ETHICS: USING
MOTIVATIONAL
INTERVIEWING WITH
OLDER AND VULNERABLE
ADULTS
Instructor
Mary Minten, PhD, MFT, LCADC, CST
• MINT Trainer, Training of Trainers in 2008 with Bill Miller
• MIA STEP (Motivational Interviewing Assessment:
Supervisory Tools for Enhancing Proficiency) Training of
Trainers, 2009
• Supervising and training MI since 2006
• Original research with an MI intervention for couples
wellness 2017
Ethical Principles Often Include:
Non-malfeasance
 Beneficence
 Autonomy
 Justice
 Veracity
 Fidelity

Ethical Dilemmas
Conflict within these ethical principles. For example:
Perhaps any decision we make will cause some
harm to some degree to the client.
With vulnerable populations, we often weigh
 Risk
 Preferences
 Quality of Life (autonomy, independence, meaning)
 Contextual Factors
Factors to include for vulnerable
populations



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Risk: What is causing the risk? How soon and how long there will be risk?
How will the decision mitigate risk? How will the decision cause greater risk?
Who else is at risk?
Preference: Does the adult have decision making capacity? If not, is the
surrogate being utilized and acting appropriately? What does the adult
want? Do they have the information they need to make the decision? What
is the history of their decisions?
Quality of Life: How does the adult define quality of life? How does the
decision help them meet their definition quality of life? What are the
chances they meet that quality of life without the decision? What negative
effects will the person experience from the decision? What bias do the
professionals have about quality of life?
Contextual: What are the family (including chosen family) and social
factors? What are the financial factors? Are there religious and cultural
factors? What are the justice factors? Are there available resources? What
do the laws and regulations state? Are there conflicts of interest for the
professionals involved?
Motivational Interviewing
Based on humanistic principles
 Person Centered Care: In MI the personal
relationship between client and provider comes first.
MI builds every other intervention on the therapeutic
relationship. Nothing else can happen without it.
 Provider skills include:

 Accurate empathy
 Genuineness
 Unconditional Positive Regard
Motivational Interviewing
These three principles are most certainly
requirements for effective MI practice.
They are also critical for ethical practice…
How can we do no harm, do some good, support
autonomy, discuss justice concerns, hold truthful (and
sometimes painful) realities, and truly be of service
to the person without connection, a real
relationship? MI suggests it is impossible.
MI spirit with older and vulnerable
adults
In a study using MI in working with cases of
Elder Abuse and Self Neglect (EASN)
 Prizing the therapeutic relationship and
being “person-centered”
 Therapeutic relationship came first
 Clinician found it beneficial to understand the
client holistically (think risk, preferences, QoL,
and context)
 Using MI skills and spirit helped deepen the
therapeutic relationship (MacNeil et al, 2023)
MI: Unhurried Mind
Dr. William Miller is known for saying if we act like we have
five minutes, the process will likely take hours. If we act like
we have all day, we are likely to only need a few minutes.
 Especially with vulnerable populations (lower IQ, dementia,
delusions, schizophrenia, etc), we take the extra time to
understand them and show that we have the time.
 This step is essential to the do no harm for vulnerable adults
and older adults.

 If individuals are thinking or processing more slowly, our relaxed
stance will help them communicate with us.
 Ethical dilemmas require slower thinking as they are more
complex
Yes: Older adults (and some vulnerable adults)
MAY experience changes in processing speed:



Longitudinal Studies on cognitive changes with aging – two
categories relevant

Fluid intelligence – patterns and relationship, working memory, information
processing speed – tends to decline slightly

Crystallized intelligence – knowledge acquired over time, vocabulary,
experience, remains stable & may increase over time
Overall: “As the field of cognitive aging agrees, declines in healthy
aging are exaggerated; rather, variability is the rule”
Conclusion: “elder stereotypes seem mostly inaccurate and certainly
lack nuance. Nevertheless, they likely trigger prejudices and
discrimination” (NCBI Bookshelf, p. 8)
Empathy plus unhurried mind
If we take the time to listen and understand accurately, we can develop an
understanding of client and their risks, their preferences, what is important
to them in terms of quality of life and their experience of contextual
factors. Thus improving our ability to do no harm and to aim to do some
good while supporting autonomy.
Understanding well takes time – and it is time well invested!
Empathy practice:
 Emotion words handout: Listen for emotion + content.
 Turn it into a reflection of emotion.
 Evaluate. Then post in chat if you want!
 Allow and encourage clarification (recognize even subtle markers of being
off in our effort to understand: withdraw, confrontation).
 Non-defensively correct errors to get close to client’s meaning (let’s practice
– put a new reflection of emotion in the chat).
Reflections of feeling and meaning
 Do no harm: Empathy across differences (age, race, ethnicity, nationality,
ability/disability, gender, sexual orientation, etc) goes down. This
phenomenon is possibly an effect of implicit bias. MI puts our attention
on maintaining empathy even when it is imperceptibly more difficult.
 Beneficence/Doing good: Frequent reflections (MI research suggests a
minimum of three reflections of feeling and/or meaning to any other
response (3:1)) improve client outcomes considerably. Improvements
happen across a range of change goals (medication adherence, dental
hygiene, eating better, stopping drinking, and more). The best outcomes
are seen with ratios of 10:1 or 20:1.
 More beneficence: When we help clients identify emotions and content
with accuracy and granularity, we help clients cope with their struggles
(Barrett’s research).
Challenging “sustain talk”
Study with clinicians using MI in adult protective services,
challenging sustain talk and resolving ambivalence were key
MI skill providers noted (MacNeil et al, 2023)
 Allows them to explore what was important to client even if
it what was important inhibited protection efforts

Define sustain talk and change talk
 Practice identifying them in chat

 yes/no

jaws of ambivalence
Interventions when clients are
ambivalent
Ambivalence is not uncommon in the face of change.
 In fact, it typically accompanies change.
 Thus when clients have more sustain talk, little or no
change talk, we want to see this phenomenon as
SOMETHING WE EXPECTED.
 MI offers ways to help our clients as they work
through their ambivalence.
 We’ll cover supporting autonomy first.

MI: Supporting autonomy is critical to
person-centered care
None of us have complete autonomy all the time – that’s
not autonomy!
 In MI, when we cannot provide one aspect of choice for
a client, we aim to include some other aspects of a
client’s desires and preferences and quality of life.

 We support choice in any area possible.
 We aim for harm reduction options when possible.
 We are direct and authentic when a choice is not on the
table.
 We don’t coerce agreement.
 We tend to grief and loss.
 We offer empathy, dignity, connection, and affirmation even
when we cannot change the decision or situation they are in.
Reflections that support autonomy
 You are worried if you come with me you won’t get to see
your grandson.
 You want to me keep looking for ways to help with pain. I
can do that. (Only say the last part if you can.)
 Even though you don’t like it, you are agreeing to come
with me. I appreciate your willingness.
 You are scared if you come with me you won’t get your
medications. Trusting my word on that isn’t easy.
 You don’t agree that this new living situation is better
than the last one. You are heartbroken you cannot see
your friends.
 You are attending reluctantly. You don’t like it and you
don’t want to be here.
Supporting Autonomy
Clinical note: When you use these reflections on
previous slide, DO expect to hear more of the
complaints/problems and the feelings that
accompany them. You are not attempting to avoid
hearing the problems and emotions. Listening to
the client often helps them come to terms with
things out of their control and subsequent losses. If
we reflect emotions and meaning in this part of
the process, we are doing no harm and doing
good while supporting autonomy.
Other examples of responses to sustain
talk
Double sided reflection: On one hand Jim is kind to you
on visits on the other hand he has been taking
advantage financially.
 Align with sustain talk: You want Jim’s support and
sometimes he is supportive.
 Reframe: You wanted Jim to be an ally and support
person. As we have been considering what he has done,
your views are changing.
 Affirmation: You put your trust in someone – that always
takes courage in my book. And now you are grappling
with what to do next. Even considering other options can
be scary (sad, irritating…).

Engaging client imagination
Another challenge clinicians reported in the study with adults in protective
services: some adults had trouble imaging anything differently
MI interventions that were particularly useful was engaging client imagination in
this study.
 Looking forward: what alternatives might be, what they might want
 Imaging the situation from a loved ones perspective “What might your
daughter [or other loved one inserted here] want for you?”
 Consider their ideal outcome
 Then consider a plan b – if the ideal can’t work, what is the next
option? (MacNeil et al, 2023).
In chat – please put your thoughts on these interventions, and if you used
them or a version of them yourself in the past, what was helpful and not
helpful?
Cognitive challenges and supporting
autonomy
Ethical concerns
 In study on clinicians using MI in cases of Elder
Abuse and Self Neglect (EASN) one of their
challenges was the concept of autonomy and how to
support autonomy when clients cognitive process are
severely challenges (dementia and other forms of
diminished capacity) (MacNeil et al, 2023)
 Discuss this concern – examples in chat please!

Additional information and research
Next up: Research on older adults that might be
helpful in using motivational interviewing to support
ethical practice with older and vulnerable adults.
 This particular set of studies focused on older
adults: please use your experiences to see what
overlap might exist with vulnerable adults of all
ages and share in the chat as we go any
connections (similarities or differences) in the chat.

QoL, Autonomy, Preferences
In a longitudinal study
of 12 older adults (7685) in England in the
years 2020-2021 the
research team used
sophisticated
qualitative
methodology to go
beyond the “snapshot”
quantitative approach
of values/preferences,
quality of life, and
autonomy for older
adults.
QoL, Autonomy, Preferences
Early findings showed the
necessity of viewing these
factors as complex and
multifaceted constructs.
The findings challenge the
congruence of common
interpretations of a
concept such as
“independence”
with older people’s views, showing areas of
commonality and discrepancy”
(Gilmore-Bykovskyi, February 2024, pp. 1-4)
QoL, Autonomy, Preferences
All of the participants, 7 women
and 5 men, lived in the community
and lived with either a spouse (5)
or alone (7), and all were white.
The researchers used 16 openended questions posed 12 months
apart to gather information that
addressed the following concepts:
1) “participation (engaging in meaningful life activities),
2) autonomy (being able to make and act upon your own decisions), and
3) control (having control over whether and how help is received” (Ibid, p.
QoL, Autonomy, Preferences

Theme 1 - In most other research “activities of daily living”
(ADLs)* are typically used as measures to discern the
independence level of older adults and vulnerable adults. In
this study, though, the participants viewed ADLs as a “pretty low
bar” and realistically did not represent participant descriptions
of independence. These folks uniformly acknowledged that ADLs
Were important but that independence “was not
just about the ability to complete an activity but
about the ability to complete activities that were
of value to, or on the ‘wish list’ of the individual”
(Ibid, p. 12). In brief, these folks wanted to
engage in meaningful activities.
QoL, Autonomy, Preferences

Theme 2 - Another part of this study
offered participants the opportunity to
review their scores on the measures of
another study, a quantitative one. In
doing so, participant responses
indicated the “chasm that can exist
between what is measured and the
lived situation” (Ibid, pp. 13-14).
For the participants, the “context” of the activity was
critical in order to understand or appreciate the
nuances of how these folks lived their lives, their lived
situations.” Checking a box on a scale, a measure did
not seem to account for those nuances.
QoL, Autonomy, Preferences

We can surmise that the
stereotyped older or
vulnerable adult does not exist,
that older and vulnerable
adults have many differences
from each other in their lived
lives, in how they respond to
disabilities and aging.
Older Adults and Health Care
Professionals

We are encouraged to
work with an older and
vulnerable adults toward
a shared vision rather
than striving toward an
assumptions of quality of
life, autonomy, meaning
that hold little meaning
for the individual.”
Final interventions if time
Value card sort
 Providing information and advice:
 Therapeutic relationship

 More rupture markers and options to resolve them
 SET: Support, Empathy, Truth
Ask, exchange, ask
In MI, we give the information/advice in ways that reduce
harm and improve our changes of doing some good and
support client autonomy
 Ask: Ask permission. (“Can I give you some information
about that medication?”)
 If the person says no, allows us to give information or advice
when it is more likely to be received. If the person says yes,
the question reduces defensiveness significantly
 Exchange information: (IF the person gives permission)
share what you know and listen to what they know. Often
shorter pieces of information from us are more helpful.
 Ask: what they think about the information (and
listen/reflect)
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Last bits
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Questions
Thank you and have a good end of week and
weekend!