Using MI to Facilitate Adolescent Reproductive Health Behavior Change
December 3, 2014
Melanie A. Gold, DO, FAAP
Clinical Professor of Pediatrics
Division of Adolescent Medicine, Department of Pediatrics
University of Pittsburgh Student Health Services
magold@pitt.edu
Introduction
MI is a foundational skill or tool for helping people change behavior. MI helps teens and
young adults arrive at their own solutions to behavioral issues.
Learning Objectives
1. Identify 2 adolescent health behaviors you want to help teens change using MI
2. Describe 4 elements of the spirit of Motivational Interviewing (MI) and 4 processes of
MI
3. Begin to effectively convey information and advice using MI style
Definition of MI
A collaborative, goal-oriented style of communication with particular attention to the
language of change that is designed to strengthen personal motivation for and commitment
to a specific goal by eliciting and exploring teen’s own reasons for change within an
atmosphere of acceptance and compassion.
Key Points
1. Overall style of MI is guiding, which incorporates elements of directing and following
styles
2. Ambivalence is normal when preparing for change; one can be stuck there for a
while
3. Directing style + arguing for change when ambivalent = arguments against change
4. Teens are more persuaded by what they hear themselves say than what you say!
Three Essential Elements of MI
1. MI is a particular kind of conversation about a specific behavior change
2. MI is collaborative (teen-centered, partnership, honors autonomy, not expert to
recipient)
3. MI is evocative (elicits a teen’s own motivation and commitment to change)
Spirit of MI has 4 components
1. Collaboration
2. Acceptance
3. Compassion
4. Evocation
The Spirit of MI should be Partnering or Collaborative. Ask yourself” Am I wresting or
dancing with my adolescent teen?” MI is done for or with someone, not on or to them.
Acceptance is made up of 4 elements
1. Absolute worth - Prize and respect teen’s inherent worth and potential
2. Accurate empathy - Communicate active interest in and effort to understand teen’s
perspective
3. Autonomy support- Honor and respect teen’s autonomy, irrevocable right, and
capacity for self-direction
4. Affirmation - Acknowledges the teen’s strengths and efforts
Compassion is the 3rd component and entails promoting teens’ welfare and best interest
Evocation communicates that “You have what you need and together we will find it.” You
do this with open-ended questions and interspersed reflections. You want to be evoking
what is already present, not installing what is missing – metaphor of drawing out teen’s
perspective like drawing water from a well.
Four Processes of MI
1. Engaging- Establish a helpful connection and working relationship
2. Focusing- Develop and maintain a specific direction in the conversation about
change
3. Evoking- Elicit teen’s own arguments for change
4. Planning- Develop commitment to change and specific action plan
Core Communication Skills: OARS
Open-ended Questions: Encourages teen to do most of the talking
Ask questions that invite elaboration
Tell me more about that ……
Avoid questions that can be answered with “yes” or “no” or with one or two word answers
(2 open questions to every 1 closed)
Avoid asking more than 3 questions in a row; intersperse with reflections (2 or 3
reflections to every 1 question)
Starters for open-ended questions:
 What ……..?: What was it like? What will you do….? What did you think about..? What
is your take on..? What age do you want to have
 How ………?: How did you feel about….? How did you like….? How do you plan to….?
 Tell me about……..
 Describe for me……..
AVOID starting with words that create closed ended questions such as: Can you? Could
you? Do you? Have you? Did you? Will you? Should you? Where did you…? How long or
how many? When did you …? Who?
EXCEPT to ask permission to give information or advice, such as: Is it okay if….? Would
you mind if…? May I tell you about…? Would it be okay if?
Affirmations: Respect and honor teen as a person of worth with the capacity for growth
and change. Recognize and comment on teen’s particular strengths, abilities, good
intentions, and efforts
 “I appreciate how hard it must have been to come in here and talk with me about this.
Thank you for being so honest.”
 “That’s a good suggestion.”
 “You worked hard to prevent this from happening and did the best you could.”
Reflections: Reflections are a way to check meaning. You form a reasonable guess as to
what the teen meant and give voice to that guess in the form of a statement. A well-formed
statement is less likely to evoke resistance. Your vocal tone should go gently down at the
end of a statement (not up like a question). Reflections let teens to hear thoughts and
feelings they expressed and ponder them. Beginners should make reflections by starting
with the word “You”. Not “It sounds like” or “What I heard you saying is” but be more
definite and guess at what teens feel or mean, which are complex reflections or just repeat
or rephrase what they just said which is a simple reflection. The teen makes a statement
and you repeat by saying “You…. “ and repeat or rephrase what the teen said. Or make a
reflection of feeling or meaning by saying “You feel …” and guess at the feeling or you can
make a reflection of meaning by saying “You think…” and guess at the underlying meaning.
Summaries: There are 3 types:



Collecting -Bouquet metaphor, draws together change talk and invites continued talk
Linking - Tie or link together current and previously said ideas to encourage reflection
of relationship between concepts
Transitional - Marks and announces shift of topic
Giving Information and Advice Using MI: Ask-Tell-Ask - An example for how to
incorporate spirit of MI and OARS skills into a typical clinical encounter. This is called
Elicit-Provide-Elicit or more recently Ask-Tell-Ask. There are four steps:
Step 1. Ask what teen knows about the topic and what options she knows of. You might
just stop here if the teen has all the accurate information or suggestions needed to move
onto the next step on planning for change.
Step 2. Ask permission to give information or advice that might help. Teens nearly always
say Yes but be prepared for what to say if the teen says No!
Step 3. With permission, tell information or advice in short chunks, not a long diatribe and
then go to the next step before offering more information or advice.
Step 4. Ask for reaction to information or advice
“What do you make of this information / these options? How does this help you or change
things?”
Adaptation: Ask permission to give information or advice in step 2 and end with saying
“and you can then tell me what you think about the information or the ideas I suggest
because you are the best judge of what will work for you.” This supports autonomy,
communicates respect and makes the whole process collaborative.
References:
Articles
 Gayes LA, Steele RG. A meta-analysis of motivational interviewing interventions for
pediatric health behavior change. J Consult Clin Psychol. 2014 Jun;82(3):521-35. doi:
10.1037/a0035917.
 Cushing CC, Jensen CD, Miller MB, Leffingwell TR. Meta-Analysis of Motivational
Interviewing for Adolescent Health Behavior: Efficacy Beyond Substance Use. J Consult
Clin Psychol. 2014 May 19. [Epub ahead of print]
 Barnes AJ and Gold MA. Promoting healthy behaviors in pediatrics: motivational
interviewing. Pediatrics in Review, 2012; 33(9):e57-68. Includes link to video.
http://link.brightcove.com/services/player/bcpid1555958052001?bckey=AQ~~,AAABN
TGpvPE~,4qE3VldHW5YmHnFjijevknrzxpJlgs3F&bctid=1802805262001
Books
 Douaihy A, Kelly TM and Gold MA. Motivational interviewing: A Guide for Medical
Trainees. New York: Oxford University Press (In Press, 2014).
 Miller WR and Rollnick S. Motivational Interviewing: Helping People Change (3rd
edition). New York: Guilford Press, 2013.
 Naar-King S and Suarez M. Motivational Interviewing with Adolescents and Young Adults.
New York: Guilford Press, 2011.
Website and DVDs
 Web site for more on MI and training: www.motivationalinterviewing.org
 Miller WR, Moyers TB, Rollnick S. Motivational Interviewing: Helping People Change. DVD
or video stream with detailed illustrations of MI, based on Motivational Interviewing, 3rd
edition (2013). http://www.changecompanies.net/motivational_interviewing.php