Motivational Enhancement therapy: a tool for professional school counselors working with adolescents.

Many adolescents whom professional school counselors regularly counsel are ambivalent and unmotivated to behavioral change. Motivational Enhancement Therapy (MET) is a counseling approach designed specifically for clients with these qualities. The purpose of this article is fourfold: (a) to identify the complexity and misconceptions of counseling adolescent students, (b) to introduce school counselors to the theoretical constructs of MET, (c) to review MET strategies for supporting change, and (d) to present case examples demonstrating MET techniques with students.

**********

The adolescents that professional school counselors (PSCs) work with can be challenging. Indeed, some counselors have noted that adolescents are the most difficult clients to work with in a therapeutic context (Church, 1994). Adolescents often display hostility, defiance, and other forms of resistance in establishing a counseling relationship and frequently are poorly motivated for behavioral change (Hanna, Hanna, & Keys, 1999; Lambie & Rokutani, 2002). For example, Trepper (1991) described counseling adolescents as an "adversarial sport" in which the counselor rarely ends up on the winning team. For this reason, many counselors avoid working with this population altogether (Biever, McKenzie, Wales-North, & Gonzalez, 1995). Students frequently come for help, or more often are sent for help, with specific problems while being in the midst of rapid developmental change (Jaffe:, 1997). Further contributing to the complexity of working with adolescents has been school counselors' lack of specific supervised training in counseling approaches with this population (Rubenstein & Zager, 1995). However, many school counseling training programs are now integrating theoretical models and experiential exercises designed and deemed effective with children and adolescents.

Many of the traditional counseling theories and approaches were developed for motivated adults. Students sent to see their PSC are nor adults and often are not motivated to change. Furthermore, research indicates when most people begin counseling they are not ready to take action to change (Isenhart, 1994); whereas the majority of counseling models are constructed for working with clients who are ready to take action to change (Prochaska, DiClemente, & Norcross, 1992). Complicating the situation further, PSCs are faced with the reality that counselor-student ratios and other noncounseling duties limit the amount of time they have to directly counsel students (Lambie & Rokutani, 2002; Stickel, 1991). Therefore, a practical school counseling approach needs to provide strategies that in a brief amount of time would assist students who may be unmotivated for change.

Stereotypical descriptions of adolescents such as moodiness, narcissism, being resistant and challenging, and having social and interpersonal problems are similar to generalizations of another difficult population, clients with substance abuse issues. For the latter group, Motivational Enhancement Therapy (MET) has been found to be an effective counseling approach (Miller, Zweben, DiClemente, & Rychtarik, 1995). MET can be brief in duration and designed for counseling clients at all levels of motivation and readiness to change. MET has been found particularly useful with individuals considered "difficult," "resistant," and "unmotivated" (Aubrey, 1998). For these reasons, MET appears to be a well-suited counseling approach for adolescents (Lawendowski, 1998).

The purpose of this article is to provide an orientation to MET, which is a brief psychotherapeutic approach intended to increase the probability that a student will begin and maintain a specific change plan aimed at reducing a problem behavior (Miller & Rollnick, 1991, 2002). The following four topics are addressed:

1. The complexity and misconceptions of counseling adolescents

2.An introduction to MET &MET strategies for supporting change

4.Case examples illustrating the application of MET

For the purposes of this article, the terms student and client will be used interchangeably to describe anyone whom PSCs may counsel in a change process including students, teachers, parents, and other school personnel.

COMPLEXITY AND MISCONCEPTIONS OF COUNSELING ADOLESCENTS

Adolescents need to be differentiated from adults and young children due to the unique transformations they are going through: their cognitive skills are becoming more powerful; new types of relationships are developing; they are becoming better at distinguishing feelings; and they are acquiring greater ability to reflect feelings (Vernon, 1993). Adolescence is a period of intense heightened narcissism and self-preoccupation (Lambie & Rokutani, 2002). PSCs need to match their counseling techniques and style to these distinctive needs.

Establishing a safe and trusting counseling relationship is the foundation for support and change (Rogers, 1995). It can be difficult to establish this relationship with adolescents who have historically questioned society's beliefs and values (Katz, 1997). It is not surprising, therefore, that they tend to mistrust counselors and often manifest this reaction crudely, intensely, provocatively, and for prolonged periods. To reduce such potential mistrust, it is helpful to let students know that mistrust is to be expected and that it is natural and healthy not to disclose and trust immediately (Kaplan & Sadock, 1998).

The drive towards autonomy and independence is powerful during adolescence, and many adolescents are hypersensitive to circumstances where they feel others are asserting power over them (Church, 1994; Lambie & Rokutani, 2002). Many adults address adolescents' "resistance" with aggressive confrontation, resulting in a power struggle and an emotional shouting match. The harder the counselor pushes to resolve the problem, the worse the situation becomes (Murphy, 1997). Not surprisingly, a confrontational style of counseling tends to produce resistance in students (Fisher & Harrison, 2000; Miller & Rollnick, 2002) who feel their personal freedom is threatened; therefore, they become defensive and use defense mechanisms such as anger, confrontation, and denial, which all may be perceived as resistance. The harder a PSC pushes, the more energy a student is going to exert to push back, confirming Newton's third law of motion: For every force there is an equal and opposite counterforce (Cowen & Presbury, 2000). On the other hand, when students feel that they are choosing to do something for their own self-interest, their motivation can be intense. Consequently, counselors should avoid using statements that belittle, label, order, prescribe, lecture, give mixed messages, or takeover the problem (McCoy, 1995). Avoidance of these types of statements will make students feel safe and reduce their defensiveness (resistance), thereby allowing them to shift their energy to self-examination of their behaviors and choices.

Peterson (1995) developed a list of tips on teens, which is useful for counselors working with adolescents to reduce the likelihood of engendering resistance. These tips include: (a) letting adolescents know you are willing to just plain listen, (b) being accessible, (c) using questions sparingly, (d) trying not to be defensive, (e) showing empathy, (f) giving praise, (g) giving positive feedback, and (h) giving them the responsibility. All these suggestions present the students with a "voice" in a respectful, empathic counseling relationship. Empathy is a foundation to counseling and a basic human need that can get overlooked. An adolescent who senses that the PSC is genuinely listening to what he or she is saying not only feels understood but also senses the underlying message: "You are a person of worth. Your feelings are important and worthy of attention" (Wexler, 1991,p. 21).

Counseling approaches do not differ in effectiveness when employed with diverse populations. However, specific styles may be more effective with specific clinical subgroups, in this case adolescents (Miller et al., 1995). Adolescent counseling approaches based on cognitive therapy or other kinds of skills training are often too dry for teenagers (Wexler, 1991), sometimes fairing to recognize the crucial role of establishing rapport through an empathic relationship. When adolescents feel genuinely understood and respected, on the other hand, they become increasingly capable of accepting limits and integrating new skills and insights. It is not always the message that is important, but the style or manner in which it is conveyed.

MOTIVATIONAL ENHANCEMENT THERAPY (MET)

Motivational Enhancement Therapy is a development of the Transtheoretical Model of Change (TMC; Prochaska et al., 1992), designed to help clients build commitment and reach behavioral change. Drawing on strategies from client-centered counseling, cognitive therapy, systems theory, and the social psychology of persuasion (Miller & Rollnick, 1991, 2002), some features of MET include: (a) motivation to change is elicited from the client; (b) it is brief in duration; (c) direct persuasion is avoided; (d) the style is generally quiet and eliciting; (e) readiness to change is seen as a fluctuating in relation to interpersonal interaction; and (f) the counseling relationship is more like a partnership or companionship than expert/recipient roles (Aubrey, 1998; Miller & Rollnick, 1995).

Transtheoretical Model of Change (TMC)

TMC is different from most theories of psychotherapy because it does not focusing on defining the problems that are to be the focal point of counseling. Rather, TMC focuses on how people change. This model allows counselors with different theoretical orientations and styles to share a common focus. Based on their own research and the findings of others, Prochaska et al. (1992) proposed that people who change their behaviors, whether on their own or with the help of a counselor, tend to go through five stages of change frequently using different processes or methods at various stages. These five stages (as cited in Ingersoll & Wagner, 1997) include the following:

* Precontemplation. The counselee does not consider his or her behavior to be a problem and/or is not currently considering changing his or her behavior.

* Contemplation. The counselee is considering that his or her behavior may be a problem and is seriously thinking of, or contemplating, changing his or her behavior.

* Preparation. The counselee has made a commitment to change a behavior he or she considers problematic and is intending to make the change soon. The individual may have a specific plan in mind or may simply have a target date set for change within the next month.

* Action. The counselee is currently in the process of modifying his or her behavior or environment to reduce or eliminate the problem identified. The individual is considered to be in the action stage for up to 6 months following the initial behavior change (assuming maintaining the change during the period).

* Maintenance. The counselee works to prevent a return to the problem behavior and to stabilize the new behaviors and/or environment that supports his or her new way of living.

Change is difficult, and most people who work to modify a behavior do not successfully maintain their gains on their first attempt. While linear progression is possible, it is relatively rare. Individuals may move back and forth between stages on any single issue or may simultaneously be at different stages of change for different behaviors. Thus, TMC offers a spiral pattern of the stages of change where people can progress from contemplation to preparation to action, but most people will lapse to an earlier stage (Prochaska, 1995). Research indicates the majority of people who relapse recycle to the contemplation or preparation stages. The spiral model does not suggest that people endlessly go in circles or regress to where they began. On the contrary, TMC is based on the belief that people learn from the lapse and can try something different the next time around to avoid the same mistakes (Prochaska et al., 1992).

TMC can guide the counselor to more successful outcomes by matching counseling processes to the client's individual level of readiness to change (Ingersoll & Wagner, 1997). That is, the counselor adapts his or her counseling to the stage where the client is in the change process. Most people beginning a counseling relationship are at precontemplation or contemplation (Isenhart, 1994), while clients attending counseling on their own volition are primarily in the contemplation stage (McConnaughy, DiClemente, Prochaska, & Velicer, 1989). At the lower stages of change (precontemplation and contemplation), the counselor works to reduce possible resistance by using nondirective counseling techniques such as asking open-ended questions, listening reflectively, affirming, and summarizing. As the client moves to the higher stages of change (preparation, action, and maintenance), the counselor becomes more directive and behavioral by assisting the client in developing and implementing a plan for behavioral change (Miller & Rollnick, 2002). When working with a student in precontemplation or contemplation, the PSC is like a caring, empathic parent. As the adolescent moves to the subsequent stages the counselor becomes a supportive coach supplying more behavioral direction.

Motivational Enhancement Therapy

MET has been thoroughly researched in the field of substance abuse with some research specific to adolescent substance abuse clients. Clients with substance abuse issues and adolescents often share the stereotypical characteristics of being resistant, challenging, and narcissistic. Therefore, it is postulated that an effective substance abuse counseling approach would also be successful with adolescents.

MET was designed as a standardized four-session counselor approach in Project MATCH (Matching Alcohol Treatments to Client Heterogeneity), a clinical trial of patient-treatment matching sponsored by the National Institute of Alcohol Abuse and Alcoholism (NIAAA). This study was the first national, multisite trial of patient-treatment matching and one of the two largest current initiatives of NIAAA. Both public and private treatment facilities as well as hospital and university outpatient facilities were represented (Miller et al., 1995). It was found that clients at low levels of readiness for change (precontemplation and contemplation) did better when placed in MET than in cognitive-behavioral therapy or 12-Step Orientated Models (Ingersoll & Wagner, 1997). In a study with 77 adolescents at a substance abuse outpatient clinic in New Mexico, Aubrey (1998) found that the MET group had significantly more treatment goals and successful outcomes, while having a higher rate of retention and a significant decrease in substance use as compared to the control group.

MET is designed to help people work through their ambivalence about change, primarily through the use of active listening and gentle feedback techniques. The MET approach is founded on the assumptions that clients have the capacity and responsibility for change and that it is the counselor's task to create conditions that enhance the client's motivation for and commitment to change (Miller et al., 1995). In brief, the goal is to prepare people for change, not necessarily to push them into changing right away (Ingersoll & Wagner, 1997). MET seeks to support intrinsic motivation for change, which leads the client to initiate, persist in, and comply with behavior change efforts. Thus, it empowers clients through practical assistance and emotional support (Aubrey, 1998).

Miller and Rollnick (1991, 2002) listed six basic motivational principles underlying the MET approach: (a) expression of empathy--the counselor communicates respect for the client and listens rather than tells; (b) assisting client in perceiving discrepancy-the counselor uses motivational psychology principles to help the client perceive a discrepancy between where he or she is and where he or she wants to be; (c) avoiding argumentation because it is seen to evoke resistance, which is a client's reaction to a threatening interpersonal interaction and resistance is a counselor's issue; (d) rolling with resistance--the counselor does not meet resistance head on, but rather "rolls with" the momentum, with a goal of shifting client perceptions in the process; (e) ambivalence is viewed as normal and openly discussed--the counselor elicits solutions from the client; and (f) support of self-efficacy--the counselor works to enhance the client's sense of self-efficacy or ability to achieve goals. People only move towards change when they perceive that there is a chance of success. Other central constructs of MET are its unique strategies to increase the likelihood of behavior change, which include handling resistance, the use of a decision balance sheet, and evoking self-motivational statements (Change talk). Each of these strategies are discussed in the following section.

MET STRATEGIES FOR SUPPORTING CHANGE

Strategies for Handling Resistance '

Miller and Rollnick (1991, 2002) described four types of resistance: (a) arguing--the client challenges, discounts or is hostile to the counselor; (b) interrupting--the client cuts the counselor off or talks over him or her; (c) denying--the client blames others, minimizes, disagrees, makes excuses and is reluctant; and (d) ignoring--the client is inattentive and does not respond or give input. A goal of MET is to reduce resistance because a lower level of client resistance is associated with long-term change.

MET offers counselors specific approaches to addressing resistance. Resistance is viewed not as a client trait but as a normal response to a perceived threat in an interpersonal context. Resistance communicates to the counselor that he or she is moving too fast and needs to more appropriately match the client. Miller, Benefield, and Tonigan (1993) compared two counseling styles (directive-confrontational and client-centered) used with 42 randomly assigned clients with substance abuse problems. In a one-year outcome, the directive-confrontational style yielded significantly more resistance from the clients, the more the counselor confronted, the more the client drank.

Defusing resistance requires PSCs to change their counseling approach to increase the student's sense of control by using the following strategies.

Simple reflection. Acknowledgment of the student's disagreement, emotion, or perception can permit further exploration rather than evoking defensiveness. The counselor responds to the student's resistance or emotionality with understanding and acknowledgment allowing the energy to dissipate.

Amplified reflection. Here the counselor reflects back what the student has said in an amplified or exaggerated form, which often results in the student recanting what he or she has said and can elicit the other side of the student's ambivalence to change. Amplified reflection encourages the student to reexamine what he or she is saying. It must be executed artfully without a sarcastic tone or hostility may be elicited.

Shifting focus. Here the counselor refocuses the student's attention away from what seems to be a barrier-blocking progress. This approach moves the student away from a topic where he or she is entrenched to an area where he or she may feel more comfortable and less defensive.

Agreement with a twist. Using the technique, the counselor initially offers agreement with the student, but with a slight change in direction. This supports the relationship, while allowing the counselor to continue to influence the direction and momentum of change.

Emphasis on choice and control. The counselor continuously emphasizes and acknowledges the student's personal choice and control because resistance often arises from psychological reactance, people thinking that their freedom of choice is being threatened and reacting by asserting their power (resistance). This approach supports the notion that ultimately the student determines change.

Refraining. This strategy is helpful when a student is offering arguments that serve to refute a personal problem. By acknowledging the validity of the student's observations and perceptions, the counselor offers a new meaning or interpretation to them. It is important to use the student's own words, perceptions, and understanding about the behavior when refraining (Miller & Rollnick, 1991, 2002).

These strategies can be used independently or concurrently and can help PSCs avoid getting into a cycle of resistance with a student sent to their office. Additionally, the techniques enable the counselor to begin to establish a sate and supportive counseling relationship while gently presenting the student with feedback that may increase his or her awareness of a potential problem behavior.

The Decision Balance Sheet

Decision making is a vital process in behavioral change (Velicer, DiClemente, Prochaska, & Brandenburg, 1985). MET views people who are not changing their dysfunctional behaviors as being ambivalent to change. MET is designed to elicit, clarify, and resolve ambivalence in a person-centered and respectful approach (Miller & Rollnick, 1995). Therefore, a goal of MET is to help clients work through their ambivalence and not to directly persuade. It is the client's task to resolve his or her ambivalence, not that of the counselor.

The decision balance strategy is designed to help clients consider the positives (advantages) and negatives (disadvantages) of changing their current behaviors or remaining the same. When people consider making a change, it is helpful to think not only about the benefits (pros) of changing and the cost (cons) of staying the same, but also to reflect upon the possible consequences of changing and the potential benefits of staying the same. This approach fosters the construction of a more realistic plan for change and helps put into action a plan of change the individual has decided upon from multiple perspectives (Ingersoll & Wagner, 1997).

A decision balance worksheet is a counseling activity where the student is asked to fill in four specified boxes. In the first box, the student is asked to write the benefits he or she receives from not changing, while in the box below he or she writes the potential positive reasons for changing. In the top-right box, the student then identifies negative consequences of not changing, while below writing the possible cost of making the change. An example of a student who is not completing her homework is presented (see Table). This strategy offers the student and counselor a more complete picture of the student's ambivalence towards change. Often the focus is only on the positives of changing (you will do better) and the negative of not changing (you will fail), missing the key fact that a person's current behavior is meeting a need, which must be filled if change is to take place and last.

Evoking Self-Motivational Statements/Change Talk

Change is linked to an individual's self-efficacy, which is a person's confidence in his or her ability to maintain the behavioral change. Self-efficacy generally varies depending on the stage of change, with persons at higher stages having increased self-efficacy (DiClemente, 1986; Miller et al., 1995). Eliciting self-motivating statements or "Change talk" is an MET approach employed to increase students' self-efficacy. Miller and Rollnick (1991, 2002) presented three categories of statements to evoke self-motivation/change talk: cognitive (problem recognition), affective (statements of concern and optimism), and behavioral (intention to change). Examples of the three types of statement used to evoke self-motivation/change talk follows.

Cognitive (problem recognition). What things may make you think that not completing your homework might be a problem for you? Can you think of any ways in which not completing your homework has made your life more difficult? How has not completing your homework stopped you from being able to do what you want?

Affective (concern). What is there about not completing your homework that makes you feel concerned? Is there anything that worries you about not completing your homework? What bothers you about knowing you have not completed your homework?

Affective (optimism). What gives you hope that things can get better? What do you think would work for you if you decided to make a change?

Behavioral (intention to change). The fact you are talking about not completing your homework shows that at least part of you thinks it's time to do something. What are the possible reasons you see for making some changes? It seems that you may be stuck right now in a pattern of not doing your homework. What changes might help you to get unstuck and change? (Miller et al., 1995; Miller & Rollnick, 1991, 2002). These statements allow the student to identify his or her concerned behavior and support his or her intention to change with optimistic encouragement.

CASE EXAMPLES ILLUSTRATING MET'S APPLICATION

Determining the appropriate MET counseling techniques and approach to use requires that the PSC appraise the student's stage of change. The following case examples are presented to demonstrate MET techniques with students at the three stages of change most commonly seen in students (precontemplation, contemplation, and preparation).

Example 1: Tim: Precontemplation stage. Mrs. Smith, an English teacher sends a 17-year-old male student named Tim who has been a "B" student to your office. Mrs. Smith referred Tim to speak with you because his grades have dropped and his girlfriend, Mary, confided to Mrs. Smith that Tim has been partying and she is concerned about him.

Counselor: Tim, do you have any idea why Mrs. Smith referred you to speak to me?

Tim: Yes. She is concerned about my grades dropping.

Counselor: Do you feel there is any reason for her to be concerned with your drop in grades?

Tim: No, there is no reason.

Counselor: So, everything is fine with you. Well, is it true that your grades have dropped? (Agreement with a twist)

Tim: My grades have dropped but I will bring them up; I have just been in a little bit of a funk lately.

Counselor: Tim, could you tell me about the funk you have been in? (Emphasize student's personal choice)

Tim: It really isn't a big deal. (Pause) My girlfriend has been on my case.

Counselor: What has she been on your case about?

Tim: Different stuff.

Counselor: Would you mind sharing an example of what she has been on your case about? (Emphasize student's personal choice)

Tim: She's always telling me I go out too much.

Counselor: Going out too much? (Paraphrase)

Tim: Yah, going out too much with my friends.

Counselor: Do you think this is a problem?

Tim: No, but she does and so do my parents.

Counselor: So your girlfriend and parents think that you are going out too much, but you don't think it is a problem. (Assist student in perceiving discrepancy) Do you have any idea why they think this is a problem for you?

Tim: Because they are dumb.

Counselor: So you think they are worrying about nothing. (Reflection/Reframing)

Tim: Pretty much.

Counselor: Do you have any other ideas why you may think they are concerned about you?

Tim: I guess because my grades have dropped and we haven't been getting along as well lately.

Counselor: So it sounds like your girlfriend, parents, and Mrs. Smith are concerned about you and your recent changes. (Reflection/Summarizing)

Tim: Yes.

Students at the precontemplation stage are often not aware that a problem exists. At this stage the student may need information and feedback to raise his or her awareness. In this example, Tim seemed unaware that he was having any type of problem. MET would suggest that aggressive confrontation would be counterproductive and engender resistance. Therefore, the counselor used active listening techniques and gently drew out discrepancies in what Tim was saying--there is no problem, but your girlfriend, parents, and teacher are concerned about you. The counselor also emphasized to Tim a sense of choice and control in the session by asking his permission to answer a question (Would you mind ...). At the end of the meeting, it seemed that Tim's awareness had risen about his going out being a possible problem. Raising awareness is a step forward in contrast to having confronted Tim with his partying being a problem and getting into an emotional power struggle.

Future sessions with Tim would focus on strengthening the counselor-student relationship, while continuing to raise Tim's awareness of his possible problem through gentle confrontation where incongruences would be identified and explored. Once Tim's awareness increased, the counselor would work with and support Tim in the resolution of his ambivalence towards change. Throughout the process, the counselor and Tim would work together collaboratively and in a respectful fashion assisting Tim to improve his current situation.

Example 2: Jennifer: Contemplation. Mrs. Brown calls you and asks you to talk with her daughter, Jennifer, who is an energetic and intelligent seventh grader. She generally earns "C" grades and has a history of classroom-related behavior problems such as talking in class and not doing her work. Mrs. Brown would like you to speak with Jennifer about her classroom behavior problems and poor grades.

Jennifer: You sent a pass for me?

Counselor: Yes. I spoke to your mother and she asked me to talk with you. Is it okay that we talk? (Emphasize student's personal choice)

Jennifer: I guess so.

Counselor: Jennifer, do you have any idea why your mother would like me to talk to you?

Jennifer: Probably about my grades and Mr. Jones' science class.

Counselor: Mr. Jones' science class? (Paraphrase)

Jennifer: Yes, I am not doing well in that class and he has sent me to the office for talking in class. Mr. Jones just hates me.

Counselor: So, you feel Mr. Jones doesn't like you?

Jennifer: Yes, he hates me and has always picked on me; he is just a jerk.

Counselor: Have your grades dropped? (Shifting focus)

Jennifer: Yes, my grades have dropped.

Counselor: Do you think your grades and getting sent to the office is a problem? (Problem recognition, self-motivational statement/change talk)

Jennifer: Well, I am not sure. My parents and teachers keep telling me it is a problem.

Counselor: What types of things do they tell you?

Jennifer: I could do so much better if I applied myself and tried to stay focused.

Counselor: So, it sounds like your family and teachers think it is a problem but you are unsure. (Reflection/Assist student in perceiving discrepancy)

Jennifer: Yah. (Pause) I know I could do much better if I tried but I just don't know.

Counselor: Well, Jennifer, what do you think are some good reasons to change your behavior? (Intention to change, Self-motivational statement/Change talk, Decision balance approach)

Jennifer: My parents and teachers would be off my back and I would get better grades.

Counselor: Those are some great reasons. (Amplified reflection) What do you think are some good reasons for you not to change and to keep thing the way they are? (Decision balance approach)

Jennifer: Hah, I guess it is easier.

Counselor: Could you tell me a little bit more about how it is easier?

Jennifer: Well, I like to talk to my friends and I can't see them much after school because I have swimming practice and my parents have me on restriction.

Counselor: So Jennifer, it sounds like if you were to change, you would lose contact with some of your friends but your parents and teachers would be off your back and your grades would likely improve. (Reframe/Summarize) Is that correct?

Jennifer: Yes, I guess so.

Counselor: Is it possible that if you choose to change, your parents may take you off restriction so you could talk with your friends after school, while at the same time improving your grades and getting your parents off your back? (Optimism, Self-motivational statement/Change talk)

Jennifer: I guess.

Counselor: Do you have any ideas what might work for you if you decided to make a change? (Optimism, Self-motivational statement/Change talk)

Jennifer: I think if I really focused in class and my parents supported me by taking me off restriction.

Counselor: So, it sounds like you see change as a real possibility for you if you choose to make that choice. (Reflection/Emphasize student's personal choice)

Jennifer: Yes, I could do it if I really want to.

Students at the contemplation stage are aware that others perceive a problem but are ambivalent about changing. At this stage, the MET counselor's goal is to collaborate with the student to tip her ambivalence towards change. In this example, Jennifer seemed aware that others see her having a problem but she was unsure. Therefore, the counselor used active listening techniques and asked Jennifer to look at both sides of changing, bringing to her awareness that if she chooses to make the change she may gain some benefits but also may lose something she likes. The counselor attempted to emphasize Jennifer's choice and provided her with information about changing using self-motivational statements/change talk while presenting incentive to change and accentuating the positives of changing. At the end of the brief session, it appeared that Jennifer's scale to change was vacillating more towards change than at the start of the meeting. The one thing the PSC needs to remember when counseling students at this level is that if the counselor moves to the action stage before the student is ready, resistance will likely be engendered.

Example 3: John: Preparation. John is a ninth-grade student who has poor grades and has missed a considerable number of days from school. He is an intelligent young person whose poor school performance appears directly related to his poor school attendance. The counselor has met with John previously and John now seems motivated to change.

Counselor: Hey John, how are you feeling today?

John: I am okay and made it to school.

Counselor: John, I am happy to see you today. How do you feel about attending school more often? (Emphasize student's personal choice)

John: I think it is something I need to do so I can graduate and get a job someday.

Counselor: Have you thought about any possible ways that you could start attending school more? (Intention to change, Self-motivational statement/ Change talk)

John: Yes, I have talked to my mother and she is going to help me get up in the morning and get here.

Counselor: I know your mother works the evening shift. Is she always home in time to get you up so you can make it to school before classes begin?

John: No, not always.

Counselor: Would you be willing to make a change in your plan? (Emphasize student's personal choice/Collaboration)

John: Sure, I guess so.

Counselor: Would you be able to set an alarm clock to wake you up in case your mother happens not to get home from work in time?

John: Yes. That shouldn't be a problem.

Counselor: John, are you willing to do an experiment for the next week? (Emphasize student's personal choice)

John: What kind of experiment?

Counselor: The experiment is for you to do the plan we just discussed for the next week. At the end of that week you are to come see me and let me know how you did as far as attending school on time and how it was for you.

John: Sure. That shouldn't be a problem at all.

Counselor: So you understand the experiment and don't have any questions? (Reflection)

John: Nope, I got it. I will see you in one week.

Students at the preparation stage are considered motivated for change. Frequently they use statements like, "it is time to make a change" or "bow can I make a change?" The counselor's job is work with the student to develop a change plan that is acceptable, accessible, appropriate, and effective (Miller & Rollnick, 1991, 2002). In the example, the counselor collaborated with John to develop a plan that the student accepted, and that was age appropriate and possible, while being potentially effective. Beginning the plan with an "experiment" allows the student to try the strategy for a short time and return to the counselor for support and possible modification in the plan. The experiment takes the blame off the student if he is unsuccessful at the first attempt to change and allows him to receive the additional support and make accommodations to the strategy. The PSC needs to match the student as best as possible at this stage or the student will likely move back to contemplation.

CONCLUSION

Working with adolescent students can be frustrating but also very enjoyable. One day a student may be angry and cynical, while a day later she or he is pleasant and hopeful. It is important that PSCs working with these students like and respect adolescents; not all counselors are meant to work with this age group. PSCs are in a unique position to intervene early and provide ongoing support to these young people. Many of the characteristics attributed to teens such as being resistant and challenging are not necessarily the qualities of the young person but the traits that are engendered by adults aggressively confronting them.

MET is a brief counseling approach supported strongly in research that offers a specific and tangible model of behavioral change while providing strategies to counselors on how to best match students' level of readiness to change. Furthermore, MET provides clear strategies for how to work with students who appear "resistant" and "unmotivated."

MET as presented in this article is an individual counseling approach. The author is not suggesting that individual counseling is the only or best approach to supporting change in a school environment. Students respond differently to individual, group, and family counseling. It is the counselor's task to best match students' needs with the available resources. MET has been employed with successful outcomes as a group counseling approach (Ingersoll & Wagner, 1997), while family counseling with adolescents has also been found effective (Micucci, 1998). PSCs must work with the resources available to them and, in some cases, serve as a liaison between the school, outside agency, and families to best match a student's needs (Lambie & Rokutani, 2002).

MET offers a counseling approach that matches adolescents' attributes well. This model presents PSCs with a different perspective on students while providing useful and effective strategies to support change. MET's theoretical perspectives on student resistance and change and its techniques can be integrated into other theoretical models, thereby better matching the individual school counselor's style. The intent of this article is to offer a different conceptualization of change and strategies to increase students' readiness to change.

Example Decision Balance Sheet

                   Benefits/Pros             Cost/Cons
                   Get to sleep more         Failing my class

Not Changing       Get to meet friend         May not past this grade
                     after school
                   Am similar to my friends   Can't be on the athletic
                                                team
                   School is dumb             Parents are mad

                   Will not be grounded       Friends may get mad
                   Parents will be happy      Will have to work harder
                     with me

Making a Change    Will pass my classes       May still not do well
                   Will move to the next      Will have to change
                      grade
                   Can get back on the team

Note: Adapted from Ingersoll & Wagner (199"7).

References

Aubrey, L. L. (1998). Motivational interviewing with adolescents presenting for outpatient substance abuse treatment. (Doctoral dissertation, The University of New Mexico, Albuquerque, 1998) Dissertation Abstracts International, 59, 1357.

Biever, J. L., McKenzie, K., Wales-North, M., & Gonzalez. R. C. (1995). Stories and solutions in psychotherapy with adolescents. Adolescence, 30(118), 491-499.

Cowen, E. W., & Presbury, J. H. (2000). Meeting client resistance and reactance with reverence. Journal of Counseling and Development, 78, 411-419.

Church, E. (1994).The role of autonomy in adolescent psychotherapy. Psychotherapy, 31(1), 101-108.

DiClemente, C. C. (1986). Self-efficacy and the addictive behaviors. Journal of Social and Clinical Psychology, 4, 302-315.

Fisher, G. L., & Harrison, T. C. (2000). Substance abuse: Information for school counselors, social workers, therapists, and counselors. Needham Heights, MA: Allyn & Bacon.

Hanna, F. J., Hanna, C. A., & Key, S. G. (1999). Fifty strategies for counseling defiant, aggressive adolescents: Reaching, accepting, and relating. Journal of Counseling and Development, 77, 395-404.

Ingersoll, K., & Wagner, C. (1997). Motivational enhancement groups for the Virginia Substance Abuse Treatment Outcomes Evaluation (SATOE) model: Theoretical background and clinical guidelines. Richmond: The Office of Mental Health and Substance Abuse Services, Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services.

Isenhart, C. E. (1994). Motivational subtypes in a n in patient sample of substance abusers. Addictive Behaviors, 19, 463-475.

Jaffe, C. M. (1997). A hierarchical model of adolescent development: Implications for psychotherapy. Adolescent Psychiatry: Developmental and Clinical Studies, 21, 3-33.

Kaplan, H. I., & Sadock, B. J. (1998). Synopsis of psychiatry: Behavioral sciences/clinical psychiatry (8th ed.). Baltimore: William & Wilkens.

Katz, P. (1997). Adolescence, authority and change. Adolescent Psychiatry: Developmental and Clinical Studies, 21, 49-65.

Lambie, G. W., & Rokutani, L. J. (2002). A systems approach to substance abuse identification and intervention for school counselors. Professional School Counseling, 5, 353-359.

Lawendowski, L. A. (1998). A motivational intervention for adolescent smokers. Preventive Medicine, 27, A39-A46.

McConnaughy, E. A., DiClemente, C. C., Prochaska, J. O., & Velicer, W. F. (1989). Stages of change in psychotherapy: A follow-up report. Psychotherapy, 26, 494-503.

McCoy, K. (1995, April). Communication barriers. Retrieved June 3, 2002, from The Parent Resource Center: http://www.tnpc.com/parenttalk/adolescence/teens2.html

Micucci, J. A. (1998). The adolescent in family therapy. New York: Guilford.

Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455-461.

Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford.

Miller, W. R., & Rollnick, S. (1995). What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-334.

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people to change addictive behavior (2nd ed.). New York: Guilford.

Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1995). Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence (Vol. 2, Project MATCH Monograph Series). Rockville, MD: National institute of Alcohol Abuse and Alcoholism.

Murphy, J. J. (1997). Solution-focused counseling in middle and high school Alexandria, VA: American Counseling Association.

Paterson, E. (1995). Communication barriers: 14 tips on teens. Retrieved June 3, 2002, from The Parent Resource Center: http://www.tnpc.com/parenttalk/adolesence/tenns49.html

Prochaska, J. O. (1995). An eclectic and integrative approach: Transtheoretical therapy. In A. S. Gurman & S. B. Messer (Eds.), Essential psychotherapies: Theory and practice. New York: Guilford.

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behavior. American Psychologist, 47, 1102-1114.

Rogers, C. R. (1995). A way of being. New York: Houghton Mifflin.

Rubenstein, A., & Zager, K. (1995). Training in adolescent treatment: Where is psychology? Psychotherapy, 32(1), 2-6.

Stickel, S. A. (1991, February). A study of burnout and job satisfaction among rural school counselors. Paper presented at the annual conference of the Easter Educational Research Association, Boston, MA.

Trepper, T. (1991). Senior editor's comments. In M. Worden (Ed.), Adolescents and their families: An introduction to assessment and intervention (pp. ix-x). New York: Haworth.

Velicer, W. F., DiClemente, C. C., Prochaska, J. O., & Brandenburg, N. (1985). Decisional balance measure for assessing and predicting smoking status. Journal of Personality and Social Psychology, 48, 1279-1289.

Vernon, A. (1993). Developmental assessment and intervention: With children and adolescents. Alexandria, VA: American Counseling Association.

Waxier, D. B. (1991). The adolescent self, strategies for self-management, self-soothing, and self-esteem in adolescents. New York: W.W. Norton.

Glenn W. Lambie, Ph.D., LPC, NCC< NCSC, CCMHC, is an assistant professor, Department of Human Development and Psychological Counseling, Appalachian State University, Boone, NC. E-mail: [e-mail]

The author wishes to thank Dr. Chris Wagner, Virginia Commonwealth University, for introducing him to Motivational Enhancement Therapy.