale FIRST-trial MET manual; each such borrowing is tagged.

What it is: a brief, manualised, four-session individual treatment that applies motivational interviewing (MI) plus structured, normative feedback from a pre-treatment assessment. It was written as one of the three Project MATCH treatments for alcohol problems and later adapted for drug use (and, per NREPP, for diet/activity, HIV risk, smoking and medication adherence). [source: MATCH-MET; NREPP]
Where it sits: it is sometimes placed with the person-centred/experiential approaches. The manual itself contrasts MET with nondirective Rogerian therapy: it keeps the empathic, client-centred stance but is deliberately directive and strategic. [source: MATCH-MET; MET-Drug]
How change happens: the client, not the therapist, is responsible for and capable of change. The therapist creates conditions (empathy, personalised feedback, developed discrepancy, support for self-efficacy) that tip the client's own decisional balance toward change, then helps the client turn that into a self-chosen, concrete plan. MET does not teach coping skills; it mobilises the client's own resources and natural supports. It draws on the stages-of-change model (precontemplation, contemplation, determination/preparation, action, maintenance, relapse), focusing mainly on contemplation and determination. [source: MATCH-MET; MET-Drug]
The FRAMES summary of active brief-intervention ingredients is built in: Feedback of personal risk, Responsibility of the client, Advice, Menu of options, Empathy, Self-efficacy. [source: MET-Drug; FIRST-MET]

2. Framework

Format and schedule (MATCH version)

Pre-treatment: a full assessment battery (about 7–8 hours in MATCH) whose results feed the Personal Feedback Report (PFR). [source: MATCH-MET]
Four individual sessions: Session 1 at week 1, Session 2 at week 2, follow-through Sessions 3 and 4 at weeks 6 and 12; all therapy completed within 90 days. [source: MATCH-MET; Greek translation of the same manual]
A significant other (SO), usually a spouse or partner, is invited to the first two sessions (up to two SO sessions). [source: MATCH-MET]
A breath alcohol test precedes every session; a positive reading means the session is rescheduled. [source: MATCH-MET]
MATCH required that MET not be combined with other therapeutic approaches during the treatment window, and sessions were videotaped for fidelity supervision. [source: MATCH-MET, Greek translation]
Session length: the MATCH text states no length [uncertain]. Comparators: the FIRST-trial adaptation uses 30–45 min for Session 1 and 20–30 min for follow-ups; an NREPP-reviewed trial used three 50-minute sessions. Plan roughly 50–60 min for Sessions 1–2 and less for follow-through if you have no other constraint [synthesis].
Drug-abuse version: same phase logic, within up to 12 sessions total (MET plus further treatment), up to two emergency sessions, all within three months of the first session (a protocol limit of that project, not a clinical rule). [source: MET-Drug]

Phase 1 — Building motivation for change (mainly Session 1, continued in Session 2 as needed)

Goal: tip the decisional balance toward change by eliciting the client's own concerns and reasons, presenting personalised assessment feedback, and resolving ambivalence without argument. [source: MATCH-MET]
Main tools: eliciting self-motivational statements, empathic listening, questioning, feedback, affirmation, handling resistance, reframing, summarising (section 4). [source: MATCH-MET]

Phase 2 — Strengthening commitment to change (end of Session 1 if ready; Session 2)

Goal: convert motivation into a specific, client-generated change plan (Change Plan Worksheet) and an explicit commitment, with the SO's role clarified. [source: MATCH-MET]
Criterion to enter: readiness signs (less resistance and fewer objections, fewer questions about the problem, a settled or unburdened manner, self-motivational statements about deciding or being open to change, imagining life after change). If these are absent, stay in Phase 1 and delay commitment. Moving in too early is named as a main risk. [source: MATCH-MET]
Criterion to finish: signed CPW and verbal commitment; or, if the client stays ambivalent, an agreed specific date to revisit the decision. [source: MATCH-MET]

Phase 3 — Follow-through (Sessions 3 and 4)

Each session: review progress since the last visit, renew motivation (Phase 1 processes), redo commitment (Phase 2 processes), and consider further treatment once goals are clear. [source: MET-Drug; MATCH-MET table of contents; FIRST-MET]
Moving back: any time ambivalence or resistance resurfaces, return to Phase 1 strategies; a decision does not end the need for them. [source: MATCH-MET]
Ending: termination recapitulation in the last session (section 4). [source: MET-Drug; FIRST-MET]

3. Guiding principles

The five MI principles named by the manual, plus the stance commitments it spells out. [source: MATCH-MET; MET-Drug]

Express empathy: respectful, non-hierarchical, skilled reflective listening; you are trying to understand, not to judge or fix.
Develop discrepancy: help the client see the gap between current use and their own goals and values; with precontemplators, first raise awareness of consequences.
Avoid argumentation: the client, not you, should voice the arguments for change; never push a diagnostic label such as 'alcoholic'.
Roll with resistance: treat ambivalence as normal; meet resistance with reflection, not confrontation; invite the client to generate solutions.
Support self-efficacy: give specific hope that change is possible; discrepancy without self-efficacy tends to produce defensiveness, not change.
Personal responsibility and free choice: say repeatedly, in plain words, that whether and how to change is the client's decision.
Resistance is shaped by therapist behaviour: the drug-abuse manual puts it as "client resistance is a therapist problem" — if you notice you are arguing, change strategy. [source: MET-Drug]
Directive but not prescriptive: you deliberately select what to reflect and steer toward discrepancy and commitment, but you do not tell the client what they must do.
Selective reinforcement: reflect, affirm and summarise self-motivational statements more than other material.
Supportive companion plus knowledgeable consultant: listen more than you tell; give information and advice when asked or with permission, always with qualifiers.
Motivation before skills: no skill training, no 'how-to' prescriptions, no coping-strategy teaching, no intensive marital therapy within MET; turn how-to questions back to the client.
Abstinence commended, not imposed: give every client a rationale for abstinence; the client chooses the goal (drug version: harm-reduction steps count as progress).
No powerlessness framing and no direct confrontation of 'denial'.
Ambivalence persists after a decision: change is often gradual and tentative; keep checking commitment rather than assuming it.
Client resources first: mobilise the client's own ideas and natural supports (especially the SO) rather than substituting the therapist's plan.

4. Intervention inventory

Order follows the course of treatment: session set-up, Phase 1 strategies, Phase 2 strategies, significant-other work, then follow-through and administrative procedures. All example wording is illustrative unless quoted and cited.

4.1 Pre-session sobriety check

Purpose: make sure the client can take in feedback and make decisions; used before every session. [source: MATCH-MET; MET-Drug]
Steps: (1) breath test before each session; (2) if positive (the drug-abuse manual uses a cut-off of .05) or there are clear signs of other drug impairment, reschedule rather than proceed; the drug manual allows a urine sample if impairment is disputed; (3) reschedule promptly and without moralising. [source: MATCH-MET; MET-Drug]
Example language (illustrative): "Today's reading tells me we wouldn't get the most out of this hour. Let's find a time this week when we can."
Watch for: the reschedule turning into a lecture; treat it as a practical matter and keep the alliance. Settings without breathalysers can rely on observed signs (the FIRST manual tests only when intoxication is suspected). [source: FIRST-MET]

4.2 Session 1 opening: introduction, rationale and limits of treatment

Purpose: set the collaborative frame and make client responsibility explicit from minute one. [source: MATCH-MET table of contents; MET-Drug; FIRST-MET]
Steps: (1) introductions, confidentiality limits, recording if any; (2) explain that this is a brief treatment with a set number of sessions, that you will go over the assessment results together, and that the client will decide whether and how to change; (3) say what MET is not (you will not tell them what to do or teach a programme); (4) move to open eliciting of concerns before feedback (the FIRST manual allots about 5 min to the introduction, 15 to open discussion, 10 to feedback). [source: MET-Drug; FIRST-MET]
Example language (illustrative): "Over these four sessions we'll look closely at your drinking, using the results of the tests you took. I won't be telling you what you have to do — that decision is yours. What I can do is help you see the picture clearly and think it through."
Watch for: clients expecting to be told what to do or confronted; name the difference early.

4.3 Eliciting self-motivational statements

Purpose: get the client, not the therapist, to voice concern and reasons for change. Three categories are named: openness to input about drinking, acknowledgement of real or potential problems, and expressed need, desire or willingness to change. [source: MATCH-MET]
Steps: (1) open questions about why they came, what they like and dislike about drinking, what concerns them, what others have said, why they might need to change; (2) once the client is talking, keep it going with reflection, requests for examples and "what else?"; (3) if it stalls, walk through topic areas — tolerance, memory lapses, relationships, health, legal, financial, work or school, and any pre-treatment assessment findings (the drug manual adds behaviour, coping, dependence, emotional and mental functioning). [source: MATCH-MET; MET-Drug]
Example language (illustrative): "What concerns you about your drinking?" … "What else?" … "Tell me about a time that happened."
Watch for: working sign = the client is producing the reasons; failing sign = you are supplying them, or the client is answering only with yes/no.

4.4 Gentle paradox (Phase 1)

Purpose: when direct eliciting stalls, voice the side against change so the client argues for it. [source: MATCH-MET; MET-Drug]
Steps: (1) state, without sarcasm, doubt about whether the client is concerned or wants to change; (2) or state the client's position slightly more strongly than they did, so they step back from it; (3) reflect what the client says next.
Example language (illustrative): "Maybe this isn't something that worries you enough to do anything about yet."
Watch for: any hint of sarcasm or manipulation; the manual warns overdoing it can provoke hostility. Use sparingly and only with a good alliance.

4.5 Listening with empathy (reflective listening)

Purpose: the main response throughout MET; builds alliance and selectively reinforces self-motivational content. [source: MATCH-MET]
Steps: (1) reflect what the client said, often slightly reframed, sometimes naming the feeling behind it; (2) choose what to reflect — prefer self-motivational statements, let other content pass; (3) for ambivalence, reflect both sides joined with "and"; (4) while reflecting, suspend advice, agreement, disagreement, suggestions, warnings and questions. [source: MATCH-MET]
Example language (illustrative): "So the hangovers are starting to cost you at work, and that bothers you more than you expected."
Watch for: working sign = the client elaborates and corrects you; reflecting only the pro-change side of an ambivalent client can evoke the other side. [source: MET-Drug]

4.6 Questioning

Purpose: draw out the client's own feelings, ideas, concerns and plans rather than telling them how to feel or act. [source: MATCH-MET]
Steps: ask an open question, then respond to the answer with reflection, affirmation or reframing — not another question.
Example language (illustrative): "How do you see your drinking fitting with what you want for your kids?"
Watch for: question–answer chains; aim for more reflections than questions [synthesis].

4.7 Presenting personal feedback (Personal Feedback Report)

Purpose: give objective, normative information about the client's own drinking and its effects, in a non-confrontational way, to develop discrepancy. Always done in Session 1. [source: MATCH-MET]
Content: the MATCH PFR covers alcohol consumption, estimated peak blood-alcohol levels, risk factors, problem severity, serum chemistry (liver-related blood tests) and neuropsychological test results, each compared with norms (Appendix A of the manual). Item-level details of Appendix A are [uncertain]. The drug manual uses its own PFR with a client handout, "Understanding Your Personal Feedback Report". [source: MATCH-MET table of contents; MET-Drug]
Steps: (1) give the client (and SO) a written copy; keep one; (2) go item by item: the client's score, what it means, how it compares with the normative range; (3) pause after each item; watch reactions, including non-verbal ones (sighs, tears), and reflect them; (4) reflect self-motivational responses; meet resistant responses with reframing or double-sided reflection; (5) periodically ask for the client's reaction, e.g. "What do you make of this?" or "Does this surprise you?"; (6) if the SO reacts, reframe the comment toward the caring behind it, then ask the client's own view; (7) know the battery well enough to answer questions accurately. [source: MATCH-MET]
Example language (illustrative): "This figure is your average number of drinks per week. Compared with adults in this country, it's higher than most. What do you make of that?"
Watch for: rushing through items to 'get the facts across'; arguing about accuracy (reflect the doubt, do not defend the test); feedback that overwhelms (slow down, affirm). Working sign = the client starts interpreting the results themselves.

4.8 Affirming

Purpose: strengthen alliance, self-responsibility and self-esteem; reinforce effort and self-motivational statements. [source: MATCH-MET]
Steps: notice and name genuine strengths, efforts and intentions, sincerely and regularly; affirm attendance, honesty, past change attempts.
Example language (illustrative): "It took real honesty to fill in those questionnaires as fully as you did."
Watch for: hollow praise; affirmations must be true and specific.

4.9 Handling resistance: general rule

Purpose: prevent the argument trap; resistance predicts poor outcome and is shaped by therapist style. [source: MATCH-MET; MET-Drug]
Steps: never meet resistance head on; do not argue, judge, warn, persuade with logic or evidence, interpret the resistance, invoke authority, use sarcasm or ask why the client resists. If you notice you are arguing, switch to one of the techniques in 4.10–4.13 or to simple reflection. [source: MATCH-MET]
Watch for: sustain talk (arguments for not changing) versus discord in the relationship; the FIRST manual names both and treats discord as a rupture to repair (section 5). [source: FIRST-MET]

4.10 Amplified reflection

Purpose: reflect a resistant statement in a more extreme form so the client backs away from it toward balance. [source: MATCH-MET]
Steps: (1) reflect the resistant statement, stated a little more absolutely than the client did; (2) keep the tone neutral; (3) reflect whatever the client says in reply.
Example language (illustrative): Client: "My wife exaggerates." Therapist: "So she has no real reason to be worried at all."
Watch for: overdoing it or sounding sarcastic, which the manual warns can provoke hostility.

4.11 Double-sided reflection

Purpose: acknowledge the resistant statement while adding the other side the client voiced earlier. [source: MATCH-MET]
Steps: reflect the current statement, then join it ("and") with something pro-change the client said before.
Example language (illustrative): "Drinking is how you unwind after a hard shift, and you also told me the mornings after are getting harder to face."
Watch for: using "but", which cancels the first half [synthesis].

4.12 Shifting focus

Purpose: step away from a stuck issue toward something workable. [source: MATCH-MET]
Steps: acknowledge briefly, then redirect to the current task or another topic.
Example language (illustrative): "I don't think the label matters much right now. What I'd like to understand is how drinking is affecting you."
Watch for: use it to defuse, not to avoid important material indefinitely.

4.13 Rolling with (accepting the opposing position)

Purpose: remove the pressure the client is pushing against. [source: MATCH-MET]
Steps: agree that the client may well decide to keep drinking as before; emphasise it is their choice; this often brings them back toward balance. Autonomy statements serve the same function in the FIRST adaptation. [source: MATCH-MET; FIRST-MET]
Example language (illustrative): "You may well decide this isn't worth changing. That's genuinely up to you."
Watch for: it must be sincere, not a tactic delivered with a wink.

4.14 Reframing

Purpose: recast information in a light that makes change seem meaningful or possible, using the client's own words. [source: MATCH-MET]
Steps: (1) take something the client presents as harmless or positive, or as hopeless; (2) offer an alternative meaning that keeps their dignity and opens options. Manual examples: high tolerance ('I can hold my liquor') reframed as a risk factor because it removes intoxication warning signals; drinking reframed as a reward after a hard week, as protecting the family from the client's stress, or as a way of keeping the marriage stable — each implying needs that could be met without drinking. [source: MATCH-MET; MET-Drug]
Example language (illustrative): "Being able to drink a lot without feeling it sounds like an advantage, but it also means your body has stopped sending you the warning."
Watch for: reframes that sound like a correction; offer tentatively and check the response.

4.15 Summarising

Purpose: let the client hear their own self-motivational statements again and link material. [source: MATCH-MET]
Steps: (1) brief progress summaries during the session; (2) a longer end-of-session summary; (3) include self-motivational statements and also the client's reluctance, so the summary is not rejected as one-sided; (4) close with a check such as what you missed. [source: MATCH-MET]
Example language (illustrative): "Let me pull together what you've said. On one hand … and on the other … What did I leave out?"
Watch for: the client correcting or adding — that is a good sign of engagement.

4.16 Recognising readiness (transition check)

Purpose: decide whether to move from Phase 1 to Phase 2. [source: MATCH-MET]
Steps: (1) look for the readiness signs: resistance and objections drop, fewer questions about the problem, the client seems more settled or unburdened, makes self-motivational statements about deciding or being open to change, imagines life after change; (2) run through the manual's readiness checklist of warning signs: missed or cancelled appointments not rescheduled; a coerced client who has not discussed their reactions (anger, relief); indecision about further sessions; treatment differing from expectations without this being discussed; guardedness or resistance to suggestions; treatment experienced as degrading rather than a fresh start; (3) if signs are lacking, explore ambivalence further and delay firm decisions. [source: MATCH-MET]
Watch for: the manual's named risks — moving too fast, pressing for commitment early, accepting an emphatic commitment without checking it, and forgetting that a decision can be lost if action is delayed.

4.17 Key (transition) questions

Purpose: open the shift from reasons to plans. [source: MATCH-MET]
Steps: summarise the reasons for change and remaining ambivalence, then ask an open question about what the client wants to do; follow with planning prompts about how and what could get in the way. Manual examples include "What do you make of all this?" and "What might stand in your way?" [source: MATCH-MET]
Example language (illustrative): "Given everything we've looked at, where does this leave you?"
Watch for: a flat or resistant answer means return to Phase 1, not push harder.

4.18 Discussing a plan

Purpose: negotiate a change plan built from the client's own ideas. [source: MATCH-MET]
Steps: elicit the client's options and ideas; reflect and summarise them; do not prescribe a plan or teach specific skills. [source: MATCH-MET]
Example language (illustrative): "What ideas do you have about how you might go about it?"
Watch for: you doing the planning. If the client asks you to, see 4.21.

4.19 Communicating free choice

Purpose: reduce reactance and reinforce responsibility. [source: MATCH-MET]
Steps: state repeatedly that the client is free to choose, including to continue drinking as before; the manual's example is "No one can change your drinking for you. Only you can do it." (drug version: "only you can change your drug use"). [source: MATCH-MET; MET-Drug]
Watch for: undermining this message elsewhere with warnings or 'musts'.

4.20 Consequences of action and inaction (decisional balance sheet)

Purpose: make the anticipated outcomes of changing and not changing explicit. [source: MATCH-MET]
Steps: (1) ask the client (and SO) what is likely to happen if drinking continues as now; (2) ask about benefits of change, fears about changing and what the client would miss; (3) optionally have the client write pros and cons for two options — continuing to drink as before vs changing; (4) respond with reflection, summary and reframing. [source: MATCH-MET]
Example language (illustrative): "If nothing changes, what do you imagine the next year looks like? And if you did change, what might be better?"
Watch for: lists dominated by the therapist's ideas; the content must come from the client.

4.21 Information and advice

Purpose: provide accurate information and the therapist's view without taking over the decision. [source: MATCH-MET]
Steps: (1) give specific, accurate information when the client or SO asks, then ask their reaction; (2) if asked for an opinion, give it with qualifiers (the decision is theirs; check they really want it); a mild 'hard to get' stance is allowed; (3) acceptable advice: what change seems needed, client and SO working together, general kinds of changes that support sobriety; (4) turn requests for specific how-to strategies back to the client; (5) if you do not know, say so and offer to find out. [source: MATCH-MET] The FIRST adaptation frames this as elicit–provide–elicit: ask what they know, give information with permission, ask their reaction. [source: FIRST-MET]
Example language (illustrative): "I can tell you what I think, if you'd like, though you're the one who'll decide. Would that help?"
Watch for: advice slipping into skill training or instruction.

4.22 Goal negotiation: emphasising abstinence

Purpose: make sure every client hears a rationale for abstinence while keeping choice. [source: MATCH-MET]
Steps: (1) commend abstinence rather than prescribe it; avoid coercive language; (2) cover three points with everyone: successful abstinence is a safe choice; there are good reasons to try a period of abstinence (learning how dependence developed, breaking habits, building confidence, pleasing a partner); no one can guarantee a safe level of drinking; (3) argue persuasively but not coercively against moderation when any of these apply: liver disease or other medical conditions worsened by drinking, psychological problems likely to worsen, idiosyncratic intoxication, strong external demands to abstain, pregnancy, medications hazardous with alcohol, a history of severe problems or dependence; (4) use the manual's severity tables (MAST/ADS ranges and long-term outcome data) to tell high-severity clients considering moderation that people with similar scores did far better with abstinence; (5) for clients not ready to commit to abstinence, offer intermediate options such as a time-limited trial of abstinence (the manual gives about three months as an example) or tapering toward abstinence. [source: MATCH-MET]
Drug version: abstinence is presented as the safest choice, but harm-reduction steps (e.g. safer injecting, less hazardous routes or drugs, reduced use) count as progress; insisting on abstinence may increase dropout; voice concern about specific risks such as pregnancy or medication interactions. [source: MET-Drug]
Example language (illustrative): "I can't tell you there's a safe amount for you to drink, given your liver results. Some people choose to try three months without alcohol and see how it goes. What do you think of that?"
Watch for: goal arguments that become power struggles; return to reflection and choice.

4.23 Paradox and value dilemmas in Phase 2

Purpose: handle residual resistance during commitment work. [source: MATCH-MET]
Steps: (1) gently give permission to continue drinking as before; or (2) pose a dilemma by setting two of the client's inconsistent goals or values side by side and asking whether both are possible. [source: MATCH-MET]
Example language (illustrative): "I'm wondering whether it's possible to keep drinking the way you have and also keep the marriage you've described wanting."
Watch for: sarcasm; use only within a solid alliance.

4.24 Change Plan Worksheet (CPW)

Purpose: record the client's plan in their own words. [source: MATCH-MET; FIRST-MET]
Steps: (1) do not start Phase 2 by filling in the form; let content emerge in dialogue, then use the CPW as a checklist; (2) cover six areas: changes the client wants to make (including positive things to start or increase, not only things to stop); the most important reasons; concrete first steps (when, where, how); how other people, including the SO, can help; how the client will know the plan is working; what could interfere and how to handle it; (3) the client keeps the original (the manual suggests carbonless forms); the therapist keeps a copy. [source: MATCH-MET]
Example language (illustrative): "Let's get down on paper what you've been telling me, so you can take it with you."
Watch for: vague steps; ask "when" and "where" until the first step is specific.

4.25 Recapitulation

Purpose: a broad summary near the end of commitment work to consolidate the decision. [source: MATCH-MET]
Steps: summarise the concerns from Phase 1, any new information, the client's self-motivational statements, the SO's role and the plan; invite corrections and add them to the CPW; check accuracy. [source: MATCH-MET; MET-Drug]
Example language (illustrative): "Here's how I understand where you've got to… Do I have that right?"

4.26 Asking for commitment

Purpose: obtain a verbal (and signed) commitment to the plan. [source: MATCH-MET]
Steps: (1) ask directly whether the client is ready to commit; (2) review the CPW, reinforce expected benefits and the consequences of not changing; (3) ask about fears, doubts and obstacles and how client and SO would handle them; (4) clarify the SO's role and the follow-up visits (weeks 6 and 12 in MATCH); (5) the client signs the CPW; (6) if the client remains ambivalent, do not force it: accept the ambivalence, express confidence they will resolve it, and agree a specific date to revisit the decision. [source: MATCH-MET]
Example language (illustrative): "Is this something you're ready to commit to?" / "It sounds like you're not quite there. How about we come back to this decision on the 14th?"
Watch for: an over-emphatic yes; probe it gently (the manual warns against accepting such commitments uncritically).

4.27 Involving the significant other

Purpose: build rapport with the SO, increase their awareness of the problem, strengthen their commitment and sense of their own role, gather their feedback and improve cohesion. This is collaborative involvement, not marital or family therapy. [source: MATCH-MET]
Steps — Phase 1: (1) join with the SO by asking about their experiences and concerns; (2) normalise family stress as common in families affected by drinking; (3) ask about costs of continued drinking; (4) introduce SO feedback gradually so the client does not feel ganged up on; balance concerns with affirmations of the client. Phase 2: (5) invite the SO to give examples, voice support for the client's steps, and make their own commitments (especially in the second SO session); (6) address differing expectations about goals, using assessment data, and work toward mutually acceptable goals; if they cannot agree, postpone the decision. [source: MATCH-MET; MET-Drug]
Family-conflict option: when partners disagree, the client can try to change the partner's view, wait, or focus on building their own life away from drinking; the manual encourages the last (e.g., not going to the bar with the partner). [source: MATCH-MET]
Example language (illustrative): "You've been living alongside this for a while. What has it been like for you?"
Watch for: sessions turning into complaint sessions; redirect criticism (see section 5 for disruptive SOs).

4.28 Follow-up note after Session 1

Purpose: strengthen engagement between Sessions 1 and 2. Listed in the MATCH table of contents; content detailed in the drug manual. [source: MATCH-MET table of contents; MET-Drug]
Steps: mail a personalised handwritten note soon after Session 1 including: a joining message, affirmations, the seriousness of the problem, highlights from the session, optimism about change, and the next appointment; keep a copy in the file. [source: MET-Drug]
Example language (illustrative): "I appreciated how openly you talked about your results on Tuesday. You raised some important concerns, and I'm optimistic about what you can do. See you on the 21st."
Watch for: confidentiality of mail; agree with the client how to contact them [synthesis].

4.29 Session 2 and follow-through sessions (reviewing progress, renewing motivation, redoing commitment)

Purpose: consolidate and sustain change (Phase 3). [source: MET-Drug; FIRST-MET; MATCH-MET table of contents]
Steps: (1) open with a brief recap of the previous session; (2) complete any unfinished feedback; (3) review progress: situations where the client used and where they did not, high-risk and successful situations; (4) renew motivation with Phase 1 strategies (assume ambivalence persists); (5) redo commitment with Phase 2 strategies, revising the CPW as needed; (6) discuss whether further treatment is wanted, once goals are clear. [source: MET-Drug; FIRST-MET]
Example language (illustrative): "Let's look at how the last few weeks went — the times it went the way you planned and the times it didn't."
Watch for: treating a lapse as failure; reframe it as information and recommit [synthesis, consistent with the stages-of-change view of relapse in MET-Drug].

4.30 Termination

Purpose: close the course with a consolidating recapitulation. [source: MET-Drug; FIRST-MET]
Steps: final recapitulation covering the client's motivators, commitments made, affirmation of progress, further change goals, maintenance, self-efficacy, and reminders about follow-up contacts; optionally ask about the worst outcomes of returning to use and help the client anticipate obstacles; deal with any special problems still evident. [source: MET-Drug]
Example language (illustrative): "Looking back over these four sessions, here's what stands out to me about what you've decided and why…"

4.31 Telephone consultation between sessions

Purpose: support without turning calls into extra sessions. [source: MET-Drug]
Steps: client or SO may call; keep calls brief and documented; affirm the contact, reflect ambivalence and normalise concerns; do not provide a substitute session. [source: MET-Drug]

4.32 Emergency sessions and further treatment

Purpose: limited flexibility inside a brief protocol. [source: MET-Drug]
Steps: the drug manual allows up to two emergency sessions at the clinician's discretion; MATCH lists "crisis intervention" among special problems but its content is [uncertain]. Further treatment is considered in follow-through once goals are clear. [source: MET-Drug; MATCH-MET table of contents]

5. Handling problems

The manual text gives specific guidance on resistance, premature commitment, disruptive SOs, intoxication, missed appointments and telephone contact. The MATCH sections on treatment dissatisfaction and crisis intervention are listed in the table of contents; their content is [uncertain]. Items marked [synthesis] are guidance consistent with MET principles.

Resistance and arguing

Treat rising resistance as a signal about your own behaviour; stop persuading and use reflection (simple, amplified, double-sided), shifting focus, rolling with, or reframing (4.9–4.14). Never ask the client why they are resisting. [source: MATCH-MET; MET-Drug]

Discord or rupture in the relationship

The FIRST adaptation separates sustain talk from discord and repairs discord by reflecting the client's reaction, apologising where appropriate, shifting focus and affirming. [source: FIRST-MET]
Example (illustrative): "I've been pushing, and that's not my job here. I'm sorry. Let's go back to what matters to you."

Stuck, ambivalent client (no readiness signs)

Do not move to commitment; return to Phase 1, explore ambivalence, use the decisional balance and further feedback; if commitment is still not forthcoming, agree a specific later date to revisit the decision rather than forcing it. [source: MATCH-MET]
If the client is still precontemplative by Session 2, keep the follow-through sessions as motivational check-ins and leave the door open [synthesis].

Premature or over-emphatic commitment

Do not accept it at face value; check details, anticipate obstacles, and keep using Phase 1 strategies in later sessions because ambivalence persists. [source: MATCH-MET]

Client arrives intoxicated

Breath test; positive (or clear drug impairment) means reschedule; the drug manual allows a urine test if impairment is disputed. [source: MATCH-MET; MET-Drug]
Check safety before they leave (transport, who is with them) [synthesis].

Missed appointments and non-adherence

Call promptly; explore reasons (uncertainty, ambivalence, frustration, coercion) with reflective listening and reframing; send a note within two days; make up to three attempts to reschedule. [source: MET-Drug]
In MET, non-adherence with the plan is not 'non-compliance': review what happened, renew motivation and redo the plan (4.29) [synthesis].

Coerced or mandated clients

The readiness checklist flags coerced clients who have not discussed their reactions; invite and reflect anger or relief about being sent, and emphasise what remains their choice. [source: MATCH-MET; MET-Drug]
Be transparent about what you report to the referrer and keep it separate from the client's decisions [synthesis].

Disruptive or hostile significant other

Patterns named: comments that strain the relationship and raise client resistance; hostile or indifferent attitudes; refusing changes the client asks for (e.g., stopping harassment about past drinking). Response: first reflect and reframe (e.g., toward the caring behind the criticism); if that fails, intervene directly to stop the pattern and limit the SO's role to giving factual information about drinking and learning about the problem and treatment. [source: MATCH-MET; MET-Drug]
If you suspect intimate partner violence or coercive control, see client and SO separately and do not continue joint sessions until safety is assessed [synthesis].

Client insists on moderation despite high severity or contraindications

Present the abstinence rationale and severity data persuasively but not coercively; offer a time-limited trial of abstinence or tapering; accept the client's decision and keep monitoring. [source: MATCH-MET]
If withdrawal risk is likely when stopping, arrange medical assessment before an abrupt abstinence trial [synthesis].

Client asks for coping skills or 'how to'

Turn the question back: elicit the client's own ideas. If skills are clearly needed, consider referral to further treatment after MET rather than teaching within it. [source: MATCH-MET; MET-Drug]

Client overwhelmed or shamed by feedback

Slow down, reflect the feeling (the manual explicitly asks you to reflect non-verbal reactions such as tears), affirm, and support self-efficacy before continuing; you can postpone remaining items to Session 2 (the drug manual allows completing feedback in Session 2). [source: MATCH-MET; MET-Drug] Specific pacing is [synthesis].

Lapse or relapse between sessions

Treat relapse as part of the change cycle; review the situation without blame, renew motivation, revise the CPW. [source: MET-Drug (stages of change)] Detailed handling [synthesis].

Crisis, suicidality or acute psychiatric deterioration

The drug manual allows up to two emergency sessions; specific crisis content is [uncertain]. [source: MET-Drug]
Pause the protocol: conduct a standard suicide-risk assessment, collaborative safety planning and lethal-means counselling (safe storage and removal), and refer to appropriate services; resume MET when stable [synthesis].

Drift by the therapist

Common drifts: teaching skills, lecturing on risks, reflecting only pro-change talk, arguing over labels or test accuracy. Audio-record and review sessions against the MET strategies; fidelity in the source trials relied on recorded sessions and supervision, and MINT trainers and MI coding tools are the usual route today. [source: MATCH-MET; NREPP] Self-review routine [synthesis].

Telephone calls used as therapy

Keep brief, document, affirm, reflect ambivalence, and bring substantive work to the next session. [source: MET-Drug]

Sources

Sources:

Motivational Enhancement Therapy Manual (Project MATCH Vol. 2), CASAA copy — tag MATCH-MET; the extracted text ended within the significant-other section, so later sections were seen only as table-of-contents headings.
Motivational Enhancement Therapy with drug abusers (CASAA manual) — tag MET-Drug; title page not visible in the extracted text, attribution to William R. Miller (1995) [uncertain]; written for a UNM project that also used CRAFT.
Greek translation of the Project MATCH MET manual, University of Patras — used for the session schedule only.
MET Manual, FIRST Trial (Maisto, Hansen, Edelman, Fiellin, Fucito, Paris), Yale — tag FIRST-MET.
NREPP intervention summary: Motivational Enhancement Therapy — tag NREPP.
NIAAA Project MATCH series listing — publication details.

Books and manuals cited:

Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992/1994). Motivational Enhancement Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals with Alcohol Abuse and Dependence. Project MATCH Monograph Series, Vol. 2. NIAAA (NIH Pub. No. 94-3723).
Miller, W. R. (1995). Motivational Enhancement Therapy with Drug Abusers. CASAA, University of New Mexico [uncertain: details].
Miller, W. R., & Rollnick, S. Motivational Interviewing: Helping People Change (3rd ed., 2013) — background, not drawn on.

← Previous · III-029Motivational interviewing Next · III-031 →Humanistic integrative counselling