98 Years of Leadership in Social Justice Motivational Interviewing With Co-Occurring Adolescents: An Introduction Michael Fox PCC LCDC III Center for Innovative

98 Years of Leadershipin Social Justice

Motivational Interviewing

With Co-Occurring Adolescents: An

Introduction

Michael Fox PCC LCDC IIICenter for Innovative PracticesThe Begun Center for Violence Prevention Research & Education

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

© Center for Innovative Practices and the Ohio Department of Mental Health and Addiction Services (2000 -2015). Use by

permission only.

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


permission only.

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


permission only.

Developmental Theories

• Piaget– Concrete Operational to Formal Operational

-short-term goals -longer-term goals-concrete discussions -abstract discussions

about change

• Erikson– Industry v. Inferiority 6 to 11 years– Identity v. Role Confusion 12 to 18 years– Intimacy v. Isolation Young Adults


permission only.

BrainTriadic ModelErsnt, Romeo and Andersen (2009)

Prefrontal Cortex

(Modulation)

Striatum(Approa

ch)

interaction

Amygdala(Avoidanc

e)

Implications for risk-taking• Prefrontal Cortex: self-

monitoring 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


permission only.

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


permission only.

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


permission only.

Stages of Change

Precontemplation

Contemplation

Preparation Action

Maintenance


permission only.

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


permission only.

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


permission only.

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


permission only.

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


permission only.

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)


permission only.

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…


permission only.

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.


permission only.

What is MI?

Classic definition

Motivational Interviewing is a collaborative, person-centered form of guiding to elicit and strengthen motivation for change

Miller and Rollnick, 2009

Essential ElementsMotivational Interviewing is:

• a particular kind of conversation about change

• collaborative• evocative Miller and Rollnick, Stockholm 2010


permission only.

MI Definitions

• Layperson’s:(What is it for?)

Motivational Interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change.

• Pragmatic Practitioner(Why would I use it?)

Motivational Interviewing is a person centered ‐counseling method for addressing the common problem of ambivalence about change.


permission only.

Definitions from: Miller and Rollnick, Stockholm 2010

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


permission only.

Learning MI

Spirit of MI


permission only.

Collaboration: between therapist and client

Autonomy: of the client

Evocation: drawing out the client’s ideas about change

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


permission only.

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?


permission only.

Empathy: Adolescents

InternalGrowing independence

from parents

ExternalExpectations from family,

school, society…


permission only.

Adolescent Developmental tasks

Principles of MI

1. Express Empathy2. 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


permission only.

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)


permission only.

Principles of MI

1. Express Empathy2. Develop Discrepancy3. 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


permission only.

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


permission only.

kayakclinic.com

Principles of MI

1. Express Empathy2. Develop Discrepancy3. Roll with Resistance4. 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


permission only.

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 competenceAdapted from Naar-King & Suarez


permission only.

4 Principles of MI: Review

1. Express Empathy2. Develop Discrepancy3. Roll with Resistance4. Support Self-Efficacy

– All very important working with adolescents


permission only.

jameshasablog.wordpress.com

Skill Sets in MIBack to Basics


permission only.

amber.rc.arizona.edu/modeling

OARS

OARS is an acronym: probably first encountered practicing microskills

Open-ended questions

Affirmations

Reflections

Summaries


permission only.

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 open-ended questions?

• Can you ask too many open-ended questions?


permission only.

Practice: Open-Ended Questions

‘Client’

“I came to see you today because ____________”

‘Therapist’

Respond with 5 closed-ended questions


permission only.

Then: discuss how this process could have been improved with just one or two open-ended questionsConsider: closed-ended questions v. open-ended questions working with an adolescent

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


permission only.

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


permission only.

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”


permission only.

Reflections (Reflective Listening)

• This may be the foundation upon which all other skills are built

• Reflections have two purposes:

1. Clearly demonstrates the principle of Expressing Empathy– Validates, conveys

understanding, non-judgmental

2. Provides guidance in the direction of change by identifying areas of ambivalence


permission only.

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


permission only.

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


permission only.

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)’


permission only.

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


permission only.

energyquest.cal.gov

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


permission only.

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


permission only.

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


permission only.

4 Fundamental Processes in MIFrom 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. GuideThe strategic focus – brining things to a focus

‘focus on a change direction’


permission only.

4 Fundamental Processes in MIFrom 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. PlanThe Bridge to Change

Negotiating a change plan: a particular plan and the intention to engage in that plan


permission only.

Documents

98 Years of Leadership in Social Justice Motivational Interviewing With Co-Occurring Adolescents: An Introduction Michael Fox PCC LCDC III Center for Innovative