Motivational
Interviewing
With Co-Occurring
Adolescents: An
Introduction
Michael Fox PCC LCDC III
Center for Innovative Practices
The Begun Center for Violence Prevention Research & Education
98 Years of Leadership
in Social Justice
ˌmō-tə-ˈvā-shən
The process that initiates,
guides and sustains goal
directed actions/behaviors
-psychology.about.com
To provide with a motive:
impel
-merriam-webster.com
Positivemindwealth.com
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Ad·o·les·cence
\ˌa-də-ˈle-sən(t)s\
1: the state or process of growing up
2: the period of life from puberty to maturity terminating
legally at the age of majority
3: a stage of development (as of a language or culture)
prior to maturity
Merriam-Webster.com
“At no other time except infancy do human beings pack
so much development into such a short period.”
McNeely and Blanchard p. 1
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Adolescents
Adults
• Adolescents are not ‘little adults’
• Teens – especially ones mandated to treatment –
are frequently viewed as less competent thinkers:
compared to adults
– “he just doesn’t care…”
– “she doesn’t get it…”
• Adolescence is a time of significant
developmental (potential) maturation
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Developmental Theories
• Piaget
– Concrete Operational to Formal Operational
-short-term goals
-concrete discussions
-longer-term goals
-abstract discussions
about change
• Erikson
– Industry v. Inferiority
– Identity v. Role Confusion
– Intimacy v. Isolation
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6 to 11 years
12 to 18 years
Young Adults
Brain
Triadic Model
Ersnt, Romeo and Andersen (2009)
Prefrontal
Cortex
(Modulation)
interaction
Striatum
Amygdala
(Approach)
(Avoidance)
Implications for risk-taking
• Prefrontal Cortex: selfmonitoring and inhibitory
• Amygdala: conditioned fear
and avoidance
• Striatum (includes nucleus
accumbens): motivation
and incentive
Adolescents appear to weigh risk
more heavily toward reward and
discount loss – riskier choices
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Motivational Interviewing
• Bill Miller developed a protocol combining
Behavior Therapy techniques with a Rogerian,
Client-Centered approach: noted success related
purely to empathetic delivery.
• Began to formalize his approach demonstrating
skills to a group of psychology students in Norway
• Operationalized these ideas and published
Motivational Interviewing with Problem Drinkers
in the British journal Behavioral Psychotherapy in
1983
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Transtheoretical Model
•
•
•
•
•
Core Constructs
Stages of Change: temporal dimension
Process of Change: covert and overt activities
applied to progress toward change
Decisional Balance: weighing pros and cons of
change (and not changing)
Self-Efficacy: situation-specific confidence
Temptation: urge(s) to engage in specific
behavior(s)
Prochaska and Velicer
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Stages of Change
Precontemplation
Maintenance
Contemplation
Action
Preparation
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Precontemplation
•
•
•
•
Not acknowledging there is a problem
Not interested in change
Tend to defend the status quo
May grow quite defensive when confronted
about their ‘bad habit’
• Old language labeled this as ‘denial’ (not just a
river…), resistant or not motivated
• Ignorance is bliss…
•
Adapted from NIMH, CDC and addictioninfo.org and Prochaska & Velicer
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Contemplation
• Person starts to acknowledge their behavior(s)
are problematic
• Struggles greatly with ambivalence
• May start to think about the possibility of
change: but little to no movement is made
toward change at this point
• Weighing pros and cons – in both directions
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Preparation
• The person has made a decision about making
a change – and may attempt tentative steps
toward implementing change
• May make statements like, “I know I’ve got to
change; things can’t go on like this”
• Can be a ‘research stage’ – the person starts
gathering information about what change
might entail
•
Adapted from addictioninfo.org; SAMHSA
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Action
• Change is under way: the person is taking
action toward implementing plans
• May rely heavily on willpower
• May also be more willing to accept more help
Adapted from SAMHSA and addictioninfo.org
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Maintenance
• The behavior change is integrated into
everyday life: the change is not so much a
primary focus
• This stage can be followed by Relapse: and the
cycle can repeat
– Relapse is not a ‘stage’, but a “…return from action
or maintenance to an earlier stage” (Prochaska &
Velicer)
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Application: Stages of Change
Of 7 Critical Assumptions noted by Prochaska and
Velicer, three seem especially pertinent to the
Adolescent Co-Occurring population:
(4) Without planned interventions, populations
will remain stuck in the early stages. There is no
inherent motivation to progress through the
stages…
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Application: Stages of Change
(5) The majority of at-risk populations are not
prepared for action and will not be served by
traditional action-oriented prevention programs.
(6) Specific processes and principles of change
need to be applied at specific stages if progress
through the stages is to occur. In the stage
paradigm, intervention programs are matched
to each individual’s stage of change.
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What is MI?
Classic definition
Motivational Interviewing
is a collaborative, personcentered form of guiding
to elicit and strengthen
motivation for change
Miller and Rollnick, 2009
Essential Elements
Motivational Interviewing is:
• a particular kind of
conversation about
change
• collaborative
• evocative
Miller and Rollnick, Stockholm 2010
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MI Definitions
• Layperson’s:
(What is it for?)
• Pragmatic Practitioner
(Why would I use it?)
Motivational Interviewing
is a collaborative
conversation to
strengthen a person’s own
motivation for and
commitment to change.
Motivational Interviewing
is a person‐centered
counseling method for
addressing the common
problem of ambivalence
about change.
Definitions from: Miller and
Rollnick,
Stockholm
2010
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for Innovative
Practices and
the
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MI: Final Definition
• The Technical Therapeutic Definition
(How does it work?)
Motivational Interviewing is a collaborative, goal-oriented
method of communication with particular attention to the
language of change. It is designed to strengthen an
individual’s motivation for and movement toward a specific
goal by eliciting and exploring the person’s own arguments for
change.
Synopsis: Client-centered but directive method for helping
people resolve ambivalence and move toward healthy change
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Learning MI
Collaboration: between
therapist and client
Collaboration
Evocation: drawing
out the client’s ideas
about change
Spirit
of MI
Autonomy
Autonomy: of the client
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Evocation
MI Spirit
• Assumes that people “possess substantial
personal expertise and wisdom regarding
themselves and tend to develop in a positive
direction if given proper conditions of
support” (Miller and Moyers, 2006)
• Attainment of this spirit is not viewed as
prerequisite for beginning MI – but rather it
develops as a result of practicing it
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Guiding the Spirit: Principles
1. Express Empathy: empathy, very simply, is
‘seeing the world through the eyes of the
client’ or a vicarious experiencing of
another’s thoughts, feelings and experiences
Expressing this understanding is the basis for the
client to be heard and understood: building
opportunity for more honest expression
-How vital is this to an adolescent?
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Empathy: Adolescents
Internal
Growing
independence
from parents
External
Expectations
from family,
school, society…
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Principles of MI
1. Express Empathy
2. Develop Discrepancy: a discrepancy is a
disagreement – here, a disagreement between
where the adolescent is and where he/she
wants to be
Best when the discrepancy is between the young
person’s values/goals and current real behaviors
Adapted from motivationalinterview.org and Naar-King & Suarez
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Discrepancy: Adolescents
Adolescents have a great deal of pressure externally
regarding change: they will occasionally ‘accept’
these expectations.
Externally motivated change is less stable and more
inconsistent over time
(Naar-King & Suarez, 2012)
The adolescent should identify reasons for change:
not the clinician (easy to say: difficult to practice)
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Principles of MI
1. Express Empathy
2. Develop Discrepancy
3. Roll with Resistance: viewed as an
interpersonal process between the client and
the therapist: the client is experiencing a
conflict between their view of the ‘problem
(or solution)’ and the therapist’s view: may
be a sign the client is interpreting a potential
loss of freedom or control
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Resistance: Adolescents
(Synonyms?)
Resistance: do you fight against
it – try to paddle upstream – or
do you ‘go with the flow’ and try
to provide direction?
Moyers & Rollnick, 2002
Clinician task
• Don’t ‘paddle upstream’
• Avoiding confrontation –
rolling with resistance –
disrupts any struggle
• Resistance is a cue to ‘try
something different’
• ‘Dance, don’t wrestle’
• Confronted resistance
provides opportunities for the
adolescent to argue for value
of not changing
kayakclinic.com
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Principles of MI
1.
2.
3.
4.
Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-Efficacy: a strengths-based
approach that believes clients posses the
power of change. Self-efficacy is the client’s
belief they can change – change won’t
happen without this belief
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Self-Efficacy: Adolescents
Adolescents – especially ones in treatment – will
often see themselves as ‘falling short’ of the
expectations of those around them (parents,
courts, schools, police…)
Clinicians can support self-efficacy by
highlighting past successes, skills and strengths:
increase hope, optimism and sense of
competence
Adapted from Naar-King & Suarez
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4 Principles of MI: Review
1.
2.
3.
4.
Express Empathy
Develop Discrepancy
Roll with Resistance
Support Self-Efficacy
–
All very important
working with
adolescents
jameshasablog.wordpress.com
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amber.rc.arizona.edu/modeling
Skill Sets in MI
Back to Basics
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OARS
Open-ended questions
OARS is an acronym:
Affirmations
probably first encountered
practicing microskills
Reflections
Summaries
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Open Ended Questions
• Do you like closed-ended
questions?
• Do they elicit much
information?
• Do they convey much of
an interest?
• Are they sometimes
necessary?
• Are you tired of this
scenario?
• How do open-ended
questions help increase
relevant information?
• How do they demonstrate
more interest?
• Are there other
advantages to openended questions?
• Can you ask too many
open-ended questions?
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Practice: Open-Ended Questions
‘Client’
‘Therapist’
“I came to see you today
because ____________”
Respond with 5 closedended questions
Then: discuss how this process could have been improved with just one or two
open-ended questions
Consider: closed-ended questions v. open-ended questions working with an
adolescent
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Affirmations
MI is a strengths-based
approach that supports
self-efficacy – which
instills hope about making
difficult change.
Affirmations recognize,
validate and reinforce
client strengths
Affirmations must be
congruent and genuine
(think Rogers…)
General ‘Atta-boys’
are obviously insincere
and can damage rapport
and promote knee-jerk
disengagement: especially
in youth
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Affirmations
 May be most effective
with youth if the
therapist drops the “I”:
 “I am very happy you
have chosen to cut back
on smoking cigarettes”
VS
 “It is very impressive
that you have made a
decision to cut back on
smoking”
 Affirmations should
support strengths that
are in the direction of
change
 Can still acknowledge
the difficulties the client
has experienced
 Can be used to validate
the client’s feelings and
experiences
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Affirmations
• “Wow, you’ve really thought a lot about this”
• “With all of the obstacles you faced last week,
it is so impressive that you are back here
today”
• “When you chose not to go to that party, that
showed a lot of resolve”
• “You showed resourcefulness and great
strength helping your grandmother”
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Reflections (Reflective Listening)
• This may be the
foundation upon which
all other skills are built
1. Clearly demonstrates
the principle of
Expressing Empathy
–
• Reflections have two
purposes:
Validates, conveys
understanding, nonjudgmental
2. Provides guidance in
the direction of
change by identifying
areas of ambivalence
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Reflections
“So what I hear you saying
is…”
“You feel _____ when
_____”
• Exact or even slightly
paraphrased repetition
can sound stereotyped
and even sarcastic
– Reflections are
hypotheses…
This is an educated guess
about what your client is
saying: you are asking for
clarification – but, form
the reflection as a
statement, not a question.
If you are wrong – it is
okay: the client will help
clafify
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Reflections
• Reflections help reduce
the ‘interrogation’ feel
for adolescents with the
use of Open-Ended
Questions: it is
recommended all
questions be
sandwiched between
reflections
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Reflection Sandwich
YOU: ‘You are feeling worried that insisting your
boyfriend wears a condom will make him mad or
even suspicious (reflection). What do you predict
he might say (Question)?’
CLIENT: ‘Well, he could say I don’t love him, or that I
don’t trust him. He could even ask what I’ve been
up to’
YOU: ‘You’re worried about his trust on a couple of
fronts and also that he might think you don’t love
him (reflection)’
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Summaries
• Summaries are BIG
reflections
• They ‘connect the dots’:
may be very useful for
helping youth better
view connections
• Help link feelings of
ambivalence and
promote recognition of
discrepancies
energyquest.cal.gov
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Roadblocks
• Ordering, directing or
commanding
• Warning or even
threatening
• Giving advice, making
suggestions or
providing solutions
• Persuading with logic
• Moralizing, preaching
•
•
•
•
Disagreeing
Agreeing
Shaming or ridiculing
Reassuring or
sympathizing
• Distracting, humoring
or even changing the
subject
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Exercise
• For Dyads:
Speaker
– Identify a change you are
considering – but have not
decided to act on for sure
(something you may have
been putting off)
Counselor
– Try as hard as you can to
convince and persuade the
Speaker to go ahead and
make this change.
– Try:
• Explain why they should
change
• Give benefits of the change
• Tell them how to make the
change
• Emphasize how important
it is to make this change
• Tell/persuade them to do it
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OARS: Review
Open-ended
questions
Affirmations
Reflections
Summaries
Client-centered skills
Convey active listening
Relate empathetic understanding
Provide constant opportunity to
guide the recognition of
discrepancy
Easily ‘go with the flow’
(resistance)
Support self-efficacy
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4 Fundamental Processes in MI
From Miller and Rollnick: Stockholm 2010
1. Engage
The relational foundation:
it is Person-Centered,
emphasizes listening and
understanding dilemmas
and values
*Learn this one first
“If you don’t engage, you
don’t get to go any
farther” - Miller
2. Guide
The strategic focus –
brining things to a focus
‘focus on a change
direction’
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4 Fundamental Processes in MI
From Miller and Rollnick: Stockholm 2010
3. Evoke
“The Heart of MI”: this
process represents the
transition to MI. It utilizes:
-selective eliciting
-selective responding
-selective summaries
‘Evoke from the client their
own ideas about change’
4. Plan
The Bridge to Change
Negotiating a change plan: a
particular plan and the
intention to engage in that
plan
© Center for Innovative Practices and the
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