Motivational Interviewing

Motivational Interviewing
with Adolescents and Young Adults

Applications of Motivational Interviewing
Stephen Rollnick, William R. Miller,
and Theresa B. Moyers, Series Editors
Since the publication of Miller and Rollnick’s classic Motivational Interviewing, now
in its third edition, MI has been widely adopted as a tool for facilitating change. This
highly practical series includes general MI resources as well as books on specific
clinical contexts, problems, and populations. Each volume presents powerful MI
strategies that are grounded in research and illustrated with concrete, “how-to-do-
it” examples.
Motivational Interviewing in Diabetes Care

Marc P. Steinberg and William R. Miller
Motivational Interviewing in Nutrition and Fitness

Dawn Clifford and Laura Curtis
Motivational Interviewing in Schools:

Conversations to Improve Behavior and Learning
Stephen Rollnick, Sebastian G. Kaplan, and Richard Rutschman
Motivational Interviewing with Offenders:

Engagement, Rehabilitation, and Reentry
Jill D. Stinson and Michael D. Clark
Motivational Interviewing and CBT:

Combining Strategies for Maximum Effectiveness
Sylvie Naar and Steven A. Safren
Building Motivational Interviewing Skills:

A Practitioner Workbook, Second Edition
David B. Rosengren
Coaching Athletes to Be Their Best: Motivational Interviewing in Sports

Stephen Rollnick, Jonathan Fader, Jeff Breckon, and Theresa B. Moyers
Motivational Interviewing for Leaders in the Helping Professions:

Facilitating Change in Organizations
Colleen Marshall and Anette Søgaard Nielsen
Motivational Interviewing in Social Work Practice, Second Edition

Melinda Hohman
Motivational Interviewing with Adolescents and Young Adults,

Second Edition
Sylvie Naar and Mariann Suarez
Motivational
Interviewing
with Adolescents
and Young Adults
SECOND EDITION
Sylvie Naar | Mariann Suarez
Series Editors’ Note by Stephen Rollnick, William R. Miller,

and Theresa B. Moyers
THE GUILFORD PRESS

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provide information that is complete and generally in accord with the standards
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possibility of human error or changes in behavioral, mental health, or medical
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who has been involved in the preparation or publication of this work warrants
that the information contained herein is in every respect accurate or complete,
and they are not responsible for any errors or omissions or the results obtained
from the use of such information. Readers are encouraged to confirm the
information contained in this book with other sources.
Library of Congress Cataloging-in-P ublication Data is available

from the publisher.
ISBN 978-1-4625-4698-5 (hardcover)

To Leah King, Alex King, our parents,
our partners, fellow Minties, and the youth
who let us join them along their paths of change
About the Authors
Sylvie Naar, PhD, is Distinguished Endowed Professor in the Department

of Behavioral Sciences and Social Medicine at the Florida State University
(FSU) College of Medicine. She is also Founding Director of FSU’s Center
for Translational Behavioral Science. She is trained as a pediatric health
psychologist and has conducted health disparities research with minority
youth since the 1990s. With over 160 publications, Dr. Naar has both clini-
cal and research expertise in behavioral interventions for youth living with
HIV, focusing on adherence to medications, adherence to appointments,
substance use, and sexual risk. A member of the Motivational Interview-
ing Network of Trainers (MINT), she has provided numerous trainings to
agencies and treatment organizations nationally and internationally, with
particular emphasis on motivational interviewing (MI) with adolescents
and young adults.
Mariann Suarez, PhD, ABPP, is Associate Professor in the Department

of Medical Education at the University of South Florida Health, Morsani
College of Medicine. Dr. Suarez is a community–clinical and pediatric psy-
chologist, with specialization in child abuse and neglect and board certifica-
tion in behavioral and cognitive psychology. She served on the American
Board of Behavioral and Cognitive Psychology and publishes on the use of
MI in the treatment of substance use problems, neurocognitive develop-
mental issues, and parenting concerns. A member of MINT for decades,
she provides training nationally and internationally, with particular inter-
ests in teaching health care and community providers to use MI and evi-
dence-based practices with adolescents and young adults.
vii
Series Editors’ Note
Ten years ago a new path was opened up in the application of motivational
interviewing (MI) with the publication of the first edition of this book.
Since then, the idea that MI is helpful with adolescents and young adults
has gained traction among clinicians and practitioners in a wide range of
settings. The research literature has grown substantially from a few stud-
ies described in the first edition to more than 100 controlled trials. As the
authors note in their opening sentence of Chapter 1, “It is a beautiful thing
when career and passion come together.” This second edition shines with
clinical wisdom, a sharp eye on what works, and humility about the ever-
present challenges that arise when talking with young people.
For a reader interested in understanding MI, you will get that from
this book, along with guidelines for how to improve your skills. Then there
are the inevitable questions about what you do when a young person says
things that challenge your patience, clinical experience, and more—this is
where this second edition comes to the fore. Ten years on, a lot has been
learned, and Drs. Naar and Suarez repeatedly illuminate here how to form
a good relationship that helps young people maximize their potential at an
age when a small shift can have major impacts in later life.
Stephen Rollnick
William R. M iller
T heresa B. Moyers
ix
Preface
Most of our work involves talking with young people, and if they have one
thing in common, it is probably sensitivity to how they are spoken to. Yet
the focus of so many interventions is on content, not process, on what to
do but not how to do it. Motivational interviewing (MI) specifies how to
guide people toward behavior change by paying close attention to how we
talk to them. What are the words we can say to increase the likelihood that
young people will think about change? How can we encourage engagement
instead of rebellion?
The words we use must come from a spirit of respect for the indi-
vidual’s capacity for change, a respect young people are often not afforded.
Although many aspects of language are culturally specific, we have
found the principles of MI and the developmental challenges of adolescence
to be remarkably consistent across cultures. We have spent the last decade
training practitioners from many different professional backgrounds and
many different cultural settings in MI with adolescents and young adults.
We have also been conducting implementation research on how to train to
support fidelity and positive clinical outcomes, and conducting communi-
cation science research to determine which MI skills have the strongest
association with increased motivation in young people and their caregivers.
We have revised our presentation of MI based on this body of work, along
with the changes in the third edition of Miller and Rollnick’s Motivational
Interviewing.
Diverse applications of any method will result in innovation and adap-
tation that move away from the original statement of the method itself. This
otherwise healthy evolution carries a risk that the method itself becomes
too diffuse. We hope we have avoided this risk by staying true to the prin-
ciples of MI, emphasizing that MI is essentially a conversation about change
in which you strategically reinforce another’s own motivation to change in
xi
xii Preface
the context of a respectful, empathic relationship. We hope you will dip into
and out of this book as you learn how to use core skills and attend to the
spirit and the language that produce less frustrating and more satisfying
interactions with young people. Please note that we have chosen to use the
pronouns “they” and “their” throughout the text to balance brevity and
inclusion.
Acknowledgments
We would like to thank our family, friends, mentors, and work colleagues
who helped us create the time and space to write this book. We would like
to thank members of the Motivational Interviewing Network of Trainers for
their willingness to ponder our questions. While we cannot possibly name
all the people who helped and inspired us, we wanted to particularly thank
Bill, Steve, Terri, and Guilford Senior Editor Jim Nageotte for believing in
us. And special thanks to the people at Joe’s Bar for providing social and
intellectual connection throughout the pandemic.
xiii
Contents
1 Why Motivational Interviewing with Adolescents 1

and Young Adults?
2 Developmental Challenges and Opportunities 18
3 Getting the Spirit Right 28
4 Highlighting Choice at Every Turn 42
5 Stop, Drop, and Roll 55
6 Change Talk 74
7 Processes of Motivational Interviewing 101
8 Maintaining Change 128
9 Maximizing Motivation in Groups 141
10 Considering Caregivers 152
11 Your Motivational Interviewing Journey 165
12 Ethical Considerations 179
13 Future Directions 191
References 201
Index 215
xv
1
Why Motivational Interviewing
with Adolescents
and Young Adults?
Don’t laugh at a youth for his affectations. He is only trying on

one face after another to find a face of his own.
—L ogan P earsall Smith, Age and Death
It is a beautiful thing when career and passion come together. We have

found this to be consistently true among practitioners working with adoles-
cents and young adults, as you are afforded an opportunity to help navigate
the unique challenges and opportunities of this life stage. Your guidance
may be integral to helping young people maximize their human potential,
and even slight shifts toward positive trajectories can have lasting impacts,
but how you use this expertise can either stifle or progress the treatment
process. In your work with young people, if you have found yourself in any
of these predicaments, then this book is for you:
• Talking more of the time than either the young person or the family
members
• Advocating for “why” change would be of benefit
• Inadvertently threatening by offering education about consequences
of unhealthy behaviors
• Trying to figure out why the young person doesn’t follow through
with treatment recommendations
• Thinking, This young client isn’t ready for change so there is nothing
I can do
• Wondering if what you’re doing is really making a difference and
actually helping
Incorporating motivational interviewing (MI) into your practice can

offer a renewed sense of professional passion. MI with young people should
1
2 Motivational Interviewing with Adolescents and Young Adults
not be viewed as a technique, a trick, or something to be done to people to

make them change. It is a gentle, respectful method for communicating
about struggles and exploring alternatives consistent with the person’s own
values and goals, to maximize human potential.
Adolescence and Emerging Adulthood:

Remarkable Life Stages
While each life stage has its own challenges, adolescence and emerging
adulthood offers one of the most remarkable periods of change, along with
opportunities for both developmental growth and risky experimentation
(Nandi, Glymour, & Subramanian, 2014). Rates of high-risk behaviors, such
as unprotected sex and substance use, peak during this time (Gore et al.,
2011). Poor health behaviors, such as sedentary activity and inconsistent
self-management of medical conditions, can set the stage for lifelong health
problems (Lee, Park, & Lee, 2020). Conflict with parents while simulta-
neously dealing with pressure from peers, teachers, and other providers
(such as you) contributes additional stress. Biological factors, including the
basic nuances of blossoming hormones, and for some, coping with physi-
cal and mental health challenges, further exacerbate the toils of this life
stage. Moreover, societal labeling and the pathologizing of many normal
experimental behaviors, typical for this developmental period, are perva-
sive in both diagnostic and pop cultures. Shakespeare depicts typical adult
attitudes toward young people: “I would there were no age between ten and
three-and-twenty, or that youth would sleep out the rest; for there is noth-
ing in the between but getting wenches with child, wronging the ancientry,
stealing, fighting” (William Shakespeare, The Winter’s Tale, Act 3, Scene
3). If you can break through the sense of alienation experienced by young
people, you have a great advantage. Not only can you make a genuine con-
nection, but also you have an opportunity to shift developmental trajecto-
ries during this period of tremendous growth.
Embracing Ambivalence
It’s no secret that there are many evidence-based treatments for youth that
work when the client is committed to change. It is also no secret that the
best evidence-based treatments can fail when the young person is not moti-
vated or has significant ambivalence about making a change. You will know
ambivalence is present when hearing statements against change, nonverbal
alienation, kind refutations of advice (“Yeah but”), unspoken refutation of
advice (no follow-through or poor attendance), or outright aggressive refu-
tations of advice (“you have no idea what you are talking about!” “I don’t
Why Motivational Interviewing with Adolescents and Young Adults? 3
need another damn mother”). Perhaps this is why Trepper (1991) described
working with adolescents as an “adversarial sport” in which you rarely end
up on the winning team.
Ambivalence is not limited to youth; it is commonplace in interactions
with the adults closely involved with the young person. For example, how
many times have you heard caregivers or practitioners offer statements
such as follows:
• “I tried those silly rewards . . . but they just don’t work!”
• “It’s easy for you to tell me what to do—try and live with it . . . then
you’ll understand.”
• “In this field, I don’t have time for all that psychobabble—either they
want it or not.”
• “I thought I’d be a good parent . . . now I don’t know.”
However, those with a passion for working with young people know
that their energy, intensity, and capacity for change make the challenges
worthwhile, and MI can help turn these challenges into opportunities. In
fact, MI practitioners embrace ambivalence as an opportunity for explora-
tion. Ambivalence that is spoken may be explored, addressed, and used as
a level for change. Ambivalence that is unspoken can derail treatment, and
MI can promote an atmosphere of nonjudgment and curiosity that increases
the likelihood that underlying ambivalence is expressed.
If you have experienced this frustration and joy when working with
young people, this book is for you. It is our hope to provide you with a guide
for having a productive conversation about behavior change with adoles-
cents and young adults, and potentially their caregivers, using MI spirit and
skills. In the past decade, research on MI with young people has blossomed,
and the contexts in which MI is practiced has widened (e.g., mental health
settings, medical settings, community settings, schools). With this book, it
is our hope to meet the need practitioners have voiced for an MI resource
tailored to the unique developmental context of adolescence and emerging
adulthood and update the previous edition with the newest formulations of
MI and the newest research. We hope to guide your use of the evidenced-
based method of MI to turn even the most challenging conversations into
realistic, hopeful, and productive interactions that can actually result in
positive change. With this book, we hope that your work with young people
will transition from an adversarial sport to a game changer.
What Is MI?
In the latest edition of Motivational Interviewing, Miller and Rollnick

(2013, p. 29) offer the following beginner definition of MI: “Motivational
interviewing is a collaborative conversation style for strengthening a per-

son’s own motivation and commitment to change.” A more detailed prag-
matic definition includes the humanistic counseling approach and the term
ambivalence: “Motivational interviewing is a person-centered counseling
style for addressing the common problem of ambivalence about change.”
Finally, a more technical definition includes the previous concepts and adds
the focus on the language of change:
Motivational interviewing is a collaborative, goal-oriented style of commu-

nication with particular attention to the language of change. It is designed to
strengthen personal motivation for and commitment to a specific goal by elic-
iting and exploring the person’s own reasons for change within an atmosphere
of acceptance and compassion.
Figure 1.1 demonstrates the elements of MI, and in our adaptations

with young people we have simplified the components into four principles
of MI spirit, four core skills, four types of change talk (preparatory moti-
vational statements) that lead to commitment, and four processes (new to
the third edition of Motivational Interviewing; Miller & Rollnick, 2013). We
consider a fifth process of maintaining, which may be particularly useful
when integrating other forms of treatment, such as cognitive-behavioral
interventions.
MI Spirit
Four Components of Spirit: Partnership,

Acceptance/Autonomy, Compassion,
Evocation (see Chapter 3)
Change Four Core Skills: Emphasizing Autonomy,
Skills MI
Talk Providing Information, Reflections
(includes affirming and summarizing
reflections), Questions (see Chapters 4
and 6)
Four Components of Change Talk:
MI Processes Desire, Ability, Reasons, Need, which
lead to commitment (see Chapter 6)
Four MI Processes: Engaging, Focusing,
Evoking, Planning (consider Maintaining
as a fifth) (see Chapter 7)
FIGURE 1.1. Elements of MI. From Miller and Rollnick (2013). Copyright © 2013
The Guilford Press. Adapted by permission.
What MI Is Not
While MI is a learnable and effective method for enhancing motivation for

healthy behavior change, the process for acquiring proficiency in these
skills requires effort and practice. Miller and Rollnick (2009) discuss com-
mon misunderstandings practitioners frequently encounter when learning
MI. Understanding what MI is not will help you understand what MI is!
MI Is Not a Theory or School of Psychotherapy

MI emerged in a clinical research setting (Miller, 1983). Specific practi-
tioner behaviors associated with behavior change and positive outcomes
were evidenced in treatment session recordings. However, a common mis-
conception, even for those well versed in MI, is that MI is based on a spe-
cific theory, often erroneously attributed to the transtheoretical model of
change (TTM; Prochaska & DiClemente, 1983), also known as the stages-
of-change model. The TTM was developed in parallel at the time with MI,
and helped to open the door in appreciating the importance for interven-
tions to address the lack of motivation in persons who are not fully ready to
change. Another theory of motivation consistent with an MI approach, self-
determination theory (Deci & Ryan, 1985), explains the continuum from
extrinsic to intrinsic motivation, and is used in the next chapter to help illus-
trate the spirit of MI. Social cognitive theories, such as the information–
motivation–behavior skills model (Fisher, Fisher, & Harman, 2003), have
also been described as underlying MI-based interventions. While MI may
be consistent with many theories, in truth, it is an example of grounded
theory. That is, the method emerged from evidenced-based data (i.e., treat-
ment session recordings), rather than a translation from a particular theory
(Miller & Rose, 2009).
Similarly, MI is not based on a specific school of psychotherapy, nor is
it meant to be a treatment for all problems and conditions. While MI makes
use of client-centered counseling skills (Rogers, 1951a), it includes more
goal-oriented components. This combination of person-centered and goal-
oriented skills is what makes unique. You will not just follow the young
person’s conversation, reflecting and using active listening skills. While
these are key to MI, you will simultaneously serve as a guide in the con-
versation, focusing on aspects of change behavior that will enhance their
own internal motivation to maximize their potential. In this way, the client-
centered approach is a necessary, but not sufficient, condition. On the other
hand, MI is also not a directive approach, as in cognitive-behavioral treat-
ments. Cognitive-behavioral treatments offer young patients something
they don’t have, such as a behavioral skill or a cognitive coping strategy.
MI is about eliciting internal motivation and strengths when ambivalence is
impeding behavior change. Incorporating skills training, such as in cognitive-

behavioral therapy (CBT), may then be offered when the young person is
ready to make change. While helpful, incorporating other evidenced-based
treatments, such as CBT, is not necessarily required in using MI.
MI Is Not a Bag of Tricks and Techniques

A major difference between MI and other approaches is that it is not manu-
alized and should not be viewed as a cookbook, a bag of tricks, or a set of
techniques that are applied to young people or families. The MI method
emphasizes empathy, honesty, and collaboration. You respect the young
person as being the expert of themself, and as possessing the mechanisms
and internal resources to change (i.e., personal values, motivations, abili-
ties, skills), with or without your advice. Moreover, MI incorporates a spe-
cific style, termed spirit, without which the techniques fall flat. This style
is defined further in the next chapter, and this spirit is the first task in
learning MI. How skills are used in MI also differs from other approaches.
For example, reflections should be used strategically, versus universally.
While some MI-based interventions focus on specific techniques, such as
the use of assessment feedback (i.e., objective review of assessment tools
to heighten awareness of the need for behavior change), or the decisional
balance exercise (i.e., examining the pros and cons of behavior change)—
they do not define it.
What’s the Evidence?
MI was developed as a brief intervention for problem drinkers and debuted

in a 1983 paper published by William R. Miller in Behavioural and Cogni-
tive Psychotherapy (1983). The fundamental concepts targeted in this initial
intervention—namely, motivation and the obstacles it poses for change—
were later elaborated in 1991 by William R. Miller and Stephen Rollnick in
the seminal text Motivational Interviewing: Preparing People for Change. A
second revised edition of the text was published in 2002, and a third edi-
tion in 2013. An array of MI-based interventions for adults has made MI a
leading evidence-based treatment and a precursor or foundation for other
interventions, first in the area of substance abuse and then mental health
and physical health outcomes with several meta-analyses or systematic
reviews in the last decade (e.g., Magill et al., 2018). Applications for special
populations, including adults with cognitive impairments, and various cul-
tural adaptations, as well as novel formats of intervention, such as groups,
telehealth, and mobile apps, continue to highlight how MI can effect change
in previously unchartered research territories (Miller & Rollnick, 2013).
Since the first edition of this book, MI research with adolescents and
young adults has continued to bloom. At the time of the first edition of this
text, there was limited research on MI with adolescents and young adults,
particularly outside the area of alcohol use. Similarly, since the first edition
of this text (Naar-King & Suarez, 2011), research investigating the effects
of MI with younger populations continues to bloom. Clinical outcome stud-
ies continue to provide strong evidence for the positive effects of MI for
youth and young adults in many domains. Because the number of studies
has skyrocketed, we present systematic reviews and meta-analyses.
The literature on substance use is mixed. A meta-analysis of 84 trials
(22,872 participants) of MI for alcohol use found small effects on alcohol
measures, and the authors considered these small effects not to be clinically
significant (Foxcroft et al., 2016). However, others emphasized that these
brief interventions that can be easily scaled up may have a greater public
health impact, even with small effect sizes, than longer interventions with
larger effect sizes that are more difficult to implement widely (Grant, Ped-
ersen, Osilla, Kulesza, & D’Amico, 2016; Kohler & Hofmann, 2015). Still
others have noted methodological problems with the review (Mun, Atkins,
& Walters, 2015). A meta-analysis of brief MI interventions for alcohol use
in the emergency department included six trials and found that MI was at
least as effective as and often more effective than other brief interventions.
Jensen et al. (2011) found small but significant effects sizes for MI to
reduce alcohol and other drug use in adolescents and larger effect sizes for
smoking. A more recent meta-analysis of 10 studies of MI and illicit drug
use did not find significant effects (Li, Zhu, Tse, Tse, & Wong, 2016). In a
review of 39 studies targeting alcohol, tobacco, and other drug use in ado-
lescents, 67% showed significant effects (Barnett, Sussman, Smith, Rohr-
bach, & Spruijt-Metz, 2012).
A meta-analysis of 15 studies of MI for health behaviors other than
substance use (physical activity, sexual risk, nutrition) found small but
significant and lasting effect sizes (Cushing, Jensen, Miller, & Leffingwell,
2014). In a meta-analysis of 17 studies of MI targeting obesity, there were
no effects on objective outcomes such as BMI or cardiometabolic mark-
ers (Vallabhan et al., 2018). There was some impact on physical activity
and nutrition. The authors note that the studies were not powered suf-
ficiently to test significance. They also note that the interventions were
much shorter than recommended for obesity (fewer than six sessions). A
Cochrane review of MI for risky behaviors in youth living with HIV found
two studies with moderate quality evidence for improving short-term viral
load, unprotected intercourse, and alcohol use (Mbuagbaw, Ye, & Thabane,
2012).
In summary, brief MI yields small but significant effects for most
health behaviors. We could not find any meta-analyses of longer duration
MI, MI combined with other treatments, or MI as a pretreatment. We could

not find any meta-analysis or systematic reviews of MI for young adults.
Many researchers note that quality of training and fidelity monitoring of
intervention delivery is not always consistent and may account for incon-
sistent findings. When reviewing studies, we recommend ensuring that MI
was delivered by a member of the Motivational Interviewing Network of
Trainers, that initial training was at least a 2-day workshop, that follow-up
coaching was provided, that competency was objectively measured by cod-
ing real or simulated interactions, and that feedback and targeted practice
was provided in response to such measures.
What Does It Take to Learn MI?

Proficiency Is a Journey
Learning MI is similar to learning anything new: It requires patience and
practice. Much like an athletic person who enjoys all types of sports but
may not lead the team, many practitioners drawn to MI already have a clini-
cal foundation and professional passion for working with youth. However, as
any athlete knows, playing a sport well does not necessarily qualify one for
being in the Olympics. Similarly, becoming proficient in MI requires more
than an experience working with youth, review of a text, or attendance at a
2-day workshop. While these are all helpful, and learning even one or two
skills will improve your practice, MI proficiency requires a process of expe-
riential learning, practice, demonstration, feedback, and more practice.
Overview
We have organized the book in terms of how we train. In a typical 2-day

workshop, we would begin with ensuring the foundation of MI spirit, move
to practicing specific ways to support autonomy, and then expand on these
skills as a way to manage counter-change talk and discord. We then teach
how to recognize change talk in young people and practice reflections and
open questions in the context of change talk. We have found that trainees
are most likely to latch on to what they learn first, and thus we have moved
away from teaching OARS (open questions, affirmations, reflections, and
summaries) without a change talk context because it is hard to then undo
the tendency to reflect everything. Thus, we avoid dangers of teaching
practitioners to unintentionally elicit and reinforce counter-change talk. We
have simplified OARS by teaching affirmations and summaries as types of
reflections to avoid overwhelming practitioners with too many skills. We
then move to MI processes and consider a fifth process, that of maintaining
change, a process in which you are likely to consider integrating other

treatment approaches. Figure 1.2 demonstrates this revised approach.
A major difference between this guide and the first edition is the
removal of contributed chapters for specific populations (what we called
“Side Trips”). We hope to demonstrate our resolve in presenting MI as an
integrative approach, a universal foundation for good communication and
therapeutic process upon which other interventions can be delivered. As
such, we chose not to present MI as needing to be adapted for specific popu-
lations. Rather, we integrate different populations throughout the book. We
do this in two ways. First, we provide five case examples representing typi-
cal concerns you might see (substance use, anxiety, smoking, medication
adherence, and obesity). See our introductions of those cases later in this
chapter.
We then include a table for Chapters 3 through 8 that provides tips
for working with other populations from the “Side Trips” (juvenile delin-
quency, eating disorders, neurodevelopmental conditions, sexual health,
and opiate addiction; see Table 3.3). Finally, we have additional chapters
addressing group work and how to involve caregivers.
Engaging
VA
LUE
S
UE
S
L
VA
Change
Talk
Managing
Counter-Change
Planning Talk/Discord
Focusing
Emphasizing Autonomy
VA
ES
Spirit
LU
LU
VA
ES
Evoking
FIGURE 1.2. New conceptualization of MI for adolescents and young adults.

Chapter Highlights
• Advances in developmental science. If you are wishing you remem-
bered the developmental information you may have received over the
course of your education, Chapter 2 provides you with a review of recent
advances in understanding adolescent and emerging adult development,
with particular attention to recent findings on neurocognition and brain
development in the context of MI.
• Spirit of MI. In Chapter 3, we turn direction to understanding the
spirit of motivational interviewing. Others and we believe that practicing
the spirit of MI is a fundamental and necessary component of MI. Without
an appreciation of the spirit of MI, one would likely have difficulty in mas-
tering any of the MI skills. It would be akin to learning the words of a song
without hearing the music—both are needed for the tune to flow.
• Emphasizing autonomy. The quest for autonomy encapsulates much
of the adolescent and young adult life stage. Chapter 4 highlights one of the
most important skills you can use in MI with this population—emphasizing
autonomy.
• Responding to counter-change talk and discord. At the onset of treat-
ment, heightened ambivalence about engaging with a practitioner can be
one of the more difficult tasks in solidifying the therapeutic alliance. In
Chapter 5, we present an overview of how to recognize and respond to the
key signals that the young person’s ambivalence about changing is strong
or that there may be potential ruptures in the therapeutic relationship. Note
that Miller and Rollnick (2013) use the term sustain talk to describe lan-
guage that will sustain the status quo. We found that some of our profes-
sional groups were overwhelmed by too many terms, and counter-change
talk was easy to understand as the opposite of change talk.
• Change talk and commitment language. Chapter 6 focuses on how
you can enhance the young person’s own internal motivational by guiding
the discussion to change talk and commitment language. Skills for how to
recognize these statements and maximize the language you use to ver-
bally reinforce youth’s commitment to change, and strategies to elicit these
internally motivating statements, if they do not occur spontaneously, are
addressed. Rich examples, along with new research tailored to enhance
change talk and commitment language, including strategies targeting
implementation intentions and if–then planning, are highlighted.
• The processes. In Chapter 7, we review the new conceptualization
from the third edition of Motivational Interviewing in terms of the four pro-
cesses and how they apply to young people. We address how to use adoles-
cent and young adult values within each process as levers for change.
• A fifth process. While Miller and Rollnick (2013) subsume mainte-

nance within the planning process, we believe skills unique to maintain-
ing change warrant a process and a chapter of its own. Because MI is so
often integrated with other interventions after consolidating commitment
to change, in Chapter 8 we discuss two common treatment approaches,
cognitive-behavioral treatment and the use of extrinsic reinforcers, as part
of maintaining change.
• MI in groups. Since the last edition, Wagner and Ingersoll (2012)
have produced a fantastic guide on how to do MI in groups. We dedicate
Chapter 9 to developmental considerations of MI with groups of adolescents
and young adults and discuss how to use the processes for the life span of
the group.
• MI with caregivers. The previous edition did not address MI with
caregivers, with the exception of a “side trip” discussing MI in family ses-
sions. In Chapter 10, we address how to use MI spirit and skills to promote
caregiver motivation for treatment and suggest a possible format for inte-
grating caregivers in adolescent treatment using the MI processes.
Finally, we updated chapters on developing MI proficiency (Chap-

ter 11), ethical issues (Chapter 12), and future directions (Chapter 13).
The Five Unique Developmental–Contextual Journeys

We recognize each young person will undoubtedly progress along their
own life path, experiencing unique developmental and environmental con-
texts. We now introduce you to five youth case examples that will stream
throughout these chapters. By switching seamlessly among these cases in
our dialogue examples, we hope to demonstrate how MI is easily translated
to different target behaviors.
Travis: “Polysubstance use—I’ll worry about health later”

• I am
{ 17 years old, white, and a heterosexual male
{ “ ‘They’ say I binge drink . . . and shouldn’t use weed. You prob-
ably don’t know, but it’s legal in a lot of states now!”
{ “Havin’ to buy an upper every day before school is gettin’ so old.
If my pops hadn’t got laid off, I could get that focus stuff again—
geez, it would help.”
• People tell me
{ Pediatrician: “You have ‘high blood pressure’ and need to take
some STD and drug tests.” “I like her; she don’t harp on me, but
she says Adderall is gonna mess me up.”
{ School: “You are on ‘probation.’ ” “Duh—don’t they know I don’t
have a computer and I can’t read that well—but I can put a lot of
stuff together—like puzzles! They make it seem like it’s all my
fault, except for my phys ed teacher—he lets me be myself.”
{ Caregivers: “You can talk to them—by yourself.” “My folks said
it was OK, just don’t say the stuff I told you.”

• My interest in talking with you about change
{ “It’s OK talkin’ with you, but I don’t plan on slowing down the
part. But anything, I mean anything—that gets me out of math
class. My dose—they said I was doin’ it ‘illegally’—it wears off
by the afternoon and I need to get to work at the store. Remem-
ber—don’t tell them all the details, OK? Sparing the rod stuff—
I’m too old to keep puttin’ up with it.”
Sofia: “Trying to work on my smoking, but my inhaler keeps

me going”
• I am
{ A 19-year-old bisexual female, and I identify as Latinx
{ In college, on a scholarship for Latin studies. “I want to be a social
worker or maybe even a psychologist, lawyer, or physician—
something that helps people. I’m only 20, so I want to see the
world before I decide anything.”
• People tell me
{ “Stop smoking!” “Like I didn’t know . . . ”
{ “ ‘One more’ asthma attack and ‘another’ ED visit could ‘ruin’ my
chances of seeing the world.”
{ “My parents do love me and want the best for me—I know it
most of the time. But they were born in Mexico and don’t know
what it’s like to be a teenager in this country.”
{ “Can you help me just not to smoke in front of them? It’s their
old school values—they don’t get the pressures of college and
my struggles. I want to really make things right—but smoking is
legal, and I didn’t choose to have asthma. My mom and dad, gosh—
all my family—they smoke something of one kind or another.”
{ “If you’d help me figure out how to manage them and still be
able to once in a while smoke—I’d come back to see you. The

ED was weird—my mom was praying next to the doctor and the
nurses—it was just too much. I think I had another attack trying
to help them all calm down. It just made me want to have a smoke
and get a break from their chaos!”
Sam: “Part of me wants to be more social and part of me doesn’t”

• I am
{ 20 years old and a heterosexual white male
{ “Pretty smart and hope to go into something that makes a dif-
ference in technology—I’m on track for my honors college the-
sis! I love video games, and going into engineering or mechanics
really excites me. I don’t go out much, and I always get nervous in
groups. I just spend more and more time in my room. If I smoke
weed or drink, I can sometimes handle a party. The stress of
college and getting out from my parents—it’s my only goal, and
maybe a girlfriend. I know they helped me when I couldn’t talk
for so long, and the sacrifices they made for homeschooling—but
I’m ready to start meeting people soon.”
• People tell me
{ “My parents nag at me—always and constantly: ‘You’re too smart
with technology and need to grow up like in the real world.’ They
say they shouldn’t have homeschooled me when I refused to go
to high school.”
{ “I went to a therapist; she said I had ‘social anxiety.’ I like people,
sort of, but it’s not really of interest yet to get over this supposed
‘anxiety’; I need a few other things first . . . ”
{ “I am a virgin and sort of agree about the anxiety thing if you
want to tell me what to do. I want to learn how to date, maybe
have a few friends that would play other video games with me
and go out after class to play video games and study. If I don’t
make a lot of friends, it’s OK too. But having a girlfriend, or if
you promise not to tell, a boyfriend—anyone to just hang out
with besides my family—it would help me to feel more normal,
although I know being atypical will always be how I am labeled.”
Jenny: “My mom wants me to lose weight”

• I am
{ 16 years old, Black, heterosexual, female
{ “Sort of ready to lose weight, but I am pretty happy where I am.
My family always has food available—it’s their way of showing
they ‘care.’ And Black church is food all the time. You don’t under-
stand how tough it is to say no to the constant food and guilt I
feel for saying no during our family time. As a 15-year-old, I can’t
work for a couple of months until I finally turn 16. They don’t want
me to risk my doing well at school—I’m close to making a passing
grade in all classes right now! And don’t even tell me about work-
ing out. It takes me hours to fix my hair if I’m sweaty.”
• People tell me
{ “My mom and grandma and four brothers and sisters, we all live
together, and I have to hear every day: ‘We sacrifice for you—
when will you do the same?’ ”
{ “I can’t get to the doctor right now or go to a gym, no transporta-
tion, and Mom is pregnant again.”

{ “I’d love for you to get my mom off my back and stop hearing about
my how diabetes runs in my family. I wouldn’t mind losing a little
weight so the teasing stops, but I don’t want to be too skinny.”
Eugene: “I don’t want to think about it, but I know I can’t ignore
HIV forever”
• I am
{ A 23-year-old Black gay male
{ “Being 23 years old gives me many freedoms I could never have
in high school when I had to hide my sexuality. I was diagnosed
with HIV a year ago, and nobody really knows. I don’t have a boy-
friend, but a few older guys who I can stay with when I need to get
away from my aunt. She keeps asking me when am I really gonna
be on my own. It’s hard because I barely finished high school and
don’t have the money to go to college right now. I would love to
be the first Black man in my family to go.”
• People tell me
{ “Why haven’t you taken your HIV meds?”
{ “Didn’t you know you would catch something if you were sleep-
ing with guys?”
{ “We have support groups and counseling services but you don’t
ever go.”
{ “I don’t want to think about having HIV, and I feel pretty good
right now. I don’t have time for appointments because I am work-
ing two jobs so I can get my own place.”
What Is the MI Invitation?
We invite you to begin your own journey of learning on the MI path to

promote behavior change with adolescents and young adults. While the
following chapters offer a clinical guide, the path each of us will take to
incorporating MI principles and skills into daily practice will vary. Some
practitioners may be drawn to the person-centered components of MI and
struggle with the more goal-oriented strategies. Others may gravitate to
behavior change planning too quickly and struggle to maintain a person-
centered stance. Akin to the youth’s journey of change, your personal jour-
ney to enhance skills for using MI will include challenges and opportuni-
ties. In the following chapters, we offer a menu of options for how you can
incorporate MI in your practice, and encourage you to continue the journal
of change beyond this book and maximize your potential as a practitioner.
Table 1.1 summarizes the MI journey.
TABLE 1.1. Major Aspects of MI

Discussion questions Summary
What is MI? A collaborative, person-centered form of guiding to elicit
and strengthen motivation for change
What are the elements Spirit, skills, change talk, processes

of MI?
What is MI not? 1. Theory laden

2. A trick to make people do what you want
3. A technique
4. A decisional balance
5. Assessment feedback
6. A subclass of cognitive-behavioral therapy
7. The same as client-centered counseling
8. Easy to learn
9. What you are already doing because you recognize it
10. A panacea
What is the model of MI Spirit is the foundation, which is followed by emphasizing

used in this book? autonomy. Then you learn how to manage counter-
change talk and discord, while you elicit and reinforce
change talk to lead to commitment. The five processes
(engaging, focusing, evoking, planning, and our added
process of maintaining) can structure the flow of the
conversation.
When do you use MI? All the time—as a stand-alone intervention, as a

precursor to more intensive treatments, or as a
communication foundation upon which you deliver other
interventions
(cont.)
TABLE 1.1. (cont.)
Discussion questions Summary
What is the MI evidence Blooming in all areas: health, mental health, substance
base? use. and criminal justice. A few studies with ages 11–12;
most evidence with ages 13 and older.
How is MI different with The unique developmental context of adolescence and

young people? emerging adulthood suggests that the behavior change
journey will differ from that of adults. Prevents myths
of developmental uniformity (i.e., they’re all the same)
and continuity (i.e., adult therapies can be used the
same with young people) from negatively affecting your
success.
What are the major Biological

developmental factors to Cognitive
consider when using MI? Social
Identity
Autonomy
Relationships with family and peers
What is the MI An invitation to begin your own journey to learn MI.

invitation? Caution: You may change.
Practitioner Activity 1.1 Why MI?
Activity Goal: To consider what you see as the benefits of MI for young people
Activity Instructions:
1. List three things that surprised you about what MI is.
2. List three things that surprised you about what MI is not.
3. List three benefits of MI for young people.
4. Create your own definition of MI for young people.
5. Compare and contrast with the three existing definitions of MI from the
beginning of the chapter.
2
Developmental Challenges
and Opportunities
The young always have the same problem—how to rebel

and conform at the same time. They have now solved this by
defying their parents and copying one another.
—Quentin Crisp
Using the MI method with young people requires you to have a solid under-
standing of the unique developmental processes occurring during the
important life stages they are traversing. In the next sections, you will learn
more about how to enhance the developmental sensitivity of your conversa-
tions about change with young clients. An overview of cognitive and social–
emotional development and updates in neuroscience relevant for delivering
MI to young people are highlighted next, so you may continue to incorporate
best practices and maximize change with the young people you serve.
A Brief Review of Cognitive Development
We next review two approaches to cognitive development and discuss the

implications for MI with young people.
Stage Theory: Formal Operations

and MI Developmental Caveats
Piaget (1972) developed a comprehensive stage theory of cognitive devel-
opment emphasizing the broad patterns and qualitative changes occurring
during this period. Of relevance to the application of MI is the final stage
of cognitive development, beginning during early adolescence (ages 11–12
years), the formal operational stage. During this period, the cognitive pro-
cess of reasoning and formal thinking patterns radically changes and devel-
ops. The further along the young person is in this stage, the more likely you
18
Developmental Challenges and Opportunities 19
will be able to have conversations about ambivalence and possible plans for
change. However, there are caveats in applications of MI. Development isn’t
stagnant or consistent among all youth.
Adolescents with fewer cognitively developed resources may require
you to guide MI conversations focusing on short-term and concrete changes.
In contrast, adolescents with more developed cognitive processes, and
some entering the emerging adulthood period, may benefit from conversa-
tions targeting longer-term goals and values.
Information Processing: Interpretation Biases

and Higher-Order Thought Processes
The information-processing approach examines the young person’s percep-
tion, attention, retrieval, and manipulation of information (Siegler & Shi-
pley, 1995). Two information-processing steps are particularly relevant for
MI with young people: interpretation and higher-order thought processes.
Adults have a luxury not afforded to youth: They can use past experi-
ences as a gauge for discriminating between future choices and decisions
that can add value to their life. Young people often lack the necessary life
experiences to base their decisions on. Accurate judgments are often a work
in progress. At any moment during an MI intervention, interpretation biases,
based on a limited scope of experience, can cloud youth’s decision-making
processes (Rice & Dolgin, 2008). For example, a young person having sex
for the first time may forgo the use of protection due to a lack of experience
and misguided belief that this behavior will not result in unwanted conse-
quences, such as a sexually transmitted disease or pregnancy.
Interestingly, young people often rely on a “glass is almost half full”
philosophy, incorporating negative, disconfirming evidence in the cognitive
higher-order thought processing of information. They often seek to negate,
rather than affirm, evidence, using elimination strategies rather than con-
firmation strategies in the cognitive processing of events (Foltz, Overton,
& Ricco, 1995; Müller, Sokol, & Overton, 1999; Rice & Dolgin, 2008). For
example, a young person smoking e-cigarettes may understand it increases
harmful health risks yet believe there is no risk due to their young age.
Statements of these disconfirmatory and elimination strategies may smack
of sentiments such as “At any time I can quit—but later—I have time . . . ”
A Brief Review of Social

and Emotional Development
Identity and role formulation is one of the most important, yet perplex-
ingly complicated, tasks during a youth’s development (Baumeister, 1991;
Cole et al., 2001; Rice & Dolgin, 2008). The young person’s self-concept
begins to stabilize, yet new opportunities for destabilization become plenti-
ful (Arnett, 2004; Cole et al., 2001). For example, experimentation with
different behaviors, such as sex and substance use, can frequently prompt
opportunities for a recalibration of “personal identity,” along with laying
seeds for the formation of values that will drive many adult decisions and
life choices (Rice & Dolgin, 2008).
Recognizing the complexity of decisions in making long-term changes
at this point in the developmental period can be hard for young people.
How you roll with these multifaceted changes, which tend to be temporary
rather than stable across time, can make your MI conversations productive
in maximizing change efforts. Knowledge of the central issues surrounding
social role development provides you the opportunity to more efficiently
partner with the young person, while concurrently respecting their need to
explore and establish personal values and goals.
Identity and Adolescence
Erikson (1982) defined eight stages of psychosocial personality develop-
ment. Adolescence is characterized by the fifth stage, identity versus dif-
fusion. During this stage, the goal of establishing a personal identity is
achieved by evaluating personal positive and negative qualities to help clar-
ify one’s self-concept and determine the type of adult one wants to become
in the future (Rice & Dolgin, 2008). Identity formation occurs through
multiple role explorations and commitments to various life issues (such as
occupational, academic, religious, social, sexual, and political; Holmbeck,
O’Mahar, Abad, Colder, & Updegrove, 2006). Understanding the purpose of
multiple role explorations in forming identity will help you express accurate
empathy and guide the context of behavior change conversations.
Identity and Emerging Adulthood

As societal and economic changes have created new demands and chal-
lenges for young people, particularly those in the 18- to 25-year-old range,
we now recognize emerging adulthood as a distinct period separate from
adolescence and young adulthood (Arnett, 2004). During this period,
emerging adults experience new life roles. Research by Arnett (2004) and
others (Kroger, Martinussen, & Marcia, 2010) has shown the length of time
for young persons to actually create a personal identity has increased to
the mid- to late 20s. Emerging adulthood in Western culture is still a time
of shifting identities. There is a continued risk of experimentation with
unhealthy behaviors, posing perhaps an even greater risk for the young
people in this later emerging adulthood stage. They are no longer minors
and are faced with two additional life challenges: increased adult responsi-
bilities and decreased familial support.
Autonomy: Emotional and Behavioral Components

A core element in the journey to adulthood involves the attainment of
autonomy (Rice & Dolgin, 2008). During this time period, young people
establish their uniqueness from others, and new interests, values, goals,
and worldviews divergent from close others may emerge (Rice & Dolgin,
2008). As a normal developmental process, autonomy has been described
as having two components: emotional and behavioral.
Emotional autonomy refers to becoming free of childish emotional
dependence on adults (Rice & Dolgin, 2008). Parents can either foster an
overdependence on the developing young person or provide the opposite,
a lack of guidance and support. Clearly, a balance of both is the most pre-
ferred course of action (Rice & Dolgin, 2008). Behavioral autonomy refers
to youth learning to become more skilled in their own self-governing
behavior and independent enough to make decisions on their own accord
(Holmbeck et al., 2006; Rice & Dolgin, 2008).
While discussed in greater detail in Chapters 3 and 4, autonomy in
decision making and taking responsibility for actions serve as fundamental
components of MI (Miller & Rollnick, 2003, 2013). These issues become
especially important in interventions with adolescents and family members.
Young persons are faced with the ultimate developmental conundrum: On
the one hand, they are met with the task of exploring alternative behaviors
and roles that smack of adultlike decisions, and on the other hand, they bear
the new, yet daunting role of no longer being confined by parental and once-
perceived societal regulations.
Family Relationships
Several pseudoscientific myths and gems of clinical lore pervade the thera-
peutic culture in working with youth. For example, they often receive an
unwarranted reputation for being “rude and irresponsible”—particularly if
they do not sever ties with caregivers within a specified and normative
time frame (e.g., by the age of 18; Agenda, 1999; Holmbeck et al., 2006).
An ill-informed belief persists in our field that if during this period, ties
with parents are not severed, youth will develop significant mental health
disorders (Collins & Laursen, 1992). However, research provides us with a
more optimistic analysis of this period. It can be a time of role transforma-
tions in family relationships, increasing opportunities to enhance skills for
taking personal responsibility and decision-making authority (Holmbeck,
1996; Whiteman, McHale, & Crouter, 2011).
As many of these familial role transformations are considered a nor-

mal part of development, conflicts, disagreements, and the expression of
negative emotions toward family members can serve as a useful, adaptive
function and prime opportunity for MI interventions. You can use MI to
help the young person to negotiate these new roles and skills in decision
making and autonomy within the family unit. With proper MI guidance,
disagreements and expressions of emotion can foster values-based discus-
sions about change and evolving role transformations within the family unit
(Branje, 2018).
Peer Relationships
Similar to family relationships, peers serve an important function during
the young person’s development (Holmbeck et al., 2006; Parker & Asher,
1987; Rice & Dolgin, 2008; Steinberg, 2005). During this stage, friendships
become a primary, albeit stressful, part of the young person’s life. For exam-
ple, while social acceptance by peers tends to foster overall well-being, peer
rejection and victimization often lead to engagement in problematic behav-
iors (such as delinquency, drug abuse, and depression; Merten, 1996).
Young people mastering the tasks of autonomous decision mak-
ing typically rely on the feedback of close others, especially peers. Your
understanding of the young person’s perceptions of these relationships can
inform change talk discussions. For example, a young person may perceive
drinking alcohol with peers as a positively rewarding experience yet expe-
rience conflict with parents about it.
Depending on the nature of the relationships with parents and peers,
the topics you raise during an MI encounter will differ. For example, if the
teenager views parental approval as something of value and importance,
discussing the negative consequences received at home may be an appro-
priate focus to decrease ambivalence about drinking alcohol. You may hear
statements signaling a conversational direction to take. For example, if
youth value their parental relationships, you may hear statements such as
“My mom gets so stressed when I’m out. I hate it—she’s always working
too. But her nagging also stresses me out. I want her to chill but also want
to be able to chill too.”
In contrast, if peer relationships are more of an immediate value than
parental approval, conversations about family may increase ambivalence to
consider change and even frustration. For example, you may hear statements
such as “Enough with asking about my Mom—it’s getting old. My girlfriend
knows me waaaay better. Do you even have a license to practice—because I
could take it now—you are royally pissin’ me off—really, and I ain’t kiddin’.”
In short, how you choose to incorporate family and peer relationship
issues can provide you with several windows to explore various life fac-
ets relevant for MI interventions. Your mindful attention to these temporal
cognitive perceptions, values in relationships (which are oft wavering), and

perceived access to supports all enhance the depth and scope of your MI
conversations with youth.
Emotional Contexts of Family and Peer Relationships

Emotional stress typically arises in the face of conflict with parents and
peers. With young persons, emotions (and hormones) are often in a state
of flux. Who among us can’t recall the pangs of being a young person and
experiencing some intense emotion, be it fear, anger, or sadness, over what
now seems but a moment in the process of our development?
Cognitive processes may sometimes be compromised when the
young person appears to be in a heightened emotional state. During these
moments, your decision of how to intervene in an MI-consistent manner
(e.g., taking only a supportive stance and eliciting a discussion about behav-
ioral change at a later point) may require your clinical judgment. You may
want to avoid decision-making conversations and focus on building rapport
in these moments.
New Directions in Developmental Neuroscience
The last decade has seen a proliferation of neuroscience studies that signifi-
cantly inform how to utilize MI with young people.
Brain Development
From the onset of puberty through age 25, the adolescent brain undergoes
profound changes in structure and function (Wetherill & Tapert, 2013).
Advances in developmental neuroscience and neuroimaging demonstrate
regions of the brain develop at different rates—from birth to emerging
adulthood (Mills, Goddings, Clasen, Giedd, & Blakemore, 2014). Recog-
nizing how many adolescent behaviors can be attributed to a developmen-
tal mismatch between structural/functional imbalances in certain brain
regions is a key to MI spirit. Recent research about two key brain regions
has evidenced how structural changes affect functional behavioral outputs
in youth (Feldstein Ewing, Tapert, & Molina, 2016; Luciana & Feldstein
Ewing, 2015). Specifically, evidence is emerging on how the limbic regions
are associated with reward and emotional regulation, and how regions such
as the prefrontal cortex are associated with cognitive control. Other brain
regions, associated with the activation and processing of social information,
can actually enhance the development of adolescent cognitive executive
functions, as compared to other developmental periods (Steinberg, 2008).
For example, while impulsive behaviors may be seen as a lack of “cognitive
control,” we concur some degree of risk-taking behavior may be neces-

sary and important for youth to gain important life experiences required to
assume adult roles.
Neuroimaging Translational MI Applications

In contrast to older adults whose brains are no longer in a formative stage
of development, the neural networks of youth are being reshaped with each
learning experience. Understanding these processes can further help you
to understand the developmental challenges and opportunities of adoles-
cence and emerging adulthood.
Feldstein Ewing and colleagues (2013) have paved the way for such
translational research, linking brain activation to subsequent behavior
change, as well as documenting evidence of how practitioner’s behaviors
can positively influence brain activation. For example, activation of adoles-
cent brain networks involved in introspection and contemplation of cogni-
tively assessed behavioral efforts predict successful substance abuse treat-
ment response.
In another study, the outcomes of other verbal behavioral outcome
studies paired with neuroimaging found that listening to change talk gener-
ated by adolescents during treatment sessions resulted in greater brain acti-
vation, rather than listening to change talk (statements in favor of change)
generated by the experimenter (Feldstein Ewing, Yezhuvath, Houck, &
Filbey, 2014). These findings support the contention that reflecting change
talk elicited from the adolescent will yield greater results—in comparison
to old-school, expert-driven approaches of merely advising or warning.
In another study, complex reflections and closed questions resulted in
regional activation among adolescents receiving alcohol treatment (Feld-
stein Ewing, Houck, et al., 2016). While both were associated with bet-
ter outcomes, complex reflections showed greater activation in some brain
regions. Results provide continued support for the use of complex reflec-
tions, and add new insight into how closed-ended questions may play a big-
ger role in maximizing MI interventions with adolescents and young adults
(see Chapter 5 for further discussion of applications). These advances have
spurred a call to action for the translation of neuroscience findings to clini-
cal practice, along with enhancing the exchange of communication research
between clinicians and neuroimagers (www.scienceofchange.org).
The Impact of Social Media
The increase in social media usage by young people is arguably the biggest
cultural shift since the first edition of this book. Most teens (84% in the
United States) have their own smartphone and spend more than 7 hours
a day on entertainment screen media (Rideout & Robb, 2019). Contrary
to the concerns of many parents, increased social media usage is associ-
ated with increased self-esteem and social capital, identity exploration,
social support, and self-disclosure in adolescents and young adults (Uhls,
Ellison, & Subrahmanyam, 2017). You might have yourself experienced an
increased positive impact of social media in the face of the global COVID-19
pandemic that required social distancing. Another important finding is that
adolescents use social media to develop and maintain friendships. A major-
ity of teens make new friends through social media, and almost all of them
use social media to connect with friends daily (Anderson & Jiang, 2018).
You should have some familiarity with the social media usage of teens in
general and of your client in particular. You do not need to become an Ins-
tagrammer or post video clips on YouTube, but consider reviewing recent
statistics on social media usage (e.g., www.commonsensemedia.org), follow-
ing the social media icon of the month, reading young adult fiction, watching
young adult television, or exploring new social media outlets (e.g., TikTok,
at the time of this writing). Having some familiarity with the social media
your clients are exposed to and using will not only help you engage with
them but also provide a menu of realistic options when planning for change.
Similarly, look out for the negative influences of social media such as cyber-
bullying, depression, social anxiety, exposure to developmentally inappro-
priate content, Internet addiction, and sleep disruption or deprivation.
Summary
Adolescence and emerging adulthood are defined as the transitional devel-

opmental period between childhood and adulthood, extending from age 12
to the 20s. After infancy, it is the life stage with the greatest biological,
psychological, and social role changes (Arnett, 2004; Rice & Dolgin, 2008)
and brain development (Wetherill & Tapert, 2013). The constant flux of
change experienced during this period provides a prime opportunity for MI
intervention by positively altering the risks and potential adult trajectories
of unhealthy behaviors and poor outcomes.
The use of the MI method is fundamentally unique with young people.
Recognizing how the normal developmental processes of adolescence and
emerging adulthood regularly (and sometimes unpredictably!) affect the
young person’s motivations, decisions, and goals is necessary for using
MI effectively. An understanding of the cognitive, social–emotional, and
neurological developmental processes your clients are going through will
improve your opportunities to maximize MI conversations with them.
Table 2.1 summarizes the developmental implications for MI.
TABLE 2.1. Developmental Implications and MI
Development Implications for MI
Cognitive development
Formal Tailor discussions to youth’s cognitive resources
operations • Developed: Long-term goals and values
• Less developed: Short-term goals and concrete changes
Information Recognize interpretation biases
processing • May misinterpret consequences of behaviors
Appreciate higher-order thought processes
• Actively seeking disconfirming evidence is normal
Social and emotional development
Identity Adolescence and young adults have different perspectives
formation • Allow explorations: Multiple and evolving self-concepts
• Empathize with ambivalence
• Appreciate risk issues with increasing life responsibilities
• Be tolerant of shifts in perspective with new life roles
Autonomy Emotional and behavioral components
• Understand developmental conundrums faced by youth
{ New opportunities for exploration
{ New opportunities for more intense consequences
• Understand opposition to authority normal
Family Reframe adolescent rebellion
relationships • Normal process of identity formation and adaptive
• Help youth to negotiate new roles with family
Peer Recognize the importance of peers
relationships • Explore values and stresses associated with peers
• Guide discussions about peers as pros/cons of change
Emotional Understand cognitive processes can be compromised
contexts • Allow the tides of emotion to arise
• Surf the moment of emotional intensity with youth
• Be careful with plans for change with intense emotion
Developmental neuroscience
Brain Understand brain stability and plasticity
development • Youth’s brains are in constant transformation
• How you guide sets the stage for new learning and can facilitate
change in development of new neural paths
Appreciate co-occurring structural and functional changes
• Recognize importance of internal reward and cognitive control
centers (limbic system, prefrontal cortex)
• Understand impulsivity and risk taking can serve a functional
purpose in assuming adult role
Neuroimaging Dual processes of brain activation and practitioner behaviors
translational • Guide the MI conversation for youth to listen to their own change
updates talk—not yours
• Consider use of closed-ended questions
{ Promising evidence; verdict is still out
• Reflect change talk using complex reflections
26
Practitioner Activity 2.1. Developmental Opportunities
Activity Goal: To consider how to turn developmental challenges into develop-

mental opportunities when working with young people
1. Think about the last time you struggled in an interaction with an adolescent
or young adult. Fill out the challenges with that in mind.
2. Think about the last time you struggled in an interaction with an adolescent.
Fill out the opportunities with that in mind.
3. Write a summary statement about how you might turn challenges into
opportunities.
Area of
developmental
context Challenge Opportunity
Cognitive
Social
Emotional
Family
Peers
Social media
Create a summary statement about how I can turn challenges into opportunities
in my work with young people:
3
Getting the Spirit Right
Learning to stand in somebody else’s shoes, to see through

their eyes, that’s how peace begins.
—Barack Obama
Engaging
VA
LUE
S
UE
S
L
VA
Change
Talk
Managing
Counter-Change
Planning Talk/Discord Focusing
VA
Spirit
UE
L
UE
L
VA
S
Evoking
MI is a method or style of an interaction with a foundation we call spirit.

Miller and Rollnick (Miller & Rollnick, 2013) call MI spirit a mindset and
heart-set. While skills and strategies are important elements of MI, they do
not define it. As Miller (2008) has noted, if you only learn MI skills without
understanding the spirit, it is like learning the words to a song without any
music. In the next sections, we review the four interrelated components of
the spirit of MI: partnership, acceptance, compassion, and evocation, some-
times used as the acronym PACE (Miller & Rollnick, 2013).
Partnership
In contrast to prescriptive approaches, when you are the expert handing

down wisdom, the MI spirit is based on a collaborative partnership between
28
Getting the Spirit Right 29
you and the young person. While you will often need to collaborate with
parents regarding goals, behavior change will not occur in the absence
of a partnership with the youth. You may also experience a professional
conundrum during this process, in which you are caught between the goals
of authority figures and the goals of the young person. Of course, this is
parallel to the pressure that the young person feels. The challenge is to
guide the young person toward setting goals that will satisfy the need for
independence and at the same time address the pressure to get along with
authority figures.
Rollnick, Miller, and Butler (2008) expand on this guiding style. A
guide helps people find their way safely and solve situations for them-
selves. Similar to a parent on the playground, there should be a balance
of helping, supporting, and avoiding harm, while simultaneously allowing
the child to experiment and problem-solve for him- or herself. Thus, col-
laboration involves a joint process, not merely serving the client’s impulses
and desires or only satisfying your (or others’) agenda. You must be honest
(with yourself and the young person) about your role in promoting both
autonomous decision making and positive behavior change in order to
maximize the client’s potential. For example, a prescriptive approach to
substance abuse treatment may insist on abstinence as the only solution,
but a collaborative approach may consider a harm-reduction goal consistent
with the young person’s desire for change. However, as a guide it may be
appropriate to offer information about the success of abstinence approaches
when the young person is ready to hear it.
In the case of Jenny struggling with obesity, a prescriptive approach
might delineate calorie restrictions or engage the parents in setting limits
on access to food. However, both of these strategies will be more likely to
fail without collaboration with her. Alternatively, these interventions are
more likely to succeed if, in conversation with the practitioner, Jenny deter-
mines she is committed to losing weight by cutting calories and that her
parents could help her by not purchasing chips and soda.
Acceptance
Profound acceptance includes four key elements, according to Miller and

Rollnick (2013): respect for absolute worth, autonomy support, accurate
empathy, and affirmation.
Absolute Worth
Kant originated the idea of humans having an absolute worth, such that
a person is an end in itself, rather than a means to an end (Kant, 2011,
p. 428). This idea underlies his moral concept of respect for persons. A
person is deserving of respect not for who they are in the world or for what
they do but simply because they are human. In contrast, from an economics
perspective, something has relative value when compared to another thing
(i.e., a nonsmoker versus a smoker; the young person who takes their medi-
cation versus another who does not). Acceptance in MI means you view a
person with absolute worth, which can be hard at times when you are faced
with the many issues presented by the young person.
Respect for absolute worth may be slipping when you feel annoyed
with a young person, when you feel the time spent with them is not “worth
it,” when you find yourself liking the young person more when they show
behavior change, or when you focus more on what they need to do versus
where they are now. When faced with these practice challenges, be sure to
remind yourself of the Kantian perspective, respecting the worth of every
person because they are human, and to find strength and value in where
the person is in the present, rather than where you think they “should” or
“could” be.
In the case of Eugene managing HIV, a statement indicating relative
worth might be “You have so much strength; I know you will decide to
take care of your health.” In contrast, a statement indicating a more MI-
consistent reflection of absolute worth might sound like “I can see so much
strength in all you are managing right now.” Viewing Eugene’s worth in
a “relative” sense suggests that he is strong only if he makes a decision
to take care of his health, whereas viewing Eugene’s worth in an “abso-
lute” sense implies he’s strong regardless of his taking steps to improve
his health.
Autonomy
Autonomy centers on accepting someone’s absolute worth and respect for

their choices regardless of outcome, simply because it is their choice and
personal right to self-governance. Grounded in self-determination theory,
one of the most widely accepted theories of motivation (Deci & Ryan,
1985), autonomy is viewed as a primary need to motivate the initiation of a
behavior and is key to psychological health. Deci and Ryan emphasize how
autonomy is not necessarily synonymous with independence (and in fact
relatedness is a second primary need) but rather refers to being true to
one’s own values and taking ownership as the causal agent of one’s own life.
For example, research has shown that offering increased choices promotes
intrinsic motivation and behavior change (Ng et al., 2012). Similarly, medi-
cal and counseling ethics emphasize that not only is supporting autonomy
effective in promoting behavior change outcomes but also practitioners are

ethically obligated to support autonomy, making increased autonomy a wor-
thy outcome in and of itself (Entwistle, Carter, Cribb, & McCaffery, 2010;
Ryan, Lynch, Vansteenkiste, & Deci, 2011).
The case of Travis who is experiencing health consequences related
to polysubstance abuse highlights how the promotion of autonomy can be
difficult for physicians, practitioners, and parents, who each may have a
different perspective of what “is best for Travis” to address multiple areas
of behavior change. It can often be easier to offer a young person advice,
with statements such as “Travis if you would just . . . ” However, a state-
ment promoting autonomy in an MI-consistent manner would sound more
like “Travis, it is your choice whether you want to quit, cut back, or discuss
other options to address your health.”
Accurate Empathy
The concept of empathy has long been considered a key component in many
different types of psychotherapy, both for the development of therapeutic
alliance and for its therapeutic effect as an intervention to relieve personal
distress. When you provide a secure and caring interpersonal context, you
enhance the development of intrinsic motivation, as relatedness is another
primary need that motivates behavior (Deci & Ryan, 1985). Adolescence is
a time when young people are separating from their parents, when relating
to others is based more on personal ideas and decisions than on those of
family members or authority figures. It is common for the young person to
experience a lack of acceptance and understanding from adults, and com-
munication with parents can deteriorate. Adolescents, particularly younger
adolescents, may feel loved only conditionally, depending on their behavior
and compliance with external demands. However, adolescents, like all of
us, want someone to understand, listen, and believe they have something
worthwhile to say (Rice & Dolgin, 2008). Thus, your display of empathy and
acceptance is especially critical during MI encounters.
Accurate empathy implies putting yourself in the young person’s shoes
as opposed to feeling sorry for (sympathy) or identifying with (camarade-
rie) the young person. In the case of Sam with social anxiety, instead of
using statements signaling sympathy (such as “I know it is so hard at your
age”) or camaraderie (“I get it, I have a hard time at parties too”), state-
ments reflecting accurate empathy will allow the adolescent to recognize
you are actually listening to their own concerns (“I can see that you want
college to be more fun”), rather than reflecting on your own personal his-
tory and struggles.
Affirmation
Another need youth have that motivates behavior according to self-

determination theory is competence. Miller and Rollnick (2002) note that
actual behavior change occurs when a person deems the behavior impor-
tant and when he or she feels able to make the change. Young people often
perceive themselves as falling short of the expectations of authority figures,
consequently compromising their feeling able to change. When you take an
affirming stance of hope and optimism for successful behavior change and
express an honest belief in the young person’s ability, the young person is
likely to feel more competent and therefore behavior change is more likely
to occur.
In the case of Eugene, he may acknowledge that missing medica-
tions is problematic but will not set a goal for medication adherence with-
out believing there is a chance for success. He also feels a sense of shame
for “catching HIV.” While self-esteem is a general sense of one’s worth
or value, self-esteem is the belief in one’s ability to be competent in spe-
cific situations and tasks (e.g., “I can get take my meds in the morning”; “I
will figure out how to get to the doctor”). By affirming the young person’s
strengths and values, using statements that both affirm and reinforce state-
ments about confidence for behavior change (e.g., “You know how to figure
things out”), you will further facilitate internal motivation for change. (See
sections “Types of Complex Reflections” and “Questions About Personal
Strengths” in Chapter 6 for further detail.)
Compassion
Compassion has recently been added as a third element of the MI spirit

(Miller & Rollnick, 2013), to differentiate practicing MI for the good of
the client from practicing it for the practitioner’s own benefit. Compassion
refers to a dedication for promoting the welfare of others yet is distinct from
personal feelings of sympathy or personalization of the experience. This
distinction of compassion versus sympathy is similar to the skill of express-
ing empathy versus using sympathy or camaraderie-based communication.
While all MI strategies are intended to promote positive behavior change,
compassion is unique to the method in that the goals of help and support
are the priority and take precedence over any maneuvers to influence the
young person. Steindl’s discussions of the integration of MI and compassion-
focused interventions yield some suggestions for expanding this compo-
nent of MI spirit (Steindl, Kirby, & Tellegan, 2018). Compassion-focused
therapies promote the development of self- compassion as the primary
mechanism of resolving distress. In fact, a meta-analysis across 19 studies

found strong effects for the inverse relationship between self-compassion
and psychological distress in adolescents (Marsh, Chan, & MacBeth, 2018).
Self-compassion includes kindness versus judgment, humanity versus iso-
lation, and mindfulness versus overidentification with thoughts and feelings
(Neff, 2019). You can see how this conceptualization fits with MI spirit and
the MI focus on present change talk.
Caregivers are also in great need of compassion. Many caregivers are
frustrated, angry, or ashamed at what they perceive to be a failure for them-
selves or their child. Sometimes a strong identification with a young person
can lead to a practitioner’s frustration with the client’s caregiver. Practicing
compassion, with a focus on kindness, empathy, normalization, and pres-
ent versus past action, can promote parental engagement. Jenny’s mother
cares about her daughter’s health and is worried she is not modeling good
nutrition and physical activity. She needs compassion and support of self-
efficacy to change her own behavior. Travis’s parents are angry with the
mess he has made of his life. They keep trying to restrict freedoms to no
avail, and conflict is escalating. They are close to giving up and want you to
“fix him.” You can help by compassionately reframing that anger as caring.
Kindness, humanity, and a focus on present action, along with affirmation,
can go a long way in installing hope and optimism about the client’s capacity
for change.
Evocation
In MI, you evoke and elicit reasons for and concerns about change, rather
than imparting unsolicited advice. Thus, evocation may run counter to the
natural instinct to “help” the young person by correcting what you construe
as flawed reasoning or poor decision making. Miller and Rollnick (2002)
describe this phenomenon as the righting reflex, the human tendency to
correct things that are perceived as wrong. This tendency often translates
into premature problem solving and advice giving, which subsequently pre-
vents young people from being actively involved in the change process, and
actually places them in a passive role, stifling their autonomy, as well as
engendering rebellion.
In the case of Sofia, you may feel strongly pulled to correct misinfor-
mation about using quick-relief inhalers as a daily treatment when asthma
is exacerbated from smoking, without first understanding Sofia’s thoughts
and feelings about smoking and other areas of her life. The temptations to
make statements that smack of scare tactics, such as “You know, if you don’t
. . . ” can evoke resistance instead of motivation. Instead, your goal in MI is
to use evocative statements that will elicit opportunities to have Sofia argue
for change and ask for information. For example, asking a simple question,
such as “What do you know about the effects of smoking on your asthma?”
can offer a more robust opportunity to explore the associations the youth
perceives about their current behavior and valued outcomes.
Evoking implies an active process that takes MI beyond client-centered
counseling and into a goal-oriented intervention method. MI seeks to evoke
intrinsic motivation—the engagement in behaviors for personal interest as
opposed to external consequences. Although some behaviors will never be
truly intrinsically motivated because they are not pleasurable (e.g., restrict-
ing sweets, taking insulin), the young person may still internalize motiva-
tion to engage in these behaviors by transforming external demands into
personal values or goals. In many ways, this is the goal of the motivational
interview. You will learn to do this by eliciting verbalizations about the
importance of change and the confidence to change so that the young per-
son argues for change instead of you doing it for them.
Although developing discrepancy is not specified as an element or
theme of spirit in the third edition of Motivational Interviewing, we believe
it is a critical component of evocation. Behavior change is more likely to
occur when the new behavior is identified as being consistent with the
young person’s own values and goals. When a client simply accepts the
external demands and rules of others but does not believe in them, behavior
change may occur as a result of threats, guilt, or shame. However, behavior
change due to external forces is less stable and more inconsistent over time
than change due to internal forces. Thus, you can promote behavior change
by evoking, reflecting, and even magnifying the discrepancy between the
young person’s values and goals and their current status quo behaviors.
Developing these discrepancies may compel the young person to consider
and possibly change the status quo behaviors to coalesce with their own
values. For example, for a young person who highly values personal inde-
pendence, a discussion focusing on how drug use increases dependence (on
the drug, on the dealer, and on others for financial resources) may subse-
quently increase intrinsic motivation to avoid drugs.
In developing discrepancy, it is critical that you focus on the young
person’s behavior and values, not your values or social norms. The patient’s
values and goals may be external (e.g., having a girlfriend), short term (e.g.,
wanting to go to a party on Friday night), or unrealistic in your opinion
(e.g., wanting to be a rap star). However, all of the youth’s values and goals,
whether you agree with them or not, can be used to promote motivation for
change.
In the case of Jenny, she may be motivated to lose weight merely to
look good to others. If you do not agree with the value (i.e., losing weight
for appearance rather than health), it could be tempting to try to convince

her with statements you think are shocking, such as “You know, people
who are morbidly obese like you tend to die before they reach the age
of 60, and in their final decade, they suffer from all kinds of ugliness—
like going blind, being unable to walk, and having weird rashes.” However,
statements like that may result in the young person arguing against your
advice. Instead, by curbing your value judgments and using the young per-
son’s own values to develop discrepancy (e.g., “I will begin exercising so
I can fit into this dress”), behavior change is more likely to occur (see
Chapter 6). Allowing the young person the opportunity to make statements
that “shock” their own self and current perceptions about their behavior
is undoubtedly more effective than any “shock value” comments any of us
are likely to offer.
Differences between MI and Other Approaches
Now that you have a sense of MI spirit, you likely have begun to notice the
differences between MI and other approaches. MI differs from more con-
frontational approaches in that the focus is on the individual’s reasons for
change instead of persuasion or pressure from external forces. However,
MI also differs from nondirective approaches in that you are not simply
following the person’s conversation anywhere they want to go. Instead, MI
focuses specifically on guiding a discussion about behavior change to help
maximize the youth’s human potential. Table 3.1 demonstrates differences
between MI and other approaches to treatment.
Summary
In our own training and clinical practice, we have learned a few key les-
sons that we hope will enhance your MI encounters with youth. Effectively
using MI is as often about what to refrain from saying or doing as it is
about what to actually say and do in conversations with young people. We
have also learned that like many of us, drawn-out and lengthy, exhaustive
practitioner explanations can be downright boring, risking the loss of their
attention to us and compromising the gains made in establishing as well as
maintaining the essential components of the therapeutic relationship. Thus,
in the spirit of modeling what we believe are the most effective practices
for using MI with adolescents and young adults, we conclude the current
and next chapters with a tailored summary of dos and don’ts (Table 3.2) fol-
lowed by a section on adaptations for specific populations (Table 3.3).
TABLE 3.1. Spirit of MI Compared to Other Approaches

Directive approach Spirit of MI
Diagnostically driven: Diagnostically mindful:
“it’s necessary” “not sufficient for change”
• Diagnostic labels drive treatment • Diagnostic labels may offer guidance—at
• Without acceptance of a label, times
change does not occur • Labels are not necessary for change to occur
Expert role Collaborative expert
• Your expert advice dominates the • Collaboration guides each part of the
visit discussion
• Youth’s personal choices are • You elicit from the youth and may also offer
secondary to your expert advice options for how change could occur
• Your vision for change is what • You share a vision of change with the youth
counts and guide the conversation to maximize
change
Persuasive convincer Respectful guide

• Only by using persuasion can you • You recognize everyone has a different
“convince” the youth to make a path and guide the youth to discuss change
change options
• Offering a “personal” history will • You respect the youth’s developmental stage
make the youth understand their and personal change process in fostering
own struggles change
• Your therapeutic mantra may • Your therapeutic mantra may sound like “I
sound like “Street cred—I’ve was there once, as an adolescent, now it’s
been there done that—now time for me to help—only as a guide along
listen . . . ” your path”
Use of theoretical labels: Recognizing difficulties in change: language

resistance and denial • Use of labels, resistance, and denial are “not
• You view difficulties to change helpful or used in MI”
only as “resistance” and “denial” • Difficulties changing are recognized by the
• Theorized labels are the root of language offered from the youth, termed
“the problem” counter-change talk (CCT) and discord
• Fixed personality traits cannot be language
changed • You understand youth’s lack of motivation
is, in many ways, influenced by your own
therapeutic style
One right way to fix resistance Several ways to influence challenges to change
• Correction or confronting are the • Counter-change talk is met with empathy
only ways to “fix” the “problem” • “You have multiple options, and you aren’t
• “Once I confront this denial, sure which direction is best, just yet . . . ”
they’ll finally see the problems as
I do . . . ”
Goal setting: “it’s my job” Collaborative goal setting:

• Goals of treatment and strategies “we’re in this together”
are presented and directed only • Goals of treatment and strategies are
by you negotiated between the youth and you
• Youth is viewed as incapable of • Youth’s involvement in and acceptance of the
making sound decisions plan are seen as vital to successful change
Nondirective approach Spirit of MI

Following Guiding
• You allow youth to determine all • You systematically direct and guide the
of the content and direction of the youth toward discussing motivation for
interaction change
Advice With permission: advise and elicit feedback
• You avoid injecting advice and • With the youth’s permission, you offer
feedback advice and feedback where appropriate
Empathy offered variably Empathy offered purposefully
• You use empathic reflections • You offer empathic reflections selectively to
inconsistently, unconditionally, reinforce change talk and motivation
and sporadically • “You want to balance things better—it’s
• “It’s tough to balance things” really important to you”
TABLE 3.2. Spirit of MI: Dos and Don’ts

Do Don’t
Collaborate with the young person Assume to know the “real” problem/
regarding the goals and tasks of diagnosis or to have the best ideas on how
treatment in the initial encounter to fix the problem
Guide the young person to create their Prescribe a change path

own path of change
Respect absolute worth Compare the young person to what they

should or could be
Support autonomy and offer choice Take responsibility or control
Create an atmosphere of warmth and Compromise a focus on behavior change

acceptance or problem solving at the expense of
expressing empathy
Empathize without putting yourself in Sympathize and attempt to play the

the young person’s shoes—it’s their camaraderie “I’ve been there” card
path, not yours
Promote behavior-specific optimism Undermine self-efficacy by setting

by evoking discussion about hope for unrealistic goals for change
change
Model compassion Be a paternalistic salesperson
Evoke conversations about importance Tell the young person why and how to
and confidence change
Elicit discussion about discrepancy Emphasize external demands and your

between the young person’s goals/ reasons to change
values and behavior
TABLE 3.3. Tips for MI Spirit with Special Populations

Special populations may . . . MI tip MI response sounds like . . .
Juvenile delinquency
Display mistrust in “The Tailor open-ended “Everyone seems to have

System”: “You ain’t the first questions to hopes an opinion. What are your
one who gets paid to ‘help’ for more personal thoughts about how you
me. Nuthin’ works—trust freedoms to can get out of the detention
me.” improve motivation ward and get you more
for mandated freedoms now?”
Appear “oppositional”: treatment.
“Why should I trust you?” “People always nosing in
Be adaptive and your business gets real
acknowledge the old—real fast. During the
importance of rest of our time today, tell
trust to enhance me some things I should’ve
partnership. asked about you.”
Eating disorders
Not disclose emotions about Emphasize absolute “You’re right, this is about
weight/body image: “I look worth rather than you and your health.
fine—what’s everyone’s health risks tied to Perhaps not about looks.”
deal?” weight/body image.
“Despite everything you
Be frightened to discuss Reflect emotions try, your body sometimes
eating behaviors/exercise and affirm fears of feels like its ‘fighting’
rituals: “I wish I didn’t have change in weight/ against you, changing all
to talk about this. No one appearance. the time. It can be scary
understands how it feels to when it seems you are the
not have control—my body only one not in control.”
is changing. I’m just trying
to be healthy.”
Neurodevelopmental conditions
Avoid initial social Be concrete “Talking is hard

engagement/display anxiety: and offer simple sometimes.”
“I don’t know. Can I have my reflections of 3–5
tablet back?” words to increase “You look tired. Tell me two
opportunities for things that may help you
Appear to ignore you, be youth to attend and remember to . . . ”
easily distractible, and respond.
display infrequent eye
contact: “Huh?” Affirm engagement
using verbal and
nonverbal behaviors.

Sexual health
Feel embarrassed to Compassionately “It can be tough to use

disclose sexual risk-taking affirm recognition protection all the time, and
behaviors: “I do use of health and risk it’s also really important to
protection . . . sometimes.” behaviors. you.”
Defend status quo behavior Reflect and magnify “Despite the cost,
about sexual risk and health discrepancy protection of your health
practices: “Not everyone between sexual risk- is actually worth the price
can afford condoms all of the taking behaviors and to you.”
time. They are ex-pen-sive!” health values.
Opiate addiction
Not disclose actual Use evocative “What are the other things
parameters of use: “I just questions about the you do to help the pain?”
took a couple of pills a few function of opiate
times. My back pain was use to increase “People labeling you is
unbearable.” awareness of almost less annoying than
alternate choices. the lack of credit they give
Deflect remarks about you for not using.”
labels, such as “addiction”: Support self-efficacy
“I soo get it—you think I’m using reflections
an addict. Nice. Ya’ know— to spark a hope for
there’s a lot of TV shows I change by avoiding
could make a real nice livin’ use of labels the
off of—then people would youth may or may
lay off me. Hypocrites— not perceive as
they never says anything valid.
good about the days I don’t
use. How’s you write a letter
for me and my ‘diagnosis’
now? I could at least make
some money off it since no
one seems to care what I do
right these days.”
Practitioner Activity 3.1. MI Spirit
Activity Goal: To consider your own experience of MI spirit as an adolescent/

young adult
1. Consider the worst teacher/boss/mentor/coach you had as an adolescent or
young adult. What characteristics, phrases, or actions did they have? What
was your response?
2. Now consider the best teacher/boss/mentor/coach you had as an adoles-
cent or young adult. What characteristics, phrases, or actions did they have?
What was your response?
3. How do these map on to MI spirit dos and don’ts?
Worst Teacher/Boss/Mentor/Coach
Their characteristics/phrases/actions Your response
Best Teacher/Boss/Mentor/Coach
Their characteristics/phrases/actions Your response

Your Own Dos and Don’ts for MI Spirit (PACE) with Young People:
MI Dos and Don’ts for PACE
Do Don’t

4
Highlighting Choice at Every Turn
The word that allows yes, the word that makes no possible.
The word that puts the free in freedom and takes the obligation
out of love. The word that throws a window open after the
final door is closed. The word upon which all adventure, all
exhilaration, all meaning, all honor depends. The word that
fires evolution’s motor of mud. The word that the cocoon
whispers to the caterpillar. The word that molecules recite
before bonding. The word that separates that which is dead
from that which is living. The word no mirror can turn around.
CHOICE.
—Tom Robbins, Still Life with Woodpecker
Engaging
VA
LUE
S
UE
S
L
VA
Change
Talk
Managing
Counter-Change
Focusing
VA
Spirit
UE
L
UE
L
VA
S
Evoking
The development of autonomy is one of the key tasks of adolescence,

and acquiring independence of thoughts, feelings, and decisions is a basic
human need (Deci & Ryan, 1985). If you inadvertently counter this need by
pressuring the young person to change or by problem solving prematurely,
you will experience the young person pushing away strongly. MI takes the
stance that one person cannot make another person change. If we could,
42
Highlighting Choice at Every Turn 43
our jobs would be much easier, though possibly unethical. You might coerce
a temporary behavior change with an incentive or punishment, but lasting
change requires an internal process.
Your job is not to take responsibility for change but rather to support
and guide while seeking to elicit the young person’s own ideas for change
even within a constrained environment (such as “your parents say you
have certain chores to complete, but perhaps you can decide the best time
of day to complete them”). Thus, you can provide an environment of sup-
portive autonomy by eliciting the young person’s perspectives, by provid-
ing information and a menu of options, and by emphasizing personal choice
and responsibility (Williams, Gagné, Ryan, & Deci, 2002). This chapter
focuses on the strategies to support autonomy; our communication science
research suggests that not only do these strategies promote engagement
but also they can lead directly to change talk and commitment language
(Idalski Carcone et al., 2013; Jacques-Tiura et al., 2017).
Emphasize Autonomy Using You Statements
The first core MI skill with adolescent and young adults, emphasizing
autonomy, involves using you and your statements. We delineate three ways
of using language this way: (1) clarifying your role as a guide, (2) emphasiz-
ing personal choice, and (3) promoting personal responsibility.
Use You Statements to Clarify Your Role as a Guide

Your first opportunity to emphasize autonomy by clarifying your role as a
guide (“for you” and “your life”) rather than an authority figure (“to you”
and “their concerns”) is right at the beginning, in the opening statement.
The first statement you offer should encompass the MI spirit. The key is
to convey the idea that you will support the client’s desired changes (guid-
ing), rather than direct which changes should be made or emphasize what
others think should happen. For example, you might say, “Our time today
may be different than with other people who have talked to you. I am not
here to tell you what to change or how to change, or what your parents think
should happen, but rather to find out what is going on in your life and help
you make the changes you decide to make.” With this type of opening state-
ment, you can more effectively align with the young person and possibly be
perceived as someone who is distinct from other authority figures in his or
her life. As with adults who have been court-ordered to receive treatment,
young people are typically not self-referred and can feel many of their life
experiences to be constraining. Thus, an explanation of the MI approach is
even more important with this age group.
Â
TIP FOR OPENING STATEMENT: BE CAREFUL WITH INTENSITY OF YOU
Meynard (2008) suggests that while eye contact is typically considered

a sign of active listening, eye contact that is too intense may make the
young person uncomfortable. Simply displaying emotion that is too intense
or is inconsistent with the young person’s affect—for example, being too
cheery—can also alienate a teen.
Another way of lessening discomfort is to limit the use of words such
as you or your. Young persons can perceive these statements as blaming
and derogatory, and subsequently experience anger toward you, as well as
increase their avoidance of discussing relevant behavioral change issues.
Thus, statements such as “You feel confused about why you are here” may
be better received by depersonalizing the statement. Instead try “Young
people often feel confused about why they have to come here.”
Â
TIP FOR OPENING STATEMENT: RESPOND TO DISBELIEF
WITH EXPLORATION
A possible response to using such an opening strategy is disbelief, particu-

larly when the young person is in trouble with authorities. The youth may
continue to lump you in with other authority figures with comments such
as “I know you have to do your job and make me stop using” or “You have
to make me follow the rules of probation.” How you respond to statements
of disbelief is critical and can shape the course of treatment. Rather than
taking these statements personally, or attempting to provide a rationale for
treatment, you should provide an honest and forthright response that allows
the young person to take responsibility for his or her decision to engage in
treatment (or not). For example, “I can’t change what happened that made
others think you need to be here, but I can help you explore what’s going on
and how you decide you want to handle it.” You may also ask for clarification
to further understand the young person’s point of view. For example, “You
expect people to make you do things. Tell me more about that.”
Â
TIP FOR OPENING STATEMENT: AVOID THE TERM PROBLEM
Avoiding the term problem is important, for this can be viewed as similar
to a diagnosis or label: Both carry a negative connotation and also decrease
the young person’s self-efficacy to effect change in his or her behavior. For
example, young persons labeled as “alcoholic” may believe there is little
they can do to alter their drinking, as it is a “problem” or “diagnosis” that
cannot be changed. Instead, by simply naming the behavior—“You were
referred to discuss drinking”—you increase the conveyance of a nonjudg-
mental attitude, which will make the adolescent more likely to be open and
honest.
Use You Statements to Emphasize Personal Choice

The struggle for autonomy is most salient in adolescence, and the strategy
of emphasizing personal choice can be most effective with this age group.
Examples include “Yes, you’re right. No one can force you to take medica-
tions” or “If you are not ready to talk about , you can focus
on something else.” By emphasizing that it’s really the young person’s
right to choose whether to change, not only do you demonstrate MI spirit
but also you can increase change talk, decrease client responses against
change (counter-change talk), and further demonstrate MI spirit. Below is
an example from our case of Jenny struggling with weight loss.
Jenny: I don’t think I have a problem with my eating. I eat a lot of fruit,
and all my friends eat as much as I do. [Counter-change talk]
P ractitioner: It is really your choice about whether you are going to
change your eating. Your parents can force some things, like what
food they bring into the house, but they can’t watch you all the
time. It has to be your decision. [Emphasizing personal choice]
Jenny: I don’t care what they think, but I do try to eat healthy food.
[Change talk]
Â
TIP FOR EMPHASIZING PERSONAL CHOICE: EMPHASIZE CHOICE
IN HIGHLY CONSTRAINED OR DIRE SITUATIONS
Often young people’s choices are quite constrained, as they are not yet
legally allowed to make decisions for themselves. Furthermore, some
behaviors may have dire consequences if the behavior is illegal, or if the
youth is in a particularly controlled environment, such as a detention facility
or hospital. However, you can still offer opportunities of choice, even if the
consequences may be severe. For example, “I realize you will have to deal
with whatever rules are in place, but it is your choice whether to keep using
drugs.” Additionally, you can find places within the controlled environment
where the young person can choose. For example, in the case of a young
person with anorexia who is on a mandatory feeding program, they may be
able to choose which feeding supplements to begin.
Use You Statements to Promote Personal Responsibility

Statements to promote personal responsibility take the choice concept fur-
ther into the realm of values, strengths, and decisions. These include you
statements that emphasize values and goals such as “You decided you want
to live a long life and have a family” and “Your health is important to you,
regardless of what others think.” Promoting personal responsibility can
further serve to reframe a situation and emphasize strengths, such as “You
see this as a challenge to overcome” or “You want to do this to be more

independent.”
Statements promoting personal responsibility can enhance ownership
of plans or decisions made (including the consequences of those plans and
decisions). To do this, you must change language from we to you. Instead of
“our plan,” use “your plan.” Instead of “we will figure this out together,” try
“I can support you to figure this out.” Instead of “our first step is to . . . ”
or even “the first step is to . . . ” try “You want your first step to be . . . ”
Using statements that emphasize the young person’s thoughts about con-
sequences of decisions, and not your own ideas or those of other authority
figures, will add to the strength of the message you are sending.
Â
TIP: YOU EXAMPLES MAY SOUND LIKE . . .
• “You said if you take your medication, you will feel like you are
really taking care of yourself.”
• “You decided to talk about smoking so you can have more energy.”
• “You don’t want to quit smoking weed, and you are willing to deal
with the consequences.”
• “You mentioned alcohol might be worse, so maybe you want to talk
about that.”
Emphasize Autonomy When Providing Information:

The Ask–Tell–Ask Strategy
As noted in Chapter 1, MI is an integration of client-centered counseling
skills with more goal-oriented strategies. While we recommend avoiding
giving young people advice, information (such as about behavior, ideas for
plans, and other interventions) and feedback (such as about assessment
findings and lab tests) may be offered to guide clients toward goals when
they are ready to consider a change. There are also times when informa-
tion about treatment must be provided. For example, often in the first ses-
sion, you must convey certain basic information, such as confidentiality or
length of treatment. Miller and Rollnick (2013) suggest using the technique
of elicit–provide–elicit when providing information or feedback. We have
rephrased the expression as Ask–Tell–Ask.
In the Ask–Tell–Ask strategy, you will first ask for permission to pro-
vide information and elicit the person’s interest and knowledge about the
topic. Examples of questions for the first ask include “What do you know
about confidentiality?” “Would it be OK if we talked about your test results?”
“How much do you know about ways to remember taking medications?”
“Are you interested in finding out more about how smoking affects asthma?”
Then, after you reflect any change talk or provide affirming reflec-
tions (see dialogues below as well as Chapter 6), you provide information in
small, digestible bits (tell). As a point of reference, you should not provide
more than two or three sentences of information without eliciting the per-
son’s thoughts or feelings about that information. When telling informa-
tion about possible changes, always provide a menu of options to support
autonomy. For example, “Some people like to use an alarm on their phone,
some put their medications next to their toothbrush or phone charger, or
maybe you have another idea.” It is always good to end the menu of options
with an abstract alternative, even if the youth has asked you for your ideas.
“You might consider cutting back on sugar, reducing portion size, not eat-
ing after a certain time, or maybe there is something else that might work
better for you.”
After offering a small chunk of information, you will elicit the young
person’s reaction and reflect the response. Rosengren (2017) refers to this
approach as Chunk–Check–Chunk. You then elicit (the second ask) the
young person’s understanding, thoughts, feelings, or ideas for next steps
using open questions or multiple-choice questions (see Chapter 6). Exam-
ples include “In your own words, what does this mean to you?”; “Is this
new information or something you already knew?”; and “Now that you have
heard this, what might be your next step?”
The examples below demonstrate how to offer information or advice in
an MI style to our five different young clients to demonstrate how the same
core skill—Ask–Tell–Ask—can be used across different target behaviors.
Providing Information about Confidentiality to Sofia

P ractitioner: If it’s OK with you, I would like to tell you about con-
fidentiality. [Ask]
Sofia: Sure.
P ractitioner: Well, basically I won’t share information you tell me
unless it’s about hurting yourself or someone else. And in those
situations, we would talk about who would need to be told and
exactly what I would tell them. [Tell] What do you think of that?
[Ask]
Sofia: Well, I guess that makes sense. What do you mean by hurting
myself?
P ractitioner: If you told me that you were going to do something
that put your life in danger, we would have to make a plan to tell
someone else in your life to keep you safe. [Tell] How would you
feel about that? [Ask]
Providing Information about Self-Monitoring

of Medications to Eugene
P ractitioner: We talked about what logging is, and you said it was
important to help you keep track of how you are doing with your
medications. If it’s OK with you, we can decide specifically what
you want to monitor and how you want to do this. [Ask]
Eugene: I have to take my medications twice a day, once in the morn-
ing and once at night.
P ractitioner: You need to keep track of morning and evening doses.
[Reflect change talk] How would you like to do that? [Ask] Some
people prefer in the moment, and some prefer at the end of the
day. [Tell]
Eugene: In the moment might be better for remembering, but I don’t
really want to mess with my day.
P ractitioner: You would like to do it at the end of the day as long as
you have a way of remembering. [Reflect change talk] What ideas
do you have about a monitoring system that would work for you?
[Ask]
Eugene: I think using my phone would be the best bet. I could pro-
gram an alarm or something and then record it in my notes.
P ractitioner: You have some solid ideas about using your phone.
[Affirming reflection] There might also be some new apps for
keeping track of medications. [Tell]
Eugene: I could check out some of those.
P ractitioner: You could use apps or start with setting an alarm and
recording in your phone notes, or maybe you have another idea.
[Tell with menu of options] What do you think would be the best
place to start? [Ask]
Eugene: I like the alarm idea, but I better program the phone right
now or I won’t remember later.
P ractitioner : You’re good at doing things right away to help you
remember. [Affirming reflection] There are other things people
track, such as who they were with or how they were feeling, like
triggers, especially if they missed. What do you think about track-
ing that stuff? [Ask]
Eugene: I don’t know if I’m ready for that.
P ractitioner: OK! You’d prefer to start with the simple yes or no for
morning and evening medication-taking reminders—that makes
more sense to you for now. [Reflect change talk]
Providing Information about Test Results to Travis

P ractitioner: If it’s OK with you, I have some information about your
test results from when you saw your doctor. [Ask permission to
offer information]
T ravis: I guess so, but I already heard it all.
P ractitioner: Even though you aren’t sure it will make a difference,
you are willing to discuss these results. [Reflect change talk]
When you saw your doctor, it looks like you reported some drink-
ing, cannabis use, and Adderall use. Your blood work was mostly
normal, but your blood pressure was higher than it should be for
someone your age. What is your reaction to hearing this informa-
tion?
T ravis: I mean, I don’t think drinking or smoking weed is a problem. I
don’t do it too much, and I don’t think it affects my health at all. I
heard that Adderall can affect your heart, so maybe that’s why my
blood pressure is high.
P ractitioner: Drinking and smoking isn’t a problem for you, and
you are noticing that the Adderall may be affecting your health.
[Reflect change talk] I am wondering if that is something you
want to focus on, or maybe the situation at school or home is more
important to you right now. [Tell with menu of options] What do
you think? [Ask]
Providing Information about Treatment Planning to Sam

P ractitioner: What ideas do you have about how to manage fears of
being with a group? [Ask]
Sam: Well, I tried to force myself to go to these parties—but I either
just leave after 5 minutes or I just get totally wasted.
P ractitioner: You tried some really tough things right up front!
[Reflect change talk] Some people find it easier to practice testing
out new interactions in groups by starting with experiments that
are smaller and less anxiety provoking so they can better man-
age their “big picture” fears—like you mentioned going to the
store and talking to the cashier. [Tell] I wonder, what do you think
it would be like to start that way—trying out some of your less
feared situations and then work your way up to bigger ones? [Ask]
Sam: That might be easier.
P ractitioner: Starting with a small experiment might be work for
you. [Reflect change talk] If it’s OK, I could tell you about a few
things that might work. [Ask permission to offer advice] You could
make a list of fears and rank them on what’s most scary to do, or
maybe you just want to start with one or two smaller less scary
situations, like talking to the cashier as you’d mentioned, and then
work your way up from there. [Tell with menu of options] Would
either of these options work for you, or maybe you have another
idea? [Ask]
Sam: I like the idea of a list. Lists work for me usually.
P ractitioner: You know yourself and what things work best for
you—including the plan to use a list. That plan makes a lot of
sense for you now. [Emphasize autonomy with a you statement]
Summary
Strategies to support autonomy, such as emphasizing autonomy with you

statements, and Ask–Tell–Ask plus a menu of options, are the foundation of
MI with young people. Supporting autonomy conveys MI spirit, promotes
engagement, and can elicit change talk. See Table 4.1 for a summary of dos
and don’ts and Table 4.2 for application to special populations. In the next
chapter we address how to emphasize autonomy in response to counter-
change talk. What are some ways you might better support and create a
fluid, respectful, and collaborative conversation that continues to build
intrinsic motivation in your next encounters with youth?
TABLE 4.1. Supporting Autonomy: Dos and Don’ts

Do Don’t
Clarify your role as a guide Present as the expert
Offer “you” statements Convince

Emphasize personal choice and control Persuade
Promote personal responsibility Use “we” language for goals and plans
Emphasize values, goals, and plans Miss opportunities for discussion of values
Elicit consequences of decisions/actions Provide consequences of decisions/actions
Use Ask–Tell–Ask to provide Dump information

information and feedback Avoid information/feedback
Use menu of options when discussing opportunities—especially if the young
plans person asks for it and it can promote
change or support a plan
TABLE 4.2. Tips for Supporting Autonomy with Special Populations

MI response
Special populations may . . . MI tip sounds like . . .
Criminal justice
Display hostility over restrictions Combine emotion “Advice from

in personal freedoms—especially reflections with you everyone seems
when restricted to residential, statements when almost as bad as
incarcerated, and other mandated emotions run high. These being stuck here.
treatment settings: “This responses reinforce Despite being
all sucks—so do you. I hate choice opportunities pissed off, you’re
everything here. So what if I was and highlight personal still trying to
shaking things up?” freedoms, despite find a way out of
the reality of youth’s this place.”
Purposefully break rules to environmental restraints.
enhance control when faced with “Wow! You
placement in environmentally Incorporate disbelief spent a lot of
constrained contexts. reflections with you thought on
statements to emphasize keeping yourself
choice. at this level in
detention!”
Eating disorders
Be threatened when personal Combining you “You are open

choice options may be statements with some to options and
limited, when diet/treatment MI analogies, such as realize the final
recommendations are prematurely “menu,” can backfire. decision is your
offered: “I’m 16 years old! You act These strategies can call.”
like I’ve never eaten in my life. decrease engagement
I just wish everyone would stop in the therapeutic “There are
treating me like a child and let me relationship for youth several options
make a decision once in a while.” with eating disorders who we could
may have a particular discuss—which
React strongly to food-associated sensitivity to terms one would you
words and metaphors. reflecting their specific like to focus on
treatment issues. first?”
Be sensitive and mindful

about the MI-specific
language you choose
to offer. Replace MI-
specific terminology
such as “menu,” with
alternate language, such
as “options.”
(cont.)
TABLE 4.2. (cont.)
MI response
Respond with awkward nonverbal Use nonverbals and “Change can be

mannerisms, rather than verbally, offer short statements difficult.”
when autonomy to maintain to reflect ambivalence.
comfort and freedoms of preferred Engage youth in concrete “Let’s back up.
routines is challenged with and understandable If bathing every
unwanted change. language to facilitate day is too much,
engagement about fears what sounds
about making autonomous better to start?”
decisions independently.
Including nonverbals Remember age and

(Covering ears/closes eyes) “I heard developmental limitations
you—stop talking so loud. Y’all for using MI with
are always yelling at me for what youth. Adjust your
I didn’t do already. (Hand flaps.) reflections to support any
Just stop changing it.” autonomous efforts in a
developmentally sensitive
Display “tantrums” and argue manner that may, or may
against opportunities to engage in not, be consistent with
conversation in an age-appropriate the youth’s chronological
manner due to delayed age.
developmental understanding
of social expectations: “Why do
I have to bathe every day? Plus,
my mom didn’t cut the tag of the
towel. I can’t do it that much.”
Sexual health
Disengage in discussions focused Use Ask–Tell–Ask rather “What do you

on “education” about safer sexual than moving too quickly know about
practices due to fears of loss of into advice-giving mode. the benefits of
decision-making abilities: “It’s Prematurely focusing taking your
not like I haven’t heard about HIV discourages youth’s (e.g.,
before. Ya’ know, a lot of people independent autonomy birth control or
don’t get HIV either.” choices. STI treatment)?”
Believe medical management and Incorporate valued others “How might your
sexual risk-reduction practices in reflections to support boyfriend help
limit health choices: “It’s my autonomy. to remind you
body and my boyfriend. We know to take your pill
what we are doing—you can stop Autonomy-making every day?”
preaching anytime you want.” decision can be enhanced
by including sexual
practice discussions when
you incorporate loved
ones who will support
health choices.
MI response
Opiate addiction
Perceive opiate use as “under Avoid diagnostic labels, “You know you
control” and fear loss of personal such as “addiction,” to can take control
freedoms when treatment emphasize autonomy. Use over using—
discussions focus on abstinence of labels for many youth when you are
prematurely: “I’ve got this under can decrease efficacy ready.”
control—it’s not like I’m addicted and decrease motivation
or anything. I can stop anytime I to engage in discussions “The final
want.” about autonomous decision in
decisions to decrease. who you work
Seek out arguments to with is yours.
maintain a sense of control Be cautious in using “It’s I am here to
over the conversation and avoid up to you” statements help—as a guide
discussions about use that can be that can be autonomy in discussing
perceived as autonomy limiting: defeating. Some cultures options for you to
“Don’t you know—medications can perceive “It’s up to feel better.”
are prescribed by real doctors. you” as paternalistic and
What did you say you were receive these statements
again—a counselor? What do you as autonomy-defeating
know about medication?” reflections—rather than
autonomy enhancing.
Practitioner Activity 4.1. Supporting Autonomy
Activity Goal: To practice emphasizing autonomy with you statements
Activity Instructions: Change the statement below into a statement that

emphasizes autonomy with you or your.
Statement: “We can figure this out together.”
One option: “It is your choice how you figure out this problem. I’ll support you
in developing your plan.”
Alternative:
Statement: “We came up with a good plan!”
One option: “You came up with a great plan!”
Alternative:
Statement: “Your doctor is really worried about your health.”
One option: “It’s really your choice how to handle your health and the outcome
of those choices.”
Alternative:
Statement: “We really need to decide how to cut back on smoking.”
One option: “You are the only person who can decide how to cut back on smok-
ing.”
Alternative:
Statement: “You’re drinking problem is really getting you into trouble.”
One option: “You mentioned that drinking may have some pros but also some
real cons.”
Alternative:
5
Stop, Drop, and Roll
Adolescents are not monsters. They are just people trying to

learn how to make it among the adults in the world, who are
probably not so sure themselves.
—Virginia Satir
Engaging
VA
LUE
S
UE
S
L
VA
Change
Talk
Managing
Counter-Change
Focusing
VA
Spirit
UE
L
UE
L
VA
S
Evoking
Young people usually do not choose to attend treatment. Someone else usu-
ally suggests, refers, or court orders treatment. They may be distrustful of
you as an authority figure and be hesitant to collaborate. They are likely to
argue against changes because somebody else is arguing for it, or because
it is just fun. Thus, you will often need strategies to respond to counter-
change talk, disengagement, and ruptures in the therapeutic alliance before
moving on to conversations about change. We used to label young people
who behaved in these ways as “resistant.”
MI took a step in the right direction when addressing resistance as
an interpersonal process, as opposed to a trait or characteristic of the cli-
ent (Naar-King & Suarez, 2011). We now avoid the term resistance alto-
gether. Instead, we refer to counter-change talk to describe the linguistic
55
barriers to change (statements against change or statements in favor of not

changing, the latter often referred to as sustain talk). Counter-change talk
includes statements about intentions not to change (“You can tell me all you
want; I’m not going to stop drinking with my friends”), the advantages of
the status quo (“If I stop drinking, my friends will all think I’m a loser”),
disadvantages of change (“All my friends drink. Who am I supposed to hang
out with if I stop drinking?”), and pessimism about change (i.e., “It doesn’t
matter; I tried to stop before, and none of the psychobabble the counselor
told me helped”). A second barrier is discord, defined as negative comments
about treatment (“I don’t need to come here”) or about the relationship with
you (“You will never understand what it’s like for me”). Sometimes, the
young person will distract from the conversation by consistently asking the
provider about themselves.
Young people often create barriers a third way, by lack of conversation
(e.g., silence, telegraphic speech, asking “huh?” or checking their phone).
Earlier research suggested that while increases in motivational statements
(later referred to as “change talk”) are associated with behavior change in
adults, in young people, reductions in counter-change talk appear to be even
more related to behavior change than are increases in motivational state-
ments (Baer et al., 2008). Furthermore, as noted in Chapter 4, responding
to counter-change talk by emphasizing autonomy (see below) can directly
lead to change talk. In this way, you might reframe counter-change talk and
discord as an opportunity or a lever for change.
Stop, Drop, and Roll
Humans have a tendency to experience negative feelings (i.e., psychologi-

cal reactance) when they perceive that their personal freedoms are limited
or controlled (Brehm, 1966). In adolescents, these negative feelings may
manifest into outright rebellion. Not surprisingly, given the young person’s
focus on autonomy, psychological reactance has been shown to occur more
frequently during adolescence and young adulthood (Hong, Giannakopou-
los, Laing, & Williams, 1994) and may be especially likely when the young
person has not come to treatment of his or her own accord. Thus, the term
rolling with resistance in earlier editions of MI meant the provider does not
argue for change but rather expresses an understanding of the young per-
son’s point of view while emphasizing personal choice. In the most recent
edition of Motivational Interviewing (Miller & Rollnick, 2013), the term
resistance was dropped altogether, and instead the focus was on the client’s
communication behaviors, namely, counter-change talk and discord. Thus,
when you hear statements against change or in favor of not changing, we
suggest the strategy of stop, drop, and roll.
Stop, Drop, and Roll 57
First, stop refers to pausing and considering the situation. Here are
some questions you might ask yourself: Is the young person focusing on
why he or she should not change? Is he or she blaming others instead of
focusing on taking responsibility? If the answer is yes, then stop whatever
you are doing and try something different. Were you providing reasons to
change? Stop! Were you falling into the expert trap? Stop! Below, we dis-
cuss knowing when to stop and how. Next we describe how to drop and
step back. Then we discuss how to roll with the conversation in a different
direction.
Stop When You Smell Smoke

Your first step is to recognize the signs of smoke. Are you hearing negative
comments about treatment or noticing hesitation about engaging with you?
Is the young person arguing with you about not needing to change? Are
you feeling frustrated with the young person’s silence? We ask you to think
about how these comments fit on the continuum of clean air to the smoke
in a full-fledged fire, and we then offer some tips for how you might keep
the embers at bay. Small fires include desire, ability, reasons, and need to
not change or to keep doing the target behavior. Small fires also include the
passivity (e.g., agreeing to everything but then not following through, and
offering responses such as “yes, ma’am”), chattiness to avoid talking about
the target behavior, and interrupting the session to check social media. Full
blazes include annoyance and anger. These full blazes can occur immedi-
ately, or a small fire can build to a full blaze if not managed.
Once you are aware of the fire, you monitor your own behavior and
step back—don’t wrestle with the youth. Wrestling requires two people,
and if you stop, the young person cannot continue to wrestle. Recall that
psychological reactance occurs in response to a perceived threat, and none
of us responds well to a threat. You diminish reactance by becoming less
threatening in your communication. Falling into a persuading or directing
mode can be tempting, especially when the consequences of not chang-
ing are dire. However, what we have learned is that the more you try to
persuade, the more the young person resists. Sometimes this persuasion
takes the form of rescuing when you offer support and encouragement (i.e.,
“I know you can do it!”) or when you direct ideas for change (“How about
you try . . . ”) before the person is ready to listen to your ideas. Usually, you
will experience what we call the “Yeah, buts . . . ” The young person will
offer reasons these ideas will not work: “Yeah, but I’ve tried that before.”
In fact, resistance is often the result of overestimating the young person’s
readiness to change. In addition to increasing sustain talk, another danger
of persuasion is that the young person will respond with agreement without
meaning (“OK, fine, I’ll try it”), and no action or change actually occurs
after the encounter is completed. As Rollnick and colleagues (2008, p. 148)

state, “A good guide never gets too far in front.”
Dropping Under the Fire

There are three ways to drop under a fire. You can drop with accurate
empathy or affirmation. For a full blaze, it may be best to drop with an apol-
ogy.
Dropping with Accurate Empathy

As noted in Chapter 3 (“Getting the Spirit Right”), accurate empathy and
affirmation are components of acceptance. These components can be
translated into specific strategies to help you drop down under the fire.
A linguistic approach suggests that practitioners who are high in accurate
empathy show a deep understanding of what the person means and reflects
this understanding back to the person (Pérez-Rosas, Wu, Resnicow, &
Mihalcea, 2019). When the young person is typically expressing negative
emotion, Rogerian approaches suggest it is particularly important to reflect
signs of frustration, anxiety, and discord (Truax & Carkhuff, 1967). Thus,
accurate empathy is often a reflection of feeling such as “you are not happy
you have to come here” or “you are frustrated nobody is listening to you.”
Sometimes, accurate empathy comes in the form of an omission of
reflections (Resnicow & McMaster, 2012) when you are responding to fires
that are represented nonverbally. For example, to the young person who
speaks little or responds with few words (“I’m fine”), you can respond by
pointing out the message the nonverbal behavior suggests (“You’re not sure
if you want to talk to me about this” or “It seems like you’re tired of people
telling you what to do”). Finally, accurate empathy can also be described
in terms of what not to do. Table 5.1 describes 12 roadblocks to accurate
empathy from Gordon (2021). Note that several MI strategies are in this
list. These strategies may be appropriate at times but take energy away
from accurate empathy when trying to stop, drop, and roll because they
may move away from the client’s current experience.
Â
TIP FOR ACCURATE EMPATHY: AVOID UNDEREMPHASIZING FEELINGS
While it can be a concern that young people may shy away from reflec-
tions of feeling, Resnicow (2008) notes that practitioners actually tend to
underemphasize reflections of feeling because of their own personal fear
of addressing emotions. For young people, the avoidance of experienc-
ing uncomfortable emotions (such as fear or anger) can be at the core of
TABLE 5.1. Twelve Roadblocks to Accurate Empathy
Roadblocks that take away
autonomy Sounds like . . .
1. Ordering, directing, “Stop with the ‘buts’ and do something about it.”
commanding “You have to do this. It was ordered by the court.”
2. Warning or threatening “You better get your act together, or you will get
kicked out of school.”
“If you don’t change your eating, you will end up
with diabetes.”
3. Moralizing or preaching “You should really consider joining a gym.”

“You really need to make a plan.”
4. Advising, offering solutions “It’s clear that you have to . . . ”
(without permission) “I would consider . . . ”
5. Teaching, lecturing, giving “You aren’t going to get to undetectable viral load if
logical arguments you don’t take your medicine more consistently.”
“Don’t forget you only have another month to get
these sessions in before your court date.”
Roadblocks that emphasize
inadequacies or faults Sounds like . . .
6. Judging, criticizing, “You are still skipping school?”
directing, blaming “I think you’re wrong about that.”
7. Name calling, stereotyping, “That’s typical for someone with ADHD.”
labeling “Do you want to be a smoker for the rest of your
life?”
8. Interpreting, analyzing, “Your real problem seems to be . . . ”

diagnosing “Maybe this is really related to your relationship
with your dad.”
Roadblocks that try to make the
person feel better or deny the
problem Sounds like . . .
9. Generic praising or “Great job.”
agreeing “That’s exactly what I would do.”
10. Reassuring, sympathizing, “Don’t worry. Everything’s going to be OK.”

or consoling “I’m sure you’ll figure it out.”
Roadblocks that distract Sounds like . . .
11. Questioning or problem “Why are you doing it this way?”
solving “I have some ideas for you to try.”
12. Humoring or changing to a “What did you think of that game last night?”
random subject “Did you see that new comedy show everybody is
talking about?”
59
ambivalence, and discussion of emotions may be necessary for change to

occur. For example, Resnicow suggests, instead of offering the young per-
son a more cognitive response, such as “You are concerned,” you could use
language that reflects more emotional content, such as “You are worried.”
Saying you are “a little angry” when the young person is “steaming mad”
can engender more discord. As long as you are actually responding to what
the young person has expressed or implied (and not straying too far from
it), he or she still has the choice to either accept the reflection or clarify
whether what you said was inaccurate. One exception might be overly
reflecting feelings of despair and helplessness, which may in turn reinforce
negative thoughts and stifle further conversation.
Dropping with Affirmation
According to the Merriam-Webster Online Dictionary, to affirm means
not only to state positively but also to validate and confirm something the
young person has already said. Sue (2006) wrote about the concept of affir-
mations as gift giving—a present you offer to show respect for the young
person’s strengths and values, as well as to increase positive feelings about
the interaction. An honest and specific affirmation can dramatically shift
the conversation as it is hard to stay angry when someone is highlighting
strengths. We suggest that you not use generic affirmations that may ring
false, such as in the classic Saturday Night Live parody on self-help when
the character Stuart Smalley says to himself, “I’m good enough, I’m smart
enough, and doggone it, people like me!” A more challenging young person
may disengage from those generic, cheerleader-type statements. However,
affirmations that target a specific strength, value, or effort, and that (like
reflections) are close to what the person has already said, are generally
accepted. Examples include “Even though you are frustrated, you still
decided to come here today and deal with the situation” and “You have fig-
ured out a way to manage your anger and avoid the consequences of fighting
with your parents.”
Dropping with Apology
When faced with a full blaze, accurate empathy and affirmation may not
work well enough to manage the fire. Miller and Rollnick (2013) recom-
mend an apology: “I am sorry I was lecturing about quitting smoking” or
“I apologize if I insulted you and your friends.” Some practitioners have a
hard time with apologizing when they honestly do not feel they did anything
wrong. It is acceptable to use language that reflects feeling sorry for the
young person’s experience even if you are not honestly sorry about your
behavior, such as “I am sorry you feel angry about coming here” or “I am

sorry you had that experience.”
Rolling to Move the Conversation Forward

We suggest rolling with strategies to emphasize autonomy (see Chapter 4).
When faced with a full blaze, it might be necessary to switch focus.
Rolling by Emphasizing Autonomy
Turn a challenge into an opportunity using this strategy. We now know from
our communication science research that language that supports autonomy
is likely to lead to change talk (Idalski Carcone et al., 2013). The roll part of
stop, drop, and roll is a way to move the conversation toward an improved
therapeutic alliance and possibly toward change language. Recall that you
can emphasize autonomy with you statements (see Chapter 4). You state-
ments that roll by emphasizing personal choice include “It is your choice to
consider what changes you might want to make” and “It is up to you how we
use the time to improve your situation.” You statements that roll by empha-
sizing personal responsibility include “You can decide how to make the
time together most useful for you” and “My job is to help you develop the
best plan for you and not for anybody else.” You can follow these statements
with considering a menu options using Ask–Tell–Ask. You can also roll with
a question that supports autonomy, such as “What might make these ses-
sions more useful for you?” or “What do you think needs to change for
things to be better for you?” Finally, do not hesitate to roll with a pause.
After stopping and dropping with accurate empathy or affirmation, a pause
might be enough for the young person to respond in the direction of change.
Sam: I’ve been through this before and it never works.

P ractitioner: You are really persistent by coming here today.
[Affirm] (Pause.)
Sam: Yeah, well, I don’t like to give up. Maybe something will be dif-
ferent this time.
Rolling by Shifting Focus
When faced with a full blaze, you can attempt to move the conversation
forward by shifting focus. We do not mean you should shift away or ignore
relevant therapeutic content (such as discussing a sports team). Rather, you
should steer the conversation around the stumbling blocks to other areas
of therapeutic discussion. Options for shifting may include a discussion of

other areas of the person’s life that may be related to behavior change or an
intermediary goal. You may also include a simple reassuring statement to
let the young person know you do not have to focus on something he or she
is not ready to discuss.
Eugene: I do not want to take medication. [Counter-change talk] I

know that’s what you are going to tell me to do, and I am not going
to do it. [Discord]
P ractitioner: I don’t think it makes sense to tell you to do something
when I don’t know the whole story. Why don’t you tell me more
about what is going on with your health right now? [Shifting focus]
Stop, Drop, and Roll Examples
Eugene: I just can’t make all of these appointments because I don’t

have transportation, and the times they want me to come I have
to work! [Small fire]
Stop: Stop informing and giving advice.

Drop: “You seem frustrated.” [Express empathy] “I commend you for
even listening.” [Affirmation]
Roll: “It’s really up to you if you want to come to any of your appoint-
ments.” [Emphasize personal choice] “If it’s OK with you, we can
discuss some options.” [Ask–Tell–Ask]
T ravis: You don’t know what it’s like. Everyone keeps telling me what
I should do, and I’m tired of it! I don’t need another damn mother!
[Full blaze]
Stop: Stop informing, advising, or persuading.

Drop: “I am sorry it feels like we are harassing you.”
Roll: “You really know yourself best.” [Emphasizing personal respon-
sibility] “Help me understand what’s most important to you right
now.” [Shift focus]
Other Strategies
We now describe four other strategies to respond to counter-change talk

and discord if stop, drop, and roll isn’t enough.
Amplified Reflection
In an amplified reflection, you emphasize and intensify the counter-change
talk because it usually engenders a reaction in the other direction. If your
tone is straightforward and honest, then these amplified statements will
often elicit Yeah, but statements followed by reasons to change. In this way,
you evoke motivation from the young person instead of providing the ratio-
nale for them.
T ravis: Adderall doesn’t really do anything. It’s not a big deal.

P ractitioner: There is no reason at all for you to stop using Adderall.
[Amplified reflection]
T ravis: Yeah, but the doctor says that my blood pressure is up from
taking that.
P ractitioner: Getting your heart back in shape might be a reason
to stop or cut back on the Adderall. [Reflection change talk] (See
Chapter 6.)
Note that using words like might and stop or cut back are ways of ensuring
we are rolling and not pushing too hard for change.
Amplified reflections can be tricky, and we emphasize that you
must convey an attitude of empathy and not sarcasm. Too extreme of an
overstatement or a reflection in the form of a question may elicit further
counter-change talk or discord, particularly in young people who are well
known to use sarcasm in their own daily communication repertoires. For
example, “There is no reason at all to slow down your drinking?” may be
experienced as judgmental and set you back from furthering the discussion.
Â
TIP FOR AMPLIFIED REFLECTIONS: TRY A MINIMIZING STATEMENT
Like amplified statements that are somewhat counter-change talk, mini-

mizing statements understate the reasons for change or the problems the
person has had because of not changing. Minimizing statements are also
meant to increase the likelihood of the young person responding with argu-
ments for change.
T ravis: I don’t know why they made me come here. [Discord] I drink
for fun but have never had a car accident. [Counter-change talk]
P ractitioner: You’ve only had a few really minor difficulties as a
result of your drinking. [Minimizing statement]
T ravis: Yeah, but these probation appointments are a real hassle.
[Change talk] (See Chapter 6.)
Â
TIP FOR AMPLIFIED AND MINIMIZING STATEMENTS: COME ALONGSIDE
WHEN THE YOUNG PERSON AGREES
If a young person responds to amplified and minimizing statements with

agreement instead of arguing for the other side of ambivalence (e.g., “You’re
right, I have not had any problems from drinking”), there is still nothing
lost. What the agreement offers you is a greater understanding of the depth
of the young person’s attachment to the status quo behavior. At this point, it
may be wise to come alongside and reflect that now may not be the time to
change (“Slowing down on your drinking isn’t really anything you want or
need to do right now”). The young person may then argue for the opposite,
such as why it might be time to change, or you may collaboratively decide to
focus on other behaviors. Otherwise you can always shift focus to another
area that the young person might be more willing to consider.
Â
TIP FOR AMPLIFIED AND MINIMIZING STATEMENTS: CONSIDER USING
A STEM WHEN NECESSARY
Amplifying, minimizing, and coming alongside are not paradoxical inter-

ventions, for they do not involve prescribing a behavior that is in opposi-
tion to change. However, younger adolescents and those who tend to be
more concrete in their thinking may take your statements as reasons not to
change literally and mistake your statements as agreeing they should not
change. Similarly, an adolescent with oppositional behaviors may tell others
you condoned a behavior because you used such statements. In these cases,
it might be necessary to add a personalized stem, such as “You’re saying
. . . ” or “I’m hearing . . . ” to the statement to prevent these misperceptions
(e.g., “I’m hearing that you feel now may not be the right time to change”).
Pros and Cons
If stop, drop, and roll does not work to shift the conversation of change,
exploring the counter-change talk and then shifting to questions to elicit
change talk might tip the scale of ambivalence. This is sometimes called
“decisional balance,” and while it is sometimes incorrectly a core compo-
nent of MI (Miller & Rollnick, 2009), it can still be used to shift the balance
from counter-change talk to change talk. The first step is to respond to
counter-change talk by asking for elaboration. For example, if Jenny says,
“I have no reason to start exercising,” you may respond, “Tell me more
about the things you don’t like about physical activity.” By first eliciting
the reasons for the status quo behavior, you can establish rapport, roll with
the fire, and further understand the barriers to behavior change. After
establishing rapport and an atmosphere of nonjudgment, you can now safely

ask for the pros of the behavior change (e.g., beginning to exercise, cutting
back on smoking, taking medications or exercise), without eliciting resis-
tance. However, if you ask for the pros of behavior change first, increased
counter-change talk or even discord may be more likely to occur.
Â
TIP FOR PROS AND CONS: FOCUS ON ADOPTING A POSITIVE BEHAVIOR
VERSUS AVOIDING A NEGATIVE BEHAVIOR
Because young people do not respond well to discussing the cons of a

behavior that others want them to avoid, we suggest focusing on the pros
and cons of adopting a new behavior (Moore & Parsons, 2000; Nickoletti
& Taussig, 2006). Thus, for young people, the strategy may be more aptly
termed “cons and pros.” This adaptation works easily when the focus is on
a health behavior, such as taking medication for a chronic illness or begin-
ning an exercise regime. In using this strategy, you would first ask about
the cons, or the bad things about the new positive behavior (e.g., “Tell me
the not-so-good things about exercising”). After reflecting or summarizing
the young person’s view, you can then ask for the pros of the behavior (e.g.,
“What are the good things that happen when you exercise?”). When the
goal is the avoidance of a behavior such as substance use, you can focus on
the new behavior of “staying clean” rather than on the bad aspects of sub-
stance use. You begin by asking about the cons of staying clean, followed
by the pros of quitting or cutting back. As always, we ask for permission to
respect autonomy:
P ractitioner: If it’s OK with you, I would like to understand more

about your view of the situation. I am wondering, what are the
bad things about quitting smoking? [Eliciting the cons of change]
Sofia: Well, smoking helps me when I am stressed out. It’s something
I like to do at parties. [Sustain talk]
P ractitioner: It helps you to relax, and it is something you like to do
with your friends. What else do you like about smoking? [Reflec-
tion, question]
Sofia: That’s about it. [Diminishing sustain talk]
P ractitioner: OK. On the other side, what might be some reasons
for quitting or cutting back on your smoking? [Eliciting the pros
of change]
Sofia: Hmm. Well, I guess it might save me some money. [Change
talk] (See Chapter 6.)
Â
TIP FOR PROS AND CONS: WHEN THE YOUNG PERSON CANNOT EXPRESS
THE PROS OF BEHAVIOR CHANGE
If the young person is not able to come up with the pros of behavior change
on his or her own, you can continue to roll with this ambivalence by using
reflections (“So right now you are not sure there are any reasons to change”)
or by trying Ask–Tell–Ask to discuss pros (only after a thorough, empathic
discussion of cons).
P ractitioner: If you would like to hear them, I have some pros other
young people have mentioned about using condoms. [Ask]
Eugene: Sure, I guess so.
P ractitioner: Some kids have found they can protect themselves
from catching other sexually transmitted infections, or they can
make sure they don’t get someone pregnant. Others have men-
tioned they use fun condoms, such as ones with flavors or special
lubricants. [Tell] What do you think about these pros? [Ask]
Eugene: I am not sure about the fun condoms, but I don’t want to catch
herpes—that would suck! [Change talk] (See Chapter 6.)
Agreement with a Twist

In the agreement with a twist strategy, you seek to respond to counter-
change talk, first by expressing empathy to show MI spirit, and then by
reframing the statement with a new meaning that supports change. In this
way, you validate their perspective, while still offering something new,
such as a hint toward behavior change or optimism about change. Com-
mon examples include offering a possible direction for change, reframing
by affirming, and using an educational reframe.
Here is an example of giving a possible direction for change:
Sam: I really don’t know why my parents keep staying on my back

about being more social. I wish they would leave me alone!
[Counter-change talk]
P ractitioner: Your parents are really driving you crazy. [Express
empathy] I wonder if there is some way we can make all this
attention they give you more supportive. [Reframe]
Here is an example of reframing by affirming:
Sofia: I have tried to quit cigarettes so many times. Nothing works.

There is no way I can do it. [Counter-change talk]
P ractitioner: I am hearing your frustration [express empathy], but
I am also seeing your persistence. You seem to be a person who

keeps trying even when it’s hard. [Reframe by affirming]
Here is an example of an educational reframe:
T ravis: The Adderall doesn’t really affect me. I can take more and
more lately and still feel totally normal. [Counter-change talk]
P ractitioner: It’s a pain having to come here when you feel like
Adderall has little effect on you. [Express empathy] I am not sure
if you have heard this, but after people have been taking it for a
while, the body gets used to it and it needs more and more to feel
it. What do you think of that information? [Educational reframe]
Summary
In this chapter, we defined counter-change talk and discord in terms of large

and small fires. We also described how to respond to counter-change talk
and discord with “stop, drop, and roll” using strategies to express empathy,
affirm strengths and values, support autonomy, and other options on the
MI menu (see Table 5.2 for dos and don’ts and Table 5.3 for special popula-
tions). Which of these strategies will you consider trying when you feel you
are wrestling with a young person or smelling smoke? What traps do you
think you will find yourself in, and how do you think you might avoid them?
TABLE 5.2. Responding to Counter-Change Talk and Discord:

Dos and Don’ts
Do Don’t
Stop wrestling. Continue to convince, persist, or advise.
Drop back by expressing empathy or Ignore/avoid youth’s perspective

affirmations. Argue against sustain talk, attempt to
correct it, or fall into persuasion.
Roll by supporting autonomy and other Get stuck in a merry-go-round you can’t
strategies to move the conversation get off. Reflecting counter-change talk
forward. increases discord.
Apologize/shift focus to manage big fire Get stuck trying to manage counter-
ruptures that damage the framework of change talk about a specific behavior
the therapeutic alliance. target.
TABLE 5.3. Tips for Stop, Drop and Roll with Special Populations
Criminal justice
Offer negative comments Stop any urge to “What are things that
about external incentives and defend the integrity might help you earn more
treatment setting restrictions: of the treatment privileges?”
“Your token economy crap— system.
and this place is a dump. It’s all “With all of these rules
stupid.” Offer open-ended and limitations, help me
questions exploring understand.”
Ignore advice for “getting alternatives of
out of the system” and use interest for the
sarcastic statements about youth.
your understanding of criminal
justice systems: “Like, you Express empathy
know, what it’s like to be locked and drop any self-
up! What do you know?” disclosure.
Eating disorders
Champion unhealthy eating Shift focus from “Changes in eating scare you.
practices by highlighting healthy eating How about we shift our focus
the positives of status quo practices to other for now? You mentioned, when
food restrictions and impact healthy behaviors you’re at school, it takes your
on values of physically thin supporting mind off worrying about how
appearance: “At least I’m not appearance. you look. Tell me more how
fat like my parents. Eating this helps.”
more would get me looking Roll with statements
blimpish—like them.” to reinforce “You worry about your family’s
relationships with financial needs more than you
Offer Yeah, but statements valued others do about your own health. How
when you overestimate youth’s supporting youth’s do you think they’d feel if they
readiness to change diet/ changes in new diet/ knew you were sacrificing your
exercise regimens: “Yeah, I exercise regimens. health for them?”
read about that meal plan, but
my parents don’t have a lot of
money to buy all of that organic
stuff. I’m actually helping
them—they don’t have to spend
much money on me—I know
they’re broke.”

Give you an immediate “full Refrain from New people can be scary. You
blaze” when faced with challenging taught me how you like to be
unexpected procedures impulsive seen in a room with less light
involving unwanted physical statements; and noise. What are two things
contact as part of medical instead, emphasize you might want to teach the
treatment protocols: prior successes physical therapist about how to
“Nooooo—I hate when they in overcoming work with you—like you just
touch me, those physical developmental did with me?”
therapists! I’m going to jump sensory challenges
out the window right now if you to enhance optimism “We need a break. Instead of
try to bring them in the room. I for change. talking so much, how about you
mean it too!” listing two or three things you
Drop use of long- would like to work on now?”
Not communicate or use winded confusing
childlike responses, particularly statements, which
when you offer multistep advice can confuse
prematurely to youth with youth with slower
cognitive processing and verbal cognitive processing
language skill deficits: “Huh? I speeds and rupture
don’t know . . . ” the relationship with
you.
Consider shifting
focus to youth’s
developmental
strengths and less
verbally intense
strategies.
Sexual health
Focus on intentions not to Adapt an apology “I’m sorry you have to struggle
change sexual practices and/ strategy to amplify with this dilemma. The
or comply with treatment ambivalence about relationship and his feelings
recommendations: “Don’t safe-sex practices. seem more important right
go there with me about the now than your health and
condoms. My boyfriend sooo Do not feel potential safety.”
blocked his last partner when he pressured to answer
wanted to start using condoms. questions. Instead, “It’s obnoxious and you get
I don’t want him to get violent reflect or ask open pissed when everyone is in
with me too if I bring it up.” questions about your business. I understand
what the person is why you’d want to turn the
Attempt to disengage by asking meaning. Reflect tables for a minute and get
personal questions about your emotions and use information about someone
personal sexual practices: menu of options else’s sex life—take the heat
“You’re tiring me with all of strategy to shift off of you for once. Let’s shift
these damn questions. How focus on other gears; instead, of talking about
about you answer a question change topics (that your sexual practices, we could
for me—my partner and I have don’t involve you). talk about your medication,
a bet going about you. Are you school, or something else—it’s
gay, straight, or what?” your call.”
(cont.)
TABLE 5.3. (cont.)
Opiate addiction
Display unpredictable ranges of Stop in your tracks “I’m sorry—it’s like everyone
emotional responses, especially when sniffing a fast- is telling you what to do and
at the onset of treatment due the approaching blaze. perhaps my suggestions sound
co-occurring mix of physiology/ Get out of the way too generic.”
organic withdrawal symptoms of the discord by
of opioid use and personal avoiding falling into “You’re right—you aren’t a
developmental changes: “Great the expert trap, and label and have control over
idea you have—never heard use apology with what you do and don’t use.”
it before . . . gonna rush home reflection if you’ve
and flush every pill, one-by-one moved too fast in
down the toilet, soon as I get pushing the youth
home. You don’t get nuthin’ . . . to discuss change
how much my back hurts after options.
this football injury? I thought
you were different than those Drop educational
other counselors. I want outta statements and use
here now!” of labels such as
“the opioid crisis”
Show an increase in counter- and “addiction.”
change talk when unwanted These create
education comparing the youth further rifts in
to others about the health the therapeutic
risks of opioid use are offered: relationship.
“So you’re saying I’m addicted
and just a pawn in this ‘opioid
crisis’? Well, that’s just more
reason for me to not even try
since you think it’s out of my
control.”
Practitioner Activity 5.1. Stop, Drop, and Roll
Activity Goal: To practice different ways to put out small fires and big fires
Activity Instructions Part A: Respond to each counter-change talk statement

(small fire) with the following:
a. Accurate empathy
b. Affirmation
c. Emphasizing autonomy (personal choice, personal responsibility, your role
as a guide, Ask–Tell–Ask)
d. A combination of all of these strategies!
Statement: “I really like smoking weed. It relaxes me.”

One option: “It is hard to think about all this when you feel you have good rea-
sons to smoke.” [Accurate empathy] “Only you can decide what’s best for you.”
[Emphasizing autonomy]
Alternative:
Statement: “I don’t think coming here is really going to help.”

One option: “You are a persistent person for coming here even though you were
hesitant.” [Affirmation] “Would it be OK if we discussed some things that we
could do differently?” [Emphasizing autonomy with Ask–Tell–Ask]
Alternative:
Statement: “The treatment plan is going to be too hard.”

One option: “It feels like people are asking you to do a lot.” [Accurate empathy]
“It is your choice how to make it easier or start more slowly.” [Emphasizing
autonomy]
Alternative:
Statement: “I don’t have any symptoms [consequences], so I don’t

know what the problem is.”
One option: “You really know a lot about your health.” [Affirmation] “Would it
be OK if we discussed why medications [treatment] might be helpful so you can
make the best decision for yourself?” [Emphasizing autonomy with Ask–Tell–
Ask]
Alternative:
Statement: “Why does everything have to be so hard. I just think now’s

the time to have fun.”
One option: “It seems overwhelming sometimes when you just want to let
loose.” [Accurate empathy]
Alternative:
Activity Instructions Part B: Respond to discord (big fire) with the following:
a. Apology
b. Shifting focus
c. Minimizing/amplifying reflections
d. Pros and cons
Statement: “It’s just so stupid that nobody will leave me alone!”
One option: “I am really sorry it feels like everyone is harassing you!” [Apology]
Alternative:
Statement: “To hell with all this. I’m out of here.”
One option: “Maybe I really need to better understand how Adderall fits in with
your life and what you think are the benefits?” [Beginning of pros and cons]
Alternative:
Statement: “I really think they just lie. The doctor lies.

You’ll probably lie.”
One option: “It’s like nobody in the world is ever by your side.” [Amplifying
reflection]
Alternative:
Statement: “I’m just going to sit here and not talk if that’s OK with you.”
One option: “Maybe it would be easier if we talked about something else besides
whatever everybody else is harassing you about.” [Shifting focus]
Alternative:
Statement: “Yes . . . No . . . Sure . . . ”
One option: “It must seem like I am just interrogating you and I am sorry.”
[Apology] “Would it be OK if you just made a list of pros and cons so we can take
a break from talking?” [Shifting focus, pros and cons]
Alternative:
6
Change Talk
Every great dream begins with a dreamer. Always remember,

you have within you the strength, the patience, and the passion
to reach for the stars to change the world.
—H arriet T ubman
Engaging
VA
LUE
S
UE
S
L
VA
Change
Talk
Managing
Counter-Change
Focusing
VA
Spirit
UE
L
UE
L
VA
S
Evoking
By managing counter-change talk and discord, you pave the way for the
young person to take the first steps toward change. We now discuss how
to reinforce your client’s motivational statements called change talk (inten-
tions to change, disadvantages of the status quo, advantages of change, and
optimism about change). The first step is to recognize change talk, and then
you reinforce it with reflections. You can also ask for elaboration with open
questions. We will also address strategic open questions to elicit change talk
if it does not occur naturally in the conversation when you are supporting
autonomy and addressing ambivalence. Note that Miller and Rollnick (2013)
describe several person-centered guiding skills (known by the mnemonic
OARS: open questions, affirmations, reflections, and summaries). In our
years of training different types of practitioners, we have found that simpli-
fying to two of those skills—reflections and open questions—for eliciting
74
Change Talk 75
and reinforcing change talk improves the likelihood of trainees’ uptake of

these skills. Thus, in this edition we describe affirmations and summaries
as affirming and summarizing reflections. Not only does this simplify the
number of skills needed in the trainee’s mind, but also it ensures that the
affirming and summarizing statements stay close to the young person’s lan-
guage instead of straying too far into the practitioner’s interpretation.
Recognizing Change Talk
In the first few miles of the journey of change, you will hear change talk
without strong commitment. These are expressions of the young person’s
desires, abilities, reasons, and needs (DARN; see Table 6.1) to alter the
unhealthy behavior or adopt a healthy behavior. Statements of desire begin
with words such as I want, I wish, I am motivated, and I would like to. State-
ments about ability to change convey confidence but do not have to include
a declaration of readiness, such as “I think I could do that, but I am not sure
I am ready to.” Typical stems include I could, I am able to, and It’s possible.
Desire and ability statements may also take the form of things the young
person has tried to do: “I tried to talk to my boyfriend about condoms.”
TABLE 6.1. Examples of Change Talk

Preparatory change talk:
DARN Sounds like . . .
D: Desire—want, wish, “I want to stop smoking; you don’t know how hard it is.”
like “I wish I could lose some weight to be thin like
everyone else.”
“I would like to follow my parents’ rules so they
wouldn’t nag so much.”
A: Ability—can, could, “I can take my medicine on my own without my parents

able reminding me all of the time.”
“I could cut back on the weed if I wanted to.”
“I might be able to cut back on sweets on weekends.”
R: Reason—specific “I really don’t want to end up on dialysis.”

reason for change “If I get another dirty UA, they’ll kick me out of this
place.”
N: Need—have to, must, “I need to lose some serious weight.”

important (without “I’ve got to get my blood sugar totally down from where
stating specific reason) it is.”
Regardless of the success of the attempt, the act of trying indicates motiva-
tion and is considered change talk.
Statements of need add a sense of urgency to the situation and consist
of words such as I need, I must, I have to, I have got to, and I cannot keep doing
this. Statements about reasons for change can include desire and need but
add specificity to the content. Thus, reason statements can indicate that
the young person may be less ambivalent and further along in the journey
of change. For example, a statement such as “I have to do this” conveys a
need to change. In contrast, a reason statement would convey a need paired
with a specific rationale for the change. For example, “I need to do this for
my health.” Later in treatment you will hear stronger change talk indicative
of commitment, I will or I tried, as discussed in the planning process in
Chapter 7.
Â
TIP: DON’T WORRY IF REASONS FOR CHANGE ARE UNREALISTIC
Remember, the young person’s reasons for change may not be consistent
with yours or those of other adults. The reasons may also not be realistic
(such as “I need to quit smoking so I can play professional basketball”), and
you may even be tempted to laugh at the rationales some young people offer
(e.g., “I need to cut back on drinking so I can save my money for this new
video game”). Be sure to maintain a nonjudgmental stance; the end result
is increased motivation for change.
Reinforcing Change Talk
Once you have learned to recognize change talk, how do you respond to it?
Person-centered guiding skills are used to selectively respond and reinforce
change talk and to elicit more change talk with open questions. Note that
while we focus on change talk here, the same skills are used to reinforce
commitment language as discussed in Chapter 7 (I will, I tried). The pri-
mary guiding skill to reinforce change talk is the use of reflections. Reflec-
tive statements have many purposes. In Chapter 5, we note how accurate
empathy in response to counter-change talk and discord can be types of
reflections (e.g., reflections of feelings) and we touch on affirming reflec-
tions as part of stop, drop, and roll. We now review the two broad categories
of reflections for reinforcing change talk (that are inclusive of these other
types): simple reflections and complex reflections. Within these categories,
there are several different types of reflections to reinforce change talk. You
might consider these reflections as a menu of options from which to choose
what feels most right to you in the moment. Sometimes you might want to
do what feels comfortable, and sometimes you might want to try something
Change Talk 77
new. The goal is to reinforce change talk and to “pluck the change talk out
of the jaws of ambivalence” by highlighting change talk and de-emphasizing
counter-change talk (assuming you have addressed more pervasive counter-
change talk and discord with stop, drop, and roll as described in Chapter 5).
Using reflections for the first time brings both challenges and rewards.
As you begin to incorporate reflections into your repertoire, it can be com-
mon to wonder if they are sounding a bit contrived to the young person.
You may even feel a little clumsy as you begin to practice this new skill,
similar to when you first learned to drive a car. When there is so much else
to attend to, it can take a while to get comfortable and see the road ahead.
When you offer a simple reflection to the young person, it is akin to handing
over the steering wheel to the other person. While giving the keys of your
car to a first-time driver can be disconcerting, with practice you will get
more comfortable allowing the young person to lead the conversation with
you as a guide.
Â
TIP FOR REINFORCING CHANGE TALK: DON’T FORGET
AUTONOMY SUPPORT
Though this chapter focuses on guiding skills of reflections and open ques-
tions, don’t forget that statements to emphasize autonomy can also elicit
reflections. Our communication science work using sequential analysis
suggested that open questions to elicit change talk, reflections of change
talk, and statements to emphasize autonomy were significantly more likely
to lead to more adolescent change talk than were other kinds of statements
(Idalski Carcone et al., 2013). Figure 6.1 demonstrates this pathway.
Simple Reflections
When you repeat or paraphrase the young person’s change language, you
highlight change talk with a simple reflection (see Figure 6.2). The reflec-
tion is “simple” because you do not add any specific meaning or emphasis
on the content of what has been said. For example, when a young person
says, “I don’t want to come here, but I really don’t like the constant fighting
with my mom,” a paraphrase might sound like “You really don’t like the
conflict at home.” If you are using a repeating reflection, you may want to
repeat only part of the verbiage to avoid engendering a frustrated or sarcas-
tic response, such as “That’s what I just said.” Consider “You really don’t
like it” instead of a full repetition. You can also alternate your use of simple
reflections with other types of more complex reflections described below
to avoid sounding like a parrot. The idea is that by reinforcing change talk
with a reflection, you can elicit more change talk without the use of open
questions.
When will you talk Closed Questions to 68

to your partner? Elicit Change Talk %
What ideas do you

Open Questions to 57%
have about talking
to your partner? Elicit Change Talk
You are worried that 31% Change Talk

Reflections of
HIV is going to affect
Change Talk
your health.
%
You show a ton 27
of willpower when you Affirmations
say no to your friends.
%
15
It’s up to you whether Emphasizing
you are ready Autonomy
to take medication.
FIGURE 6.1. Sequential predictors of change talk.
Â
TIP FOR SIMPLE REFLECTIONS: AVOID TURNING REFLECTIONS
INTO QUESTIONS
Inflection—how you use your tone of voice at the end of a statement (turn-
ing it up into a question versus stating it in a neutral tone that smacks of
a flat-sounding statement)—can make or break the impact of your reflec-
tion. Your goal should be to maintain a neutral tone in your use of reflec-
tions, as they can easily be turned into questions without careful monitor-
ing. Turning reflections into closed-ended questions can suggest you are
not listening and may be interpreted by the young person as judging their
behavior. For example, if a person describes his drinking frequency, you
might reflect, “You drank a case of beer,” and lower the inflection to sound
straightforward. If you say, “You drank a case of beer?” the young person
may feel judged because you sound surprised and even disappointed. Try
this out loud and see how it sounds. As another example, in the case of a
Young Person’s Reflect More

Change Talk Change Talk Change Talk
• I know I am supposed • You know what you • Yeah, I just have to

take my medications are supposed to do. deal with it.
every day, but [Simple reflection:
sometimes I just repeat or paraphrase]
don’t want to think
about it.
FIGURE 6.2. Example of a simple reflection.

Change Talk 79
teenage girl who expresses sadness about her boyfriend’s behavior, a neu-
tral reflection, such as “You felt sad when your boyfriend did not show up”
would be better received than if you said, “You felt sad?” By turning the
reflection into a question you convey a sense of not really listening and, in
the worst case, could give the impression that her feelings were invalid or
unreasonable for the situation.
Complex Reflections
Miller and Rollnick (2013) specify several types of complex reflections. We
describe the types that are most appropriate with youth, and we also add
affirming reflections and summarizing reflections (for parsimony). Do not
worry about memorizing the names of each type of reflection. Instead, be
aware that you can choose from a menu of options. Your choice of reflec-
tions will be guided by your comfort as well as the young person’s commu-
nications with you.
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TIP FOR COMPLEX REFLECTIONS: DROP THE STEMS
It is common to begin reflections with stems such as “It sounds like . . . ”
or “So . . . ” or “What you’re saying is . . . ” However, in most situations,
it is generally preferable to drop the stem. The additional words are not
necessary and take away more than they add to the content of the message.
Moreover, we find that practitioners tend to overuse these stems in clinical
encounters. Many adolescents will immediately shy away from statements
such as “It sounds like you’re feeling . . . ” particularly when they have been
seen by other practitioners who use this crutch. The stems make the dis-
cussion seem more like therapy than like a conversation. If you fall into the
trap of overusing the same stem, it may foster nothing in the young person
but utter annoyance with you.
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TIP FOR COMPLEX REFLECTIONS: DON’T HESITATE TO USE THE WORD
YOU WHEN REFLECTING CHANGE TALK
When describing opening strategies in Chapter 4, we emphasized caution

in the overuse of statements beginning with you as they may increase the
young person’s reactance early in the change process. However, when
reflecting change talk, as when emphasizing autonomy, the incorporation
of you statements, as in the examples above, clearly emphasize personal
choice in the change process. By maintaining this continued collaboration
throughout your work with the young person (and not only during the initial
rapport building phase), you can enhance the client’s sense of self-efficacy
and continue to set the stage for behavior change.
Types of Complex Reflections
We present a menu of complex reflections you can use to reinforce change
talk. A reflection of the person’s true meaning expresses the implication of
the person’s statement (Figure 6.3). It sometimes feels as if you are con-
tinuing the paragraph your client has started. For example, if a young per-
son is talking about the multiple appointments he has to attend because of
his probation, you might respond with a statement such as “You are tired of
people telling you what to do.”
A double-sided reflection emphasizes ambivalence when you reflect
both sides of the young person’s mixed feelings about change. It serves
to point out the discrepancy between the adolescent’s values or goals for
change and how her behavior(s) may detract from helping her to attain
these outcomes. When engaging in these reflections, Miller and Rollnick
(2002) suggest using the conjunction and instead of but to further normal-
ize having two simultaneously occurring feelings about the target behavior,
as this ambivalence is commonly found in most persons seeking to make a
change. For example, in the case of an adolescent who smokes cigarettes
but is considering quitting, a double-sided reflection might sound like “On
the one hand you really like smoking, and on the other hand it is costing you
a lot of money.” With these types of reflections, it is also especially strategic
to end with the positive side of change, as in Figure 6.4, as the person may
be more likely to respond to the latter portion of your response.
After you have established rapport, you can begin to use reflection of
client feeling—reflecting emotions the person either described or implied
(Figure 6.5). For example, in the case of Jenny seeking to lose weight and
expressing concerns about avoiding classes due to her weight, you might
respond, “You’re disappointed when you miss out on things like participat-
ing in sports or gym class because of your weight.” As long as you are actu-
ally responding to what the young person has expressed or implied (and not

• I hate working out, but • Even though it’s hard, • Yeah, just leave me
I am going to have to do you want to do it for alone and I will figure
it every day. I know yourself and not have it out.
what I need to do and others bother you.
don’t need anybody [Reflect true
telling me. meaning/implication]
FIGURE 6.3. Example of a reflection of true meaning/implication.

Change Talk 81

• I want to quit smoking • On the one hand • Yeah, the asthma is

but I don’t think I can you’re not sure now getting really bad.
now. is the best time, but
on the other hand
you really want to
quit. [Double-sided
reflection]
FIGURE 6.4. Example of a double-sided reflection.
straying too far from it), he or she still has the choice to either accept the
reflection or clarify whether what you said was accurate.
When you reflect emotions, it is especially important to consider the
timing of the reflection. For example, if rapport has not yet been established,
a lower-intensity word (a little sad) may be better than a high-intensity word
(really depressed). However, as adolescents are a heterogeneous group, you
may also want to emphasize the most prevalent emotions discussed dur-
ing the encounter, such as feeling anger about having to change. Take, for
example, a young person who is bursting with emotions of anger and how
he might feel misunderstood if you say, “You were a little angry,” if, in fact,
he was “steaming mad.”
Affirming reflections (Figure 6.6) often flow naturally from change
talk statements and as always should be closely tied to the content of the
change talk. The key to affirmations is your use of honesty and specific-
ity. For example, instead of “You’re smart,” try “It’s smart that you are
thinking of your options.” It is also possible that an affirmation may engen-
der counter-change talk when a more challenging young person feels you
are overly enthusiastic about change. For example, when you say, “I am

• I get worried that I will • If you were able to • Yeah, I just want a
never meet someone, meet more people, normal life.
have a family, but going you would be less
out is just so stressful. worried about the
future. [Reflect feeling]
FIGURE 6.5. Example of a feelings reflection.


• I know what I need to • You really know how • Yeah, done it before.
do to quit Adderall; to make changes
I am just not sure it’s when you’re ready.
that big a deal. [Affirming reflection]
FIGURE 6.6. Example of an affirming reflection.
really happy you decided to cut back on your drinking,” the young person
may rebelliously stop the change process. To avoid this pitfall, affirmations
alternatively can be framed without the use of I statements, such as “It’s
great that you decided to cut back on your drinking.” Affirmations may be
incorporated even when you are not directly affirming behavior change. In
the earlier case of Jenny, the practitioner affirms her reasons for change
even though she is not describing actual behavior change in terms of weight
loss. Here is another example of the practitioner using caution when affirm-
ing a young person who is early in the change process. The young person
says, “I keep having these horrible hangovers when I drink. That might be
a reason to slow down.” Instead of prematurely affirming behavior change,
“It is wonderful that you are considering cutting back on your drinking,”
the practitioner affirms the patient’s strengths: “You seem to be aware of
your body’s reaction to alcohol. You really know yourself.”
Â
TIP FOR AFFIRMATIONS: CONSIDER THE TIMING
Careful consideration of the timing of your affirmation can guide the type
of affirmation you choose. Affirmations about a specific behavior may be
more acceptable when the person is more ready to change (“It’s great that
you want to cut back on your drinking”), whereas affirming strengths and
values may be more beneficial when the person is less ready to change
(“You are willing to consider difficult decisions in order to make the best
choice for yourself”). Obviously, there is no single correct way of affirming
a person. Rather, the key to affirmations, as in all reflections, is to not stray
too far from the young person’s statement.
Summarizing reflections may be used for the purpose of stringing
together several change talk statements, addressing existing ambivalence,
and guiding toward change by ending the summary in that direction. Miller
and Rollnick (2002) describe this process as picking flowers and present-
ing them back to the person in a bouquet. Summaries may be especially
Change Talk 83
relevant for young people, for they may be more prone to impulsively stat-
ing contradictory change and counter-change talk statements in the same
conversation, particularly in the face of ongoing ambivalence. For example,
Travis, who has been drinking and smoking cannabis daily, may offer change
talk at the beginning of the encounter, “I’m going to quit!” but minutes later
respond with counter-change talk: “What was I thinking? There is no way I
can do this.” While change talk may seem fleeting and consistency at times
a rarity, a summary can help “connect” the dots in a positive way. You can
go beyond merely stringing together change talk statements and begin to
tip the balance of pros and cons of behavior change. For example, “You men-
tioned a few concerns about drinking and drugs. Though you are not sure
you want to put any more chemicals inside your body, you mentioned your
mood is better when you don’t drink and take Adderall at the same time,
and you are a little worried about the changes in your blood pressure. While
you are not sure you really want to quit, you are wondering if you want to
keep using for the rest of your life.” Summaries also help a young person
with limited abstract thinking abilities to pull together different pieces of
the puzzle (“Let’s stop for a minute and go over what we’ve discussed so
far . . . ”), help you to remember all these pieces (“So to make sure that I’m
understanding everything correctly . . . ”), and let you transition to different
tasks of treatment or other components of the agenda (“We’ve covered a lot
of topics; getting back to your goals for treatment . . . ”).
Â
TIP FOR ANOTHER TYPE OF COMPLEX REFLECTION: USE ACTION
REFLECTIONS TO ADDRESS AMBIVALENCE IN CHANGE TALK
In the early stages of change, ambivalence is not resolved. Jenny, the teen
struggling with obesity, might say, “I would be able to lose weight if my
mom stopped nagging me.” Or “I tried to talk to her about helping me lose
weight, but she just does not get it.” The ambivalent young person will
often follow change talk with an undermining statement, but this should
not lead you away from reinforcing the change talk in the statement. You
can address the barriers after you reinforce the change talk. In an action
reflection (Resnicow & McMaster, 2012), you reflect what the person says
in a way that suggests a potential future action toward behavior change.
For example, “You think you can follow your meal plan if we can find a way
to have your mother stick to checking in only once a day.” An affirming
response with an action reflection is “It’s great that you have tried to talk
to your mother to reduce the fights. If we can come up with a way for her to
really understand you, it might work.” The practitioner reflects the change
talk and the ambivalence, and ends the statement with a possible action to
be discussed later during the goal setting process.
Eliciting Change Talk
You will use different types of open questions to elicit change talk. In MI,
you minimize closed-ended questions because they do not facilitate conver-
sation. Rather, closed-ended questions usually elicit single-word responses.
For example, “Do you think that cutting back on smoking would improve
your asthma?” can elicit a single word that can count as change talk, “Yeah,”
versus an open question such as “What are some reasons quitting smoking
would help you?” Too many questions, however, can make the young per-
son feel interrogated and can give the impression you are not listening to
the answers. Moyers, Martin, Manuel, Hendrikson, and Miller (2005) sug-
gest that a ratio of two reflections to every question is optimal to promote
behavior change. One way to ensure this balance in your encounters is to
use a reflective statement before and after every question.
Â
TIP FOR QUESTIONS: CONSIDER MULTIPLE-CHOICE QUESTIONS
There are also times when a young person may be stymied in the face of a
very open-ended question such as “What do you think about what the doc-
tor said?” Moreover, we have found that more ambivalent adolescents do
not like to answer these types of questions. An alternative to open-ended
questions in these situations is to provide a multiple-choice question, such
as “Do you agree, disagree, or something else?” In this way, you provide
structure for the conversation while still offering choice.
Open-Ended Question to Elaborate Change Talk

When a young person makes a change talk statement, you can ask for elabo-
ration with questions such as “Tell me more about that.” Another more spe-
cific request for elaboration used with a young person with alcohol issues
might sound like “You say now might be a time to consider cutting back
on alcohol. How would you go about it if you were ready?” Note that the
content of these questions closely parallels the subject matter of the young
person’s statements, without moving ahead too quickly to change topics or
begin behavioral change planning.
Â
TIP FOR ASKING FOR ELABORATION: AVOID ASKING FOR ELABORATION
ABOUT STEPS AND PLANS AT EARLIER STAGES OF CHANGE TALK
In this early phase of the journey, where change talk does not include a
commitment (see Chapter 7), be cautious in using direct questions about
next steps and plans. For instance, in the previous example, the practitioner
Change Talk 85
adds the caveat “if you were ready,” in order to reduce the young person’s
perception of being pushed into discussing actions or taking steps for which
he or she is not truly ready. In addition, prefacing the question with a reflec-
tion is another way you can mirror the young person’s statements, to help
guide alongside instead of stepping ahead. “You are considering cutting
back on smoking, but you are not sure now is the right time. How might you
go about doing it when you are ready?”
Â
TIP FOR ASKING FOR ELABORATION: TRY A PAUSE BEFORE JUMPING
TO A QUESTION
If your reflection is met with silence, try to resist filling the silence imme-
diately. Allow the young person the time to absorb the idea that you are
offering him or her an invitation to continue to talk. Given that adolescents
often perceive themselves as not being listened to, when you choose to
offer the gift of a reflection, we find that your present will most always be
received with open arms.
Questions to Elicit New Change Talk

You will often hear spontaneous change talk when actively listening to the
young person’s point of view. However, at times you may not hear change
talk at all. We find this is particularly common among young people who
are very ambivalent. You may be able to reduce counter-change talk and
discord with the strategies in Chapter 5 but at the same time may find that
the conversation does not automatically tilt to change talk. Below, we list
adaptations of open-ended questions to elicit change talk and to guide the
young person to maximize his or her potential. As always, you will want
to reinforce any resulting change talk with reflections, and listen care-
fully for any reemergence of resistance signaling that you have moved too
quickly.
Direct Questions
Perhaps the most direct way to elicit change talk is to ask for it (see
Table 6.2). For example, “If you decided to make a change, how would
you do it?” or “What difficulties have you experienced with your diabe-
tes?” Emphasizing your interest in the young person’s perceptions and not
rehashing other’s opinions about “what” and “how” they should change can
facilitate this process (e.g., “What do you think needs to change in your
life?” or “I am interested in what you think. What concerns you about your
drug use?”).
TABLE 6.2. Open Questions to Elicit Change Talk

Type of change talk Question to elicit change talk
Desire What would you like to work on? What do you hope to get
out of our time together? What do you want to be different in
your life? What do you hope would be better in your life if you
did ?
Ability What are some changes you have made before? What are some
difficult things you have done before? How confident are you
that you can do this?
Reasons Why would you want to make this change? What are the
benefits of making this change? How important is it for you to
do this? What do you think will happen if things stay the way
they are? How has this been helpful before? Why?
Need Why is this something you need to do? What is the best thing
that could happen if you made a change? What is the most
important reason for doing ? Why?
Commitment What is the first step you will take? What is one thing you can
do in the next week? How committed are you to making this
change? What steps have you already taken?
P ractitioner: Everyone is telling you what needs to change. What

do you want? What part of your life feels less than perfect for you
right now?
Young person: Well, I suppose my life would be better if my parents
would get off my back. [Change talk]
P ractitioner: So you might consider making a change if it would
reduce the hassle you experience with your parents. What would
it take to make that happen? [Reflection, elaboration]
Â
TIP FOR DIRECT QUESTIONS: TAILOR QUESTIONS WITH WHAT YOU
ALREADY KNOW
By tailoring questions to elicit change talk based on what you already

have learned about the young person, you further convey empathy and tie
together the person-centered and goal-oriented components of MI. For
example, in the case of Jenny, you might say, “You mentioned earlier that
you tend to eat more when your mother fights with you. What do you think
needs to change here?”
Change Talk 87
Â
TIP FOR DIRECT QUESTIONS: ASK ABOUT OTHER PEOPLE’S CONCERNS
WHEN THE YOUNG PERSON REFUSES TO ACKNOWLEDGE ANY
Inquiring about how others perceive the problem behavior can elicit change
talk. You can then follow up with reflections and explore any sense of
uneasiness they may be experiencing, drawing parallels between how oth-
ers feel and their own views about change.
P ractitioner: What is it about your behavior that other people might

see as a reason for concern?
T ravis: Well I’m not sure they have a reason, but my parents are wor-
ried about what the doctor said.
P ractitioner: So your parents are worried about you.
T ravis: Yeah, they keep saying I’m gonna have a heart attack someday
like my grandfather.
Now the practitioner can tie others’ concerns to the young person’s point
of view.
P ractitioner: So they care about you and are worried about heart
problems since there is a family history. What do you think?
T ravis: Well, I am fine right now, but I guess sometimes I wonder if I
might end up like him down the road. [Change talk]
P ractitioner: There is a part of you that wonders if you will end up
with heart problems and the drugs might make it worse. [Reflec-
tion]
Alternatively, if others’ concerns are not sufficient to elicit a discussion

about the young person’s potential reasons to change, some young people
respond to questions that consider the effects of the target behavior on
significant others.
T ravis: I am fine right now, and I wish they [parents, friends] would
not worry so much.
P ractitioner: So you are not sure this is an issue, but you don’t like
them [parents, friends] worrying. What could you do to reduce
their worry?
T ravis: Well, I guess I could cut back on Adderall, but I am not gonna
stop smoking weed. [Change talk]
P ractitioner: You know yourself best, and cutting back on Adderall

is something you’re considering. [Complex reflection with empha-
sizing autonomy]
Imagining Questions
By discussing imagined situations, you can explore the young person’s
goals and guide them to the path of change talk. Imagining extremes
involves asking future-oriented questions pertaining to how life would be
if the problematic behavior continues and/or is discontinued. For example,
“What’s the worst thing that might happen if you continue [insert problem
behavior]?” and “What’s the best thing that might happen if you decided to
stop [insert problem behavior]?” Answers to these scenarios often resound
of change talk. If the response is “nothing,” consider this to be evidence of
resistance in the relationship and roll with it (see Chapter 5).
A similar imagining approach involves asking the young person to
imagine his or her life before the problem behavior existed. For example,
“Looking back, tell me what your life was like before you started drink-
ing.” When inquiring about the past, you should allow for ample time to
answer, and particularly for those young persons with a history of strug-
gling to change the problematic behavior. Topics brought forth can provide
new insights about what is actually important to the young person (and not
just what you assumed). These topics can range from discussions about life
being simpler as a child or experiencing less conflict with parents to notic-
ing differences in appearance, health, and the like.
You can also ask the young person to look ahead by envisioning hopes
for the future and considering how their current behaviors can help or
hinder goal attainment. For example, “If you could fast-forward to a few
years down the road, what would you see yourself doing, and how does your
[problem behavior] fit with that goal, assuming nothing changes?” If the
young person is not able to see that far ahead, try shorter windows of time:
“What would your life look like one year from now?”
We have found the looking-forward strategy to be especially power-
ful because it instills hopefulness about how life may one day be different.
However, we have also found this strategy to backfire, increasing the young
person’s resistance if you are not prepared to roll with any and all responses
he or she may offer. For all of us working with young persons, it is easy
to slip into the trap of giving unsolicited advice (i.e., warning about the
hazards of their ideas, such as responding with statements such as “You’ll
end up in the hospital if you don’t . . . ”). However, these well-intentioned
warnings often do little but evoke reactance and squelch the young person’s
hopes and dreams for the future, even if they are not realistic from your
point of view.
Change Talk 89
P ractitioner: To help me understand more about you, I am wonder-

ing if you are willing to share how you see things in your future?
What do you imagine life will be like, say, 5 years from now?
Eugene: Well, I want to work with younger kids like in a school or
camp.
P ractitioner: You are interested in working with children. You said
you like to have fun, so I bet you would be good at it. How does
taking your medication fit with this goal?
Eugene: Well, I guess I have to be healthy to do that kind of work.
Kids are sick a lot! [Change talk]
P ractitioner: So taking your medication will help you stay healthy
and be able to work with kids.
By exploring the discrepancy between current behaviors and goals, the

practitioner is guiding the youth to consider improving medication adher-
ence.
Â
TIP FOR IMAGINING QUESTIONS: TRY AN ACTIVITY
Some young people may prefer to imagine beyond the use of verbal com-
munications. For example, with permission, you can have the young person
draw representations of “looking forward” and “looking back,” or act out
scenes showing “the best case scenario if I change” and “worst case sce-
nario if I don’t change.” These activities can take on a playful or serious
tone, depending on the young person’s preferences.
Questions about Personal Strengths

There are several types of questions you can use to support the young per-
son’s self-efficacy (see Chapter 7 for leveraging personal values). You can
encourage stories regarding past change successes related either directly
to the target behavior or to other difficult changes. For example, “You men-
tioned you managed to keep the job at the gas station even though nobody
helped you with transportation. How did you overcome this challenge?”
Similarly, you can inquire about personal strengths or social supports avail-
able to help with overcoming challenges (e.g., “Who helped you? What are
the things you did that made a difference?”).
For the young person who does not easily identify personal strengths,
you can explore what other people (friends, family) say about their strengths
or good qualities. An Affirmation Card Sort activity may also help the young
person identify these strengths. Akin to the values clarification exercise
(see Chapter 7), the young person is first asked to choose qualities he or
she possesses (such as thoughtful, kind, strong) from a list or stack of cards.
You then follow up with similar questions about how these qualities are cur-
rently evident in the young person’s life, in relation to both past successes
and possible behavior change options. For example, “You mentioned you’ve
always been a strong person. How might being a strong person help you if
you decided to do something about smoking?”
During this activity (and with all MI), you should convey your own
hope and optimism regarding the young person’s ability to change, as long
as it is truly consistent with your belief. Research suggests that therapist
optimism is a common factor evident in positive therapeutic outcomes
(Lambert & Barley, 2001). For example, a practitioner might comment,
“You have been really persistent in the past in trying to take your meds
even though it has been so hard. This persistence can really pay off once
you find the right strategy to help get back on meds.”
Additional Strategies to Elicit Change Talk
Two additional strategies are commonly used to elicit change talk: rulers
and feedback.
Rulers
Rulers are often incorporated into MI interventions (Miller & Rollnick,
2013), though we have found that asking about “readiness” may be too
abstract for young clients. We prefer an importance ruler. After asking per-
mission, you describe or show a picture of the ruler, with anchors of 1 as
the lowest and 10 as the highest. You then ask the young person to rate
the importance of making a change on the ruler on this scale from 1 to 10:
“How important is it to you to change [problematic behavior]?” It is help-
ful to explain the point scale. For example, explain to your client, “Some
young people feel quitting drugs is not at all important and would give it
a rating of 1. Other people believe this is the most important thing and
would rate it a 10. Others might be in the middle, like a 4, 5, or 6. Where
are you at?”
After the young person chooses a number, for example, 4, your first
task is to reflect the response and provide a contextual meaning for the cho-
sen value (e.g., “You are somewhere in the middle. Changing this behavior
might be important but maybe isn’t your top priority”). Second, you should
ask about why the young person did not choose a lower number (“Tell me
why are you are a 4 and not a 1 or a 2”). By inquiring about lower numbers,
you increase the likelihood that the young person will respond with change
talk. That is, you are guiding him or her to defend a position in favor of
Change Talk 91
change, rather than argue against it. They might say, “Well, I know even-
tually I have to stop using drugs, but I am not sure I want to right now.”
However, if you had instead asked, “Why were you a 4 and not a higher
number?” you would have guided the young person to argue for reasons
against change (“I really like smoking and it helps me to relax”). These
slight shifts in your communication provide a critical distinction and tool
for eliciting change talk instead of encouraging sustain talk. Note that if the
person responds that they are a 1 on the ruler, this is a clue for you to return
to strategies to respond to sustain talk (Chapter 5).
Â
TIP FOR RULERS: TRY THE RULER FOR DIFFERENT TYPES OF CHANGE TALK
The ruler strategy may be used for other types of change talk, particularly
ability (recall that readiness to change is a function of importance and abil-
ity). In a confidence ruler, the young person rates confidence in his or her
ability to change on a 10-point scale. You might respond, “You say you are
a 7. Though you are not 100% sure, you are pretty confident you could do
this if you wanted to. Why are you a 7 and not a lower number?” Similar
to the importance ruler, exploring confidence with the scale elicits change
talk, with the focus on personal abilities to change. Another possibility to
promote engagement in treatment is to ask the young person to rate how
they feel about coming to treatment (e.g., how much they want to come,
how important it is to come, how confident they feel in being able to work
with you). When you ask why the young person chose that number and not
a lower number, you elicit reasons to engage in treatment!
Â
TIP FOR RULERS: TRY ASKING WHAT IT WOULD TAKE TO GET
TO A HIGHER NUMBER
The question “What would it take to get to a higher number?” also elicits
change talk by requiring the young person to think about making a change
without having to commit yet.
P ractitioner: You said you were about a 5 in how ready you are to
start exercising. Sort of ready, but you’re not sure. What would it
take for you to be a higher number?
Jenny: I guess if I could find something I like, I might be higher. I hated
everything I’ve tried so far.
P ractitioner: So if you found something you liked, you might con-
sider exercising. You mentioned you used to dance. How do you
feel about dancing now?
Personalized and Normative Feedback

There is some evidence to suggest that brief MI with young people that
included feedback of assessment results had stronger effects on behavior
change than brief MI without feedback (Walters, Vader, Harris, Field, &
Jouriles, 2009). Personalized feedback involves presenting factual informa-
tion about the young person’s specific experiences with the target behavior,
with the goals of increasing concern and developing discrepancy between
the target behavior and the young person’s goals/values. The information
comes either from objective assessments (e.g., lab results, urine screens)
or from the young person’s own self-report rather than from the subjective
reports of others. Normative feedback is a strategy where you compare the
young person’s results with statistical data on similar young people (e.g.,
“You said you started having sex at 15, and everybody your age is doing it.
I have some data here on when other teenagers are starting to have sex”).
Using the Ask–Tell–Ask approach (described in Chapter 4), you will
provide only facts, without judgment or your analysis of the results. Recall
that interpretation of feedback is the young person’s task, not yours. Recall
Sam with anxiety who drinks to relax in social situations.
P ractitioner: What would you like to know about the questionnaires

you completed?
Sam: I was wondering what it was all about. I really don’t drink that
much.
P ractitioner: Based on your report, if you add up the days you drank,
you said you drank 20 out of the last 30 days for a total of 100
drinks. How does that fit with your thoughts about your drinking?
Sam: Well, I guess I did not realize I was drinking that much almost
every day.
P ractitioner: You are wondering if you are drinking more than you
realized.
Sam: Yeah, I’m OK with drinking, but I don’t want to be a daily drinker.
[Change talk]
P ractitioner: Being a daily drinker does not fit with who you want to
be. [Reflection of discrepancy]
Personalized feedback simply summarizes the person’s assessment

results. In contrast, normative feedback facilitates the young person’s com-
parison of him- or herself with similar others using population data (i.e., age,
gender, race, etc.). For example, “You reported drinking about 20 drinks
per week. Would you be interested in knowing how your use compares with
others your age? This study here shows that male college students drink an
Change Talk 93
average of nine drinks per week.” In providing information, some young per-
sons may respond better to visual presentation (see Chapter 9), and using
relevant norms specific to the young person (race, gender, age, geographic
region) is key. If information is not available or is not specific to the young
person, it is better to present personalized feedback instead. For example,
young persons with HIV may not pay attention to normative substance use
data from young people without HIV. Some young people may reject being
presented with normative data, as they may perceive themselves to be dif-
ferent from the norm, do not consider the behavior as a problem, and/or are
not ready to make any changes. For example, “These data are old; every-
body I know drinks as much as me.” The young person may even question
results from the objective assessment or the self-report questionnaires (i.e.,
“This can’t be right, these questions are stupid anyway”). As with all forms
of sustain talk, you can roll with these statements and further explore how
the adolescent interprets their problematic behavior. For example, “OK, so
as you see it, the assessment was not right. How much do you think you have
been drinking, and what do you make of it?” In this way, you emphasize your
respect for the young person’s point of view while continuing to implement
other, more relevant strategies.
A recent study (Davis, Houck, Rowell, Benson, & Smith, 2016) sug-
gested that normative feedback is most associated with behavior change
when change talk is already frequent and can be detrimental when change
talk is not. Thus, we recommend you be cautious with timing and use nor-
mative feedback when you have already heard and reinforced change talk.
Summary
Do not worry about memorizing types of change talk. Instead, focus on rec-
ognizing any change talk and get in the habit of automatically reinforcing it
with reflections or requests for elaboration, decide which strategies to elicit
change talk fit with your personal style, and always be on the lookout for
bumps in the road with young people, as counter-change talk and discord
may arise at any time (see Chapter 5). The dialogue below shows how elicit-
ing and reinforcing change talk with open questions and reflections flow in
a conversation.
Jenny: My mother nags at me all the time, and it’s not as easy as she
thinks. If she got off my back I might do a lot better [Ability to
change], but the arguments we have are just too much; they just
make me want to eat more.
P ractitioner: You might do a lot better with following your eating
plan if you and your mother would stop fighting. [Action reflec-
tion]
Jenny: Yeah, all day long she hassles me about what I ate. It makes me
want to just quit this whole thing, but I really want to lose some
weight before summer. [Desire for change]
P ractitioner: You really want to do this before the summer. [Simple
reflection] Tell me more about why you want to lose weight before
summer. [Question to elaborate change talk]
Jenny: All the kids hang out outside in shorts and T-shirts. When it is
hot, I won’t go because I don’t want to wear clothes that show my
fat. [Reasons for change]
P ractitioner: It’s great that you want to lose weight so you can go
outside and be with the other kids. [Affirming reflection] What
would it look like if your mother would support you instead of
fighting with you so that you reach your goal? [Open-ended
question—looking forward]
Jenny: Well, she just needs to leave me alone because I really need
to make this plan work. [Need for change] Maybe she could just
check in with me at the end of the day, but I am not sure she would
do it.
P ractitioner: You have some great ideas here. [Affirming reflection]
When you fight with your mom, you want to eat more. This upsets
you because you really want to lose weight so you are more com-
fortable hanging out with your friends this summer. Your idea is
to talk to your mother about only checking in with you about eat-
ing at the end of the day. [Summarizing reflection]
While change talk may be the map of change, MI spirit is the necessary
scenery. The elicitation and reinforcement of change talk within a founda-
tion of partnership, acceptance, compassion, and evocation is the key to
MI. We suggest direct questions to elicit desire, ability, reasons, and need
(we will discuss commitment language in the next chapter). We note that
emphasizing autonomy and experiential activities are especially useful with
young people. We also note that while we prefer open questions, multiple-
choice questions and even closed questions can still be used to elicit change
talk. We simplify previous conceptualization of MI by addressing the rein-
forcement of change talk with simple and complex reflections, emphasiz-
ing that affirming and summarizing are main types of complex reflections.
Table 6.3 summarizes change talk dos and don’ts, while Table 6.4 describes
adaptations for special populations.
Change Talk 95
TABLE 6.3. Recognizing, Eliciting, and Reinforcing Change Talk:

Dos and Don’ts
Do Don’t
Recognize and reinforce Neglect
• All change talk, regardless of type. • Opportunities to reflect change talk.
• Elaboration of youth’s cons and pros • A cautious pause before you respond.
that reinforce/enhance change talk. • Evoking counter-change talk versus
change talk will create barriers for
youth to discuss change possibilities.
Gently pull Force and get stuck

• Attend to the flow of conversation with • Force responses with closed-ended
open-ended questions. questions and reinforce discord
• Pull out change talk from the jaws language.
of youth’s ambivalence using change • Reinforce counter-change talk with
talk reflections—it can lead to clearer reflections of discord—it can lead
streams that flush out ambivalence. to murky waters where the jaws of
ambivalence clamp shut.
Vary creative reflections Be one-sided or use common reflections

• Vary types/frequency of reflections. • Reflect only one side of ambivalence.
• Be creative in reflecting change talk. • Use commonly overused stems.
• When you creatively use reflective • “It sounds like . . . ”
change talk, you pave the road for • When you generically reflect change
youth to explore new territories in talk, you can stagnate change
considering options on their path of processes by conveying to youth their
change. voice in change is not special.
Avoid inflections Waste a reflection

• Reflect with mindful attention to vocal • Turn reflections into questions.
intonation. End your responses with • End responses with a concerto of vocal
neutral tone. tones—doing that offers a window for
• Attend to intonation—neutral youth to jump out of the conversation
intonations offer guidance on how the and disengage when it’s unclear how
youth may respond to a question or they might respond to you.
response to your reflection.
Be creative Be boring
• Use open-ended questions to elicit • Use closed-ended questions or
change talk, not counter-change talk. interrogate with a series of questions.
Balance ratios Forget to reflect

• Balance ratios of questions with • Sacrifice opportunities to respond to
reflections—tailor both to change talk. change talk by taking the “easy road,”
using closed-ended questions and
counter-change talk reflections.
Use rulers—for hope Use rulers to tank hope

• Focus rulers exercise to elicit hope. • Use rulers exercise to tank hope.
• Use the road less traveled option— • Offer a “why isn’t the grass greener?”
inquire about “low numbers” that will option by inquiring about “higher
evoke change talk. numbers,” forcing youth to focus on
pessimism and barriers to change.
(cont.)
TABLE 6.3. (cont.)
Do Don’t
Use Ask–Tell–Ask Defend and data dump
• Incorporate change talk into feedback • Speak “the truth” or offer research
using the Ask–Tell–Ask strategy. data/statistics of interest to only you.
• Dump irrelevant information/factoids
on the young person—it will hinder
change processes further.
Specifically affirm Generically affirm
• Affirm specific change efforts with • Offer generic and overly enthusiastic
concrete behavioral terms. affirmations too quickly.
• Use You sentence stems. • Use I statements in sentence stems.
• “You completed your homework and • “I think it’s a fantastic job!”
feel great about it!”
Summarize periodically Haphazardly summarize
• Be purposeful in choosing • Stray too far from the person’s
opportunities to present a collection of statements and offer random summary
reflections, link themes, and transition statements.
to other foci of change.
TABLE 6.4. Tips for Change Talk with Special Populations

MI response sounds
Special populations may . . . MI tip like . . .
Criminal justice
Avoid responding to change Use omission “Being scared to

talk reflections in an honest reflections. freely talk about
manner when fearing external Highlighting realistic changing—there’s a
contingencies: “Yeah, I hear fears about what the risk—your ideas may
you. But if I really talk about youth discloses can not be supported by
this—will you tell my parole enhance youth’s trust everyone.”
officer?” in you and facilitate
change talk. “It’s important for us
Question your authority to focus on your own
when you prematurely focus Drop the expert goals and not the ones
on change talk: “Don’t try role. Step back and other people make for
using that psychobabble on reflect prior change you.”
me. Please don’t waste your talk statements when
time . . . ” encountering “don’t”
statements.
Change Talk 97
MI response sounds
Eating disorders
Respond well to Listen for novel change “Sometimes the efforts

reinforcement of change talk statements. Reflect you’ve made to avoid
talk with dietary compliance all small changes change can make you
efforts, although it may not maximizing healthy actually work harder
sound like “typical” change efforts—even when than doing it.”
talk: “All I had to do was just they include a question.
drink this crappy electrolyte “Getting your phone
drink and eat a couple extra Tie in reflections fixed is important to
bites?” of other change helping you track your
efforts broadly meals on the calendar.
Appear “coy” in responding related to health. Use How might you use it
to questions about difficulties opportunities to reflect to track on the diary,
with change efforts: “I forgot change about any/all or are there other ways
to write down the meal diary health-seeking efforts you might want to
we made . . . my iPhone supporting the goals of include your phone to
crashed this week—I at least treatment. help you monitor your
got that fixed.” changes?”
Appear to “ignore you” if your Simplify your “Change, yes. It’s

change talk reflections are reflections and something you want
long-winded. demonstration of MI to do.”
spirit.
May repeat your phrases “My fault—too many
while digesting your overly Be specific and simple questions at once.
worded phrases: “Change, in eliciting change talk. What are some reasons
change, change?” Direct questions versus you want to take these
strategic questions may medicines.”
Get fatigued and frustrated be best. Apologize if
with you when faced with you have confused the
multiple change talk questions young person.
and reflections: “You ask too
many questions! What do you
want me to do?”
(cont.)
TABLE 6.4. (cont.)
MI response sounds
Sexual health
Express concerns about Combine emphasizing “There are some

consequences of relationships autonomy with hurdles and you
when changing sexual affirmations and made a big change for
practices: “I bought the double-sided your own health and
condoms and put one on for reflections. he’s still on board to
us—surprised him with a support you too.”
rainbow-colored one! Neither Use Ask–Tell–Ask to
one of us liked it as much.” offer feedback in an “You’ve made a lot of
MI-consistent manner new updates and are
Explore different safe sexual to support change when excited about these
practices all at once that may potential sexual health changes. What do you
compromise risk and ask your risks can be minimized. know about the risks
opinion: “I’m trying it all right of pregnancy when
now. Monday I took the pill, you use different birth
Tuesday we tried condoms, control methods every
Wednesday . . . well I forget day?”
what happened . . . , but on
Thursday I started my period
and we didn’t need to use
anything. I’m finally doing
these changes! What do you
think?”
Opiate addiction
Hesitate to respond to your Give slower-paced “Let’s slow it down;

reflections of change talk verbal responses to these are important
and fear the unknown— change talk statements. decisions you are
of biological withdrawal Recognize how making.”
(including concerns for physiological/cognitive
obtaining opioids if not withdrawal symptoms
prescribed): “Give me a may alter cognitive
second . . . I’m not sure what processes and youth’s
I’d feel like if I stopped using.” verbal responses.
Display heightened sensitivity Refocus on short-term “Taking the time to

and overly emotional changes as youth with a think about how to
responses when your change longer history of opioid make the next change
talk questions involve longer- use may have greater is as important as
term goals not matching difficulties committing taking time out to
youth’s short-term goals: to longer-term changes. think when you feel
“You keep asking me about Tailoring questions to like using.”
what my life will be like when evoke change talk for
I’m not hooked on this stuff. short-term goals can
I’m just trying to think how enhance self-efficacy
I’ll make it through this week and makes committing
and not use!” to longer-term goals
more attainable.
Change Talk 99
Practitioner Activity 6.1. Change Talk
Activity Goal: To learn how to elicit and reinforce different types of change talk
with open questions and reflections
Activity Instructions: For each type of change talk, consider the example pro-
vided, and then craft your own. Don’t worry if there is some overlap, as some
types of change talk can be interchanged for others (especially reasons and
need), but just practice to expand your repertoire of types of change talk and
ways to evoke it.
Desire Change Talk

Example
Sounds like: I want to get off probation.
How to elicit it: Why would you even want to avoid some of these friends right
now?
How to reinforce it: Avoiding these friends will help you get off probation.
Your Example for Desire Change Talk

Sounds like:

How to elicit it:

How to reinforce it:

Ability Change Talk

Example
Sounds like: I could quit any time I want.
How to elicit it: Tell me, what would it take for you to feel like you could quit?
How to reinforce it: So you really have the skills to quit now if you choose.
Your Example for Ability Change Talk

Sounds like:

How to elicit it:


Reasons Change Talk

Example
Sounds like: I don’t want to end up with diabetes and being stuck in a wheel-
chair like my grandma.
How to elicit it: What are some reasons you might want to lose weight?
How to reinforce it: So you have personally seen some bad things that can hap-
pen, and you don’t want that to be you.
Your Example for Reasons Change Talk

Sounds like:

How to elicit it:


Need Change Talk

Example
Sounds like: I need to stop going to the emergency room because of this asthma.
What if they start charging me when I am over 18?
How to elicit it: On a scale from 1 to 10, where 1 is “I don’t need to quit smoking
at all” and 10 is “I need to quit ASAP,” where are you at? Why did you pick that
number and not a lower number?
How to reinforce it: You really need to quit so you can reduce the risk of big
medical bills messing up your future.
Your Example for Need Change Talk

Sounds like:

How to elicit it:


7
Processes
of Motivational Interviewing
Going with the flow is responding to cues from the universe.

When you go with the flow, you’re surfing life force.
It’s about wakeful trust and total collaboration with what’s
showing up for you.
—Danielle L a Porte
Engaging
VA
LUE
S
UE
S
L
VA
Change
Talk
Managing
Counter-Change
Focusing
VA
Spirit
UE
L
UE
L
VA
S
Evoking
After years of MI research and development, the flow of MI is organized

in terms of four foundational processes: engaging, focusing, evoking, and
planning (Miller & Rollnick, 2013). We have added a fifth process of main-
taining, which may be particularly useful when integrating other forms of
treatment, such as cognitive and behavioral interventions (Naar & Safren,
2017), as discussed in Chapter 8. Maintaining as a process is especially
critical for young clients who have to maintain behavior change across new
developmental challenges.
101
The processes are designed to be overlapping and not necessarily

sequential. In one sense, these processes do emerge sequentially in the
initial session(s). For example, engagement is a foundation without which
treatment cannot progress. Evoking occurs with a clear focus because
you are evoking motivation for specific target behaviors. Planning should
occur only after motivation is sufficiently evoked. Maintenance of change
occurs after initial planning for change and is likely to integrate strategies
from other treatment approaches, such as cognitive-behavioral interven-
tions (Naar & Safren, 2017). Yet, in another sense, the processes are also
recursive and overlapping, such that the practitioner may need to move
between processes based on the needs of the youth. For example, you may
need to reengage if there are cracks in the foundation as treatment pro-
gresses (e.g., missed sessions). The focus may change as new challenges
and life events occur. Evoking new treatment tasks may be necessary as
the youth moves through a treatment plan. Certainly, slips may occur as
youth work on maintaining change, which may require the practitioner
to revisit the other processes. As the processes are both sequential and
recursive, we have chosen to represent the five processes as stair steps
to highlight the importance of maintaining flexibility when using MI with
youth (Figure 7.1).
In the second edition of MI (Miller & Rollnick, 2002), Wagner and
Sanchez (2002) note that people change for many reasons, all of which are
linked to their values. For example, youth who value pleasure might change
because the negative consequences of their behavior interfere with their
Maintaining
Planning
Evoking
Focusing
Engaging
FIGURE 7.1. The five processes of MI represented as stair steps. From Miller and
Rollnick (2013). Copyright © 2013 The Guilford Press. Adapted by permission.
Processes of Motivational Interviewing 103
fun. Youth who value independence might change to achieve greater free-
dom. Youth who value their peers might only change if the plan is consistent
with the peer group.
Emphasis on values as a central motivator of behavior change is not
specific to MI. Another evidenced-based approach, acceptance and commit-
ment therapy (ACT), offers a robust literature supporting the importance of
using values as a compass to guide intentional behavior (Bricker & Tollison,
2011). Both approaches share several commonalities, including a core focus
on acceptance, collaboration, and the tailoring of therapeutic efforts to a
person’s language as a vehicle to explore values and the impact of their cur-
rent and future behavioral actions on these values. While it is beyond the
scope of this text to review, there are also distinct differences between the
two approaches, including the focus on language content (MI) versus lan-
guage processes (ACT) and different therapeutic uses of values to motivate
behavior change. Furthermore, debate about whether to focus on changing
behavior or on changing core values remains an empirical question yet to be
answered. What is clear from the evidence, in both MI and ACT, is that in
many instances, therapeutic communications tailored to a person’s values
does facilitate changes serving to maximize a person’s overall well-being
and human potential.
We focus next on how using MI can incorporate values-based discus-
sions within the five processes model in your treatment of youth. Our hope
is that you will not get bogged down with trying to understand the model
as a rote list of how you can expect the change process to occur for every
youth. Rather, we hope you gain a greater appreciation of how discussions
about values and change with adolescents and young adults in MI can be dif-
ferent than with adults. By tailoring discussions using the five processes to
focus on the youth changing behaviors that will increase consistency with
their values, you can better maximize change processes with the young
person. By doing this, you avoid making plans for change for the youth that
are inconsistent with those values. Below is a description of how values are
integrated into the processes, followed by a more detailed description of
each process.
In the engaging process, the practitioner clarifies values. In the focus-
ing process, the practitioner collaboratively develops a direction consistent
with the young person’s values, what the young person finds most impor-
tant. In the evoking process, the practitioner addresses values–behavior
discrepancy to elicit change talk. In the planning process, the practitioner
ensures that plans are consistent with values to increase the likelihood
of success. Finally, in maintenance, values–behavior congruence is rein-
forced to solidify behavior change and prevent slips, and values clarifica-
tion may be revisited in case new values have emerged during the behavior
change process.
Engaging
Engaging is the process of developing rapport and understanding the cli-

ent’s dilemma. Why is the young person considering or not considering
change, and what is getting in the way? Engaging involves establishing the
working relationship and creating therapeutic alliance. Although a strong
working alliance is the foundation of any intervention approach, the practi-
tioner communication behaviors necessary to promote alliance and address
ruptures in alliance are rarely specified, and MI specifies these behav-
iors by delineating the spirit, processes, and skills. Thus, the goals of the
engaging process are to establish rapport and demonstrate the spirit of MI,
explore the young person’s values and goals, understand the young person’s
dilemma or struggle, and learn why the patient would want to change before
addressing how to change.
When the client seems hesitant to discuss the target behavior, an
option is to explore other areas of the young person’s life. These details can
appear unimportant at first glance; however, they provide a critical oppor-
tunity to learn about the goals and values of the young person. Topics to
consider inquiring about include peers (“Tell me what you usually like to do
with your friends”), family (“What do your parents typically do that drives
you crazy?”), and school (“What do you like and not like about school?”).
By allowing the youth to discuss these less risky and preferred topics, you
continue to establish the bond of trust necessary for working with young
persons. Furthermore, the young person may reveal other important inter-
mediary goals that you would not have thought of, further supporting the
notion that the young person is the expert of his or her life.
Throughout this book, we specify a lot of things to do when working
with young people, but MI also specifies many things not to do. Miller and
Rollnick describe possible traps the practitioner may fall into that lead to
disengaging and are outlined along with some things to do to escape these
traps (see Table 7.1).
Making Assessment More Engaging

Because assessment is so often a part of a typical clinical encounter and is
often mandatory in certain clinical contexts, we would like to spend some
time on the assessment trap. Assessment can often feel like an interroga-
tion. A simple way to reduce this feeling is to reflect the answers to the
questions and periodically summarize. Ideally you will refrain from a series
of questions, even if balanced with reflections, and try to elicit informa-
tion with open questions while reflecting any change talk and then sum-
marizing. With your commitment to the engaging process, the details will
emerge in a much more collaborative and less interrogative fashion. You
TABLE 7.1. Traps that Promote Disengagement

Traps Definition Escapes
Assessment trap The practitioner controls the Use open questions and
session by asking questions, respond with reflections
while the youth responds with before asking more
short answers. questions.
Expert trap The practitioner collects Summarize and then ask an

information from the young open-ended question about
person’s short answers and then next steps.
proceeds to give the youth a
prescription of “just do this.” Ask the young person about
any ideas they have for their
plan.
Premature The practitioner persists in Clarify the young

focus trap trying to draw the young person person’s agenda and the
back to talk about their own practitioner’s agenda. Then
conception of the problem discuss collaboratively and
without listening to the young meet each other halfway.
person’s broader concerns.
Labeling trap The practitioner focuses on a Use the young person’s

particular problem and then own words to describe their
refers to the target behavior (or struggles and concerns.
the young person) by this label.
Blaming trap The practitioner or the young Apologize and reflect the
person has concerns with young person’s concerns.
defensiveness about blaming:
“Whose fault is the problem?” Reframe treatment as
“Who’s to blame?” addressing the young
person’s struggle and what
they want to change rather
than deciding who is at fault.
Chat trap The practitioner and the young Briefly summarize the
person have insufficient direction “small talk” and ask a
for the conversation, making focusing question to redirect
“small talk” for a majority of the the conversation.
session.
will find out details you may have not thought to ask, and can then skip over
questions that may be irrelevant to the young person’s experience.
Â
TIP: TRY THE TYPICAL DAY EXERCISE
The typical day exercise (Rollnick et al., 2008), allows you to obtain infor-
mation pertinent to setting a collaborative agenda for treatment and has
been successfully used with adolescents (Channon, Huws-Thomas, Greg-

ory, & Rollnick, 2005). You ask the young person to walk through the activi-
ties, interactions, and associated feelings they experience in a typical day.
For example, you might say, “Think about yesterday and take me through
it. Just tell me what happened, and if you want, tell me how you felt about
things.” In using the typical-day exercise with young persons, it may be
helpful to inquire about a weekday, as well as a weekend day, as behavioral
routines can significantly differ. Note that this technique differs from other
behavioral assessment strategies, such as self-monitoring or time-sampling
procedures, in which the identification of problematic behaviors and their
associated consequences are targeted for intervention.
Engaging with Values
While exploring the young person’s perspective and understanding their
dilemma, consider using complex reflections to highlight values: “You are
talking a lot about how your parents try to tie you down. I am hearing
that independence is really important to you.” If the young person’s values
are not clear, you can ask pointed questions, such as “What things are
important to you right now?” Inquiring about the characteristics of people
who are important to the young person or discussing positive attributes
of a friend or boyfriend/girlfriend can also facilitate clarification of these
issues.
P ractitioner: If it’s OK with you to discuss, I’m wondering, what are

some things you like about your new crush?
Eugene: Well, he is really nice, and he loves animals.
P ractitioner: Kindness is something you value.
Â
TIP: TRY AN EXPERIENTIAL ACTIVITY TO CLARIFY VALUES
The Values Card Sort, originally developed for MI by Sanchez (2000), has
been effectively used in MI with young people (Resnicow, 2002). In this
activity, after seeking permission from the young person, you provide a
stack of cards with a value printed on each, along with an extra blank card
so that a value can be added if your list does not include it. Next, you ask
him or her to sort the cards into two piles, one for the more important and
the other for the less important values. From the important value pile, he
or she chooses the “top three values” that matter most to him or her. You
then can ask open-ended questions regarding how the chosen values cor-
respond with how the young person is currently living his or her life (and
later discuss discrepancies between the value and the target behavior in the
evoking process). Open-ended questions can focus on elaboration about the
value’s personal meaning (“What does health mean to you?”). Some youth
have difficulty with the card sorting task and may prefer to simply circle
the top three values in a list of values. The ACT approach offers several
experiential activities for values clarification, and many are available online
(e.g., www.positivepsychology.com).
Focusing
Focusing is the process by which a practitioner and a client become clear

on the direction and goal of the conversation at present, and possibly the
focus of future sessions. Often the direction and associated goals are about
changing behaviors, but not necessarily so. The focus may be about a choice
(e.g., forgiveness, a job change) or about an internal process (e.g., tolerance,
acceptance). Moreover, the process of focusing is more than agenda setting
or treatment planning with a list of goals or tasks. Focusing involves a col-
laborative process of determining the scope of the conversation, which can
include goals and tasks, as well as thoughts, feelings, and concerns. Thus,
the goals of the focusing process are to explore both the patient’s and the
practitioner’s agenda, clarify the direction of treatment and the focus of
each session, and guide the young person to determine what efforts will
lead to the best outcomes for them.
Agenda Setting
The spirit of collaboration in the focusing process can be expressed by
agenda setting with the young person. Agenda setting can be as simple as
offering the choice of what to discuss first: “Would you prefer to talk first
about marijuana, alcohol, or what’s going on in school?” A more thorough
approach involves eliciting the young person’s view of their concerns, by
inquiring about the issues he or she would like to discuss. You can then
also mention what you might like to talk about, and come to an agreement
with the young person about the initial decision of where to start. Certain
open-ended questions can be particularly helpful for eliciting information
from young people who do not perceive themselves as having a problem.
These questions center on inquiring about other people in the person’s life
and take the focus away from the young person. For example, questions you
can include are “What has happened that other people think you need to be
here?” or “What is it that other people are concerned about?” or “What do
other people hassle you about?”
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TIP FOR AGENDA SETTING: ASK PERMISSION
A primary strategy for conveying MI spirit in all encounters is to ask for

permission before starting. Not only does asking permission show you
are respecting the young person’s autonomy, but also it serves to increase
engagement as it requires the young person to verbally agree to participate.
This can be done as a preface for conversational tasks: “If it’s OK with
you, I would like to find out more about your substance use.” It can also
be done more formally for more intensive tasks, such as written activities.
For example, “Would you be willing for us to write down the behaviors we
just agreed to focus on in our sessions?” Of course, the young person can
always choose not to engage (i.e., respond with a no response after you ask
for permission). While this type of response can initially appear to be more
than disappointing (for you), it is ultimately more likely to increase alliance.
When young people see how you respect their decision not to engage in a
task, they are more likely to believe in the collaborative spirit you are try-
ing to convey.
Â
TIP FOR AGENDA SETTING: USE VISUAL TOOLS
Visual tools are an excellent way to engage young persons, particularly

those who are less verbal. Examples include offering opportunities to draw
or create art about the future, while discussing goals or creating a spe-
cific list of the characteristics important to what they wish their life would
be like. An agenda-setting chart, originally described by Stott, Rollnick,
and Pill (1995) and further explicated by Rollnick and colleagues (Rollnick
et al., 2008), is a visual collaborative tool for brief medical consultations.
Channon et al. (2005) adapted the tool for teenagers with diabetes to com-
plete the twofold task of both agenda setting and developing a therapeutic
alliance. In this adaptation, you explain that to best understand how the
potentially problematic behavior fits in with the person’s life, the young per-
son can create a “sort of map” with different aspects of the behavior. The
map is completed as the session progresses and can include other aspects
of the young person’s life that may be of importance. You can make the size
of the circles reflect level of importance, and the circles can overlap as dif-
ferent areas of the client’s life may not be mutually exclusive. Other areas
of interest that may not be on the treatment agenda can be written outside
the circles. Figure 7.2 demonstrates a map from the case of Jenny strug-
gling with obesity.
After the map is complete, you and the young person may then col-
laboratively decide on the agenda and potential goals of treatment. During
this part of the process, you should consider focusing on short-term goals,
rather than only long-term outcomes. Short-term goals directly related to
What is important to Jenny?
Music
Fun with
friends
Approval Teasing
School
Pets
Eating good Weight loss
Freedom food
Being happy
School
grades Fights with parents
FIGURE 7.2. Agenda map for the case of Jenny.
the behavior (e.g., not smoking cannabis during the week) or indirectly
related to the behavior (e.g., increasing participation in after-school activi-
ties) may be initially more appealing than long-term goals (e.g., quitting)
and possibly more likely to lead to success. In addition, setting intermedi-
ary goals allows young persons to experience a sense of accomplishment
and success in making changes, which can also increase their self-efficacy
for continued engagement in change.
Focusing with Values
Focusing is about guiding the young person to determine what is truly
important to them and then setting an agenda accordingly. When deter-
mining priorities, ensure that values are part of the conversation. Include
autonomy supportive and value respecting statements—such as “Since we
are deciding what to talk about today, we should make it fit with how impor-
tant being strong is to you”—to ensure MI spirit is present in the agenda-
setting task. Including values in questions about the agenda can solidify that
the agenda is consistent with the values identified in the engaging process:
“I am wondering if you prefer we start with how you and your parents are
getting along or start with talking about smoking. Given your value of being
strong, which one of these would be most important to discuss today?”
Alternatively, if not addressed previously, you can check to see if the set
agenda is consistent with values: “We decided to talk about getting a job and
taking your HIV meds more consistently. I want to make sure this fits with
your value of financial independence in the future. Otherwise, there might
be something else you need to address sooner.”
Evoking
Evoking is the process of drawing out the youth’s own words about change
so that he or she advocates for change instead of you doing it for them.
In the evoking process, you build intrinsic motivation to change the tar-
get behavior or concern of focus. In MI, this is done by eliciting change
talk with specific open-ended questions and verbally reinforcing change
talk with reflections and affirmations, as described below. Remember from
Chapter 6 that change is driven by a person’s own desire (“I want to”), abil-
ity (“I could”), need (“I need to”), and reasons (“because”), as opposed to
those of someone else. The strongest change talk is commitment language
(“I will”) about steps toward change. Reducing counter-change talk is also
important as part of the evoking process as described in Chapter 5.
Evoking may run counter to the natural instinct to “help” youth by cor-
recting what you construe as flawed reasoning, poor decision making, and/
or by imparting unsolicited advice. This is known as the righting reflex and
often translates into premature problem solving and advice giving, which
prevents clients from being actively involved in the treatment process and
leads to other forms of disengagement (such as emergence of counter-
change talk and avoidance of between-session practice in other intervention
approaches). This dilemma is often faced when providing other treatments
that highlight education about a mental health problem, followed by skills
training. MI strategies support the client’s own motivation for change, even
when the practitioner is sharing relevant information or skills training, and
is the rationale for using Ask–Tell–Ask.
In summary, the goals of the evoking process are to address ambiva-
lence and build motivation for and commitment to change by recognizing
change talk and reinforcing it, eliciting it when it’s not spontaneously pres-
ent and drawing out the youth’s ideas about change instead of problem solv-
ing for them. While specific strategies to do this are fully described in the
previous chapter, here we want to emphasize the importance of giving due
attention and time to this stage of the process. We have found that many
practitioners skip and/or gloss over the evoking process and prematurely
move from focusing to planning. It is absolutely critical for you make time
for evoking, even if the young person is making plans for change because
the verbalization of change talk is associated with an increased likelihood
of actually following through with the plan (Walker, Stephens, Rowland, &
Roffman, 2011). If the youth doesn’t say it—you can both plan on change
not happening.
Exploring incongruities between the young person’s values and cur-
rent behavior serves to elicit change talk. From the engaging process, you
should already have clues to the youth’s values that you can clarify with
reflections: “It is really important to you to be independent.” You may now
follow with an open question to develop discrepancy: “I wonder how tak-
ing care of your health might fit with this value of being independent.” The
young person may then explain, “When I get sick, I have to rely on other
people more.” You may also explore how not changing will interfere with
their value: “I wonder how missing your medications might interfere with
this value.”
The desire to be an adult or be treated as an older person can often
serve as a powerful motivator for the young person, especially when the
consequences of the current behavior result in being treated more like
a child (e.g., being forced to come to treatment, being placed in juvenile
detention). A double-sided reflection can allow you to highlight the discrep-
ancies in one succinct statement and can be particularly useful with young
persons who prefer brief feedback (e.g., “On the one hand you value making
money, and on the other hand, your drug use has you spending more than
you can afford”).
Â
TIP FOR VALUES QUESTIONS: DISCUSS THE BALANCE
BETWEEN SHORT-TERM NEEDS AND LONG-TERM VALUES/GOALS
It is key to express empathy for conflicts between short-term needs (man-

aging stress) and long-term values and goals (having a family, maintaining
employment). You may even demonstrate this discrepancy with empathy:
“It must be hard knowing that eating sugary foods satisfies your hunger,
and it can mess up your diabetes in the long run.” You can then elicit the
young person’s ideas for change: “I wonder if there are foods that might
meet both these needs—managing hunger and keeping your blood sugar
under control?”
You can also inquire about the effects of unsuccessful change attempts
(actual or hypothetical) and how these may be related to important, but
often neglected values. For example, in the case of Sofia struggling with
smoking, the practitioner explores how past attempts to cut back diverged
from her value of having fun with friends (e.g., avoiding social gatherings
where friends hang out and smoke). Addressing values in alternate ways
can promote discussions about change.
P ractitioner: You mentioned having fun is really important to you. I

am wondering if one reason you have not been able to quit smok-
ing in the past is because it messed up your fun. [Reflection of
value]
Sofia: Yeah. I started to stay home more because I was trying to cut
back on smoking. I would not go out with friends because I was
afraid I would smoke with them.
P ractitioner: It makes sense this did not work because you were not
following what is really important to you, having fun with friends.
I wonder if there is a plan that would allow you to go out with
friends and still quit smoking. [Action reflection]
Sofia: If there was, I bet I could follow it a lot better. [Change talk]
Planning
If ambivalence is the balance between remaining in the realm of the current

status quo and making a change, the planning process can be considered to
occur when the balance begins to tip toward effort to make a change. The
conversation naturally turns to statements about a possible commitment to
change and a discussion of options for a plan of action. Your goal in the plan-
ning process is to guide the young person to determine a reasonable next
step toward change, consistent with their expressed importance of chang-
ing or confidence to change that is consistent with their values. Examples
of these steps can look like an action step, engaging in a plan to research
change options, and simply attending the next session for further discus-
sion. In the planning process, you will elicit the young person’s ideas about
the specific details of the plan in terms of the whats, wheres, and whens;
discuss plans to overcome possible barriers; and then incorporate MI strat-
egies to help the youth commit to the plan.
Recall, if you move too fast and jump to premature planning in any of
the processes, you have fallen into an MI trap and essentially compromised
a golden opportunity for your client to discuss their next step along the
change process. Below, we provide a guide to prevent falling into the pre-
mature planning trap (or at least not stay in the hole for too long) and offer
key considerations for how you and the young client can collaboratively pro-
ceed along the planning process. Special attention is given to how you can
know when you have adequately explored motivation for change and are
ready to move to the specifics of change planning, along with how you can
consolidate commitment to a change plan.
Listen for Change Talk of Increasing Strength

The best way to consider when to move to the planning stage is to listen
to the young person. As previously described, you will be listening for both
change talk and sustain talk, while focusing your attention on the frequency
and intensity of change talk. At this point in the process, you hope to hear
commitment language of increasing strength. The strongest change talk
you will hear is termed commitment language. Examples include “I am
ready to lose weight”; “I am willing to cut back on my drinking”; and “I will
consider taking my medication.” Even stronger is commitment to a specific
action, with stems such as “I will . . . ,” “I am going to . . . ,” and “I swear
. . . ” Of course, you will always reinforce any commitment language by
reflecting and asking for elaboration, as these statements are the pearls in
the ocean of change talk.
A key difference between MI and more directive approaches is that
an MI practitioner both elicits and waits for commitment language, before
developing a plan for change, whereas a more directive practitioner quickly
moves to change plans or problem solving early in the encounter. For exam-
ple, if the young person makes statements beginning with commitment lan-
guage, such as “I’m going to do something about this problem” or “This
is what I know I can do,” this suggests he or she is ready to discuss plan-
ning for change. In contrast, statements offering less robust commitment
to change, such as “I think I might try,” signal to you they are continuing
to experience ambivalence that should be explored further to evoke more
consistent and commitment language, moving to a specific change plan.
Listen for Diminishing Counter-Change Talk

Counter-change talk should be diminishing (though it may not disappear!)
with the increase in change talk and commitment language. Counter-
change talk may reemerge when discussing the specifics of a plan for
change. We have learned that, especially with young people, backtracking
to counter-change talk happens often in the face of commitment. With con-
tinued counter-change talk, any efforts you make to guide the person to
plan for change will be futile and could lead to discord. Instead, your task at
this time involves backing up the conversation, rolling with resistance, and
further exploring ambivalence. Perhaps redefining the goal may be neces-
sary (e.g., eating more fruits and vegetables instead of cutting calories).
However, ambivalence does not have to be completely resolved before mov-
ing along in discussing a change plan. For example, some behaviors are not
intrinsically pleasurable (such as coming home at curfew) and may always
elicit feelings of ambivalence (“I hate this, but I’ll be home on time”). What
matters is that the young person expresses change talk that is increas-
ing in strength—to the point where commitment emerges. You can reflect
that ongoing ambivalence is a natural part of the journey of change. In our
case of Travis, counter-change talk remerges when he starts committing to
abstinence. Of course, if counter-change talk continues, you may need to
revert to other MI skills, such as those in Chapter 5.
T ravis: I know I need to quit, but I don’t know that I am ready to totally
stop partying! [Change talk followed by counter-change talk]
P ractitioner: You really want to make this change, and it will be
easier if you can find some ways to have fun while you are cutting
back. [Action reflection to pave the way toward a change plan]
In this next example, the practitioner empathically reflects the difficulty of

having to take daily medications but does not stray from reinforcing com-
mitment language and moving toward a plan for change.
Eugene: I have to stop missing my medicine if I don’t want to get sick,

but I still hate thinking about taking it every day.
P ractitioner: You seem really committed to making this change for
your health, and of course you will never enjoy taking medicine
every day. What ideas do you have that might make it easier?
[Reflection and question for change plan]
Transitioning from Evoking to Planning

When you hear increasing change talk and diminishing counter-change
talk, or when the session is wrapping up and you need to plan for the next
session, use a summary to transition to the planning process. This sum-
mary first synthesizes the ambivalence discussions, highlights the strength
of the commitment to change, and ends with a key question. In the case of
Sam, the practitioner summarizes as follows:
We have talked about a lot of different things about being social and drinking
to relax. You said you don’t think you have a problem with your drinking and
don’t mind staying home, but you want to have a family in your future. You
aren’t interested in becoming a different person, but you want to consider
tackling your fears slowly. What do you think you’ll do next?
Key questions are focused on guiding the young person to explore how
he or she might go about change and engage in next steps. In addition,
key questions allow you to test the water when you are unsure whether
it is the appropriate time to transition and begin discussing a change plan.
Examples that understate commitment if some ambivalence is still noted

include “What else might you do?” and “What do you think is your first
step?” A key question for a young person expressing strong commitment
language might be “What are your plans for next week?”
If the young person’s response to the key question is reminiscent of
counter-change talk (i.e., “I’d like to but . . . ”), it may be premature to move
to a plan focusing on behavior change. Alternatively, some remaining ambiv-
alence should be expected, and your main task at this stage is to reflect it. Of
course, if sustain talk continues, you may need to revert to earlier MI skills.
To continue the example of Sam, the dialogue below offers some ambiva-
lence about next steps, and the provider offers guidance of options along
with a key response to signal his choice in the change planning process.
Sam: Well, I am not sure how to get started.

P ractitioner: You are thinking about making a change to be more
social without relying on alcohol, but you are not sure how to
begin. Some people find it helpful to work out a plan for mak-
ing a change in small steps. If you are interested, we can talk
about some options and write down what steps there might be and
how you might want to start. [Reflection and elicit permission for
change plan]
Â
TIP FOR TRANSITIONING TO THE PLANNING PROCESS:
CONSIDER POSTPONING CHANGE PLANS IN THE FACE
OF HIGH EMOTIONAL INTENSITY
Young people may express varying degrees of emotional intensity based

on internal processes (e.g., hormones) and external stimuli (e.g., friends,
family). For example, a young person may be leading up to a change plan, as
demonstrated by increasing commitment language and decreasing sustain
talk across sessions. However, if he or she has an argument with a parent or
a breakup with a boyfriend/girlfriend right before the session, it may be dif-
ficult to engage the young person in the planning process at this time. The
situation evoking this intensity may be tied to reasons for change, but the
rational change planning process may best be put on hold until the young
person feels less charged. Asking any of us, and especially a young person,
to plan for an important change when they are emotionally frazzled is a
waste of their time and yours.
Developing a Plan
Guiding young people with MI to plan for change takes courage. You need
to understand their motivation while making sure to elicit and reinforce
commitment language. Exploring a menu of options while eliciting specific

implementation plans is critical to success (Gollwitzer, 1999). In MI, this is
accomplished via forming a change plan, a map for change where the young
person draws in as much detail as possible to diminish the likelihood of
getting lost.
Components of the Change Plan

We next turn to the specific components of the change plan, including
sample questions to elicit specificity and issues to consider during this dis-
cussion (see Table 7.2). The components include setting a goal, delineating
steps to reach that goal, reviewing reasons to reach the goal, identifying
potential barriers, and deciding on what to do to overcome barriers. After
these steps are completed, you affirm the young person’s ideas, boost self-
efficacy with statements of hope and optimism, and summarize.
Although we present the change plan process in a logical and stepwise
manner, not all steps will necessarily be completed in any one encounter,
and the order is flexible. Much akin to the skill of learning a new musical
instrument, you should not expect the young person to be able to play a con-
certo or be able to engage in an entirely novel repertoire of behaviors after
completing one single change plan. However, a guiding style will allow you
to collaboratively map out possible paths toward change, consistently using
person-centered counseling skills in an autonomy-supporting environment.
Again, motivation to change is not static. The reemergence of sustain talk
is common, especially in the face of practitioner enthusiasm for change and
goal setting beyond the person’s readiness. Thus, you should continue to
balance all questions with reflections and continue to proceed cautiously,
emphasizing personal choice and responsibility.
Here is an appropriate time to offer information or advice (with per-
mission) in a guiding style as young people may not have all the necessary
resources to fully consider all their options for a realistic change plan. We
find the Ask–Tell–Ask strategy (see Chapter 3) useful for offering a menu
of options for change. For example, in the case of Jenny, the practitioner
might begin, “If you’re interested, I can share some things other teens have
tried.” With Jenny’s permission, “Some people have started by adding a new
fruit each week, others have tried to switch out Coke for water, and others
have decided to limit the number of times they eat fast food in a week. What
ideas do you have about specific steps to get started?” If the young person
chooses one of the options you suggested, highlighting the fact that it was
their choice is key to fostering individual autonomy. Emphasizing the word
you is helpful. “Jenny, you want to start by drinking water instead of Coke.
What meal would you like to start with for now?”
The key to developing a change plan in the spirit of MI is balance:
TABLE 7.2. Components of a Change Plan

Change plan
component Examples Issues to consider
Set a goal. “What, if anything, would Are goals reasonable,
you like to work on for attainable, and consistent with
next time?” motivation to change?
“Based on what we talked Have you discussed
about today, what would intermediary goals, such
you consider to be a as thinking about behavior
personal goal?” change or issues of attendance
and participation during the
encounter?
Decide on steps to “What steps do you need to Are you falling into the expert
take to reach the take to get started?” trap?
goal.
“When would be a good Have you slipped into a
time to start?” paternalistic mode and
“warned” the young person
about issues he or she should
be discussing?
Are you more enthusiastic

about change than the young
person?
Develop if–then “What are some things that Is the young person overly
plans. might get in the way of optimistic and not realistically
this plan?” considering barriers?
“What are some things you Can you provide a menu of
can do if that gets in the options while remaining
way?” optimistic?
“What are some strengths Can you avoid drops in
you have to overcome confidence when discussing
these barriers?” barriers by eliciting change talk
around the plans to overcome
them?
Summarize, “You made a great plan Use the summary to solidify

including with specific steps A, the plan, and add in any missed
expressions of B, and C, and specific steps. Be careful not to repeat
hope and optimism, plans to overcome any any change talk questions when
and consolidate barriers, such as X, Y, eliciting commitment language.
commitment. and Z, to make sure you While it is critical to verbalize
can really do this. Why is commitment in this final
it important to you to try process, be creative in how you
to follow this plan next ask these questions to avoid
week?” annoying repetition.
balance of eliciting the young person’s ideas with offering information or

advice, balance of your use of questions and reflections, and balance of your
expressions of optimism and hope with the development of realistic and
attainable goals.
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TIP FOR CHANGE PLANS: INCREASE SPECIFICITY OF THE CHANGE PLAN
In the above scenario, the practitioner also asks for more specificity to
consolidate commitment, as the likelihood of success increases when you
guide the young person to make a concrete and doable plan. The discussion
of potential behaviors the young person will perform in the face of particu-
lar barriers to the goal will also consolidate commitment. We call these
if–then plans. Do not hesitate to use your expertise (with permission) and
offer options for these potential barriers once you have elicited all barriers
from the young person, as doing so increases the specificity of the plan.
P ractitioner: Jenny, you have made a great food plan. You have set
out the types of foods you want to eat and the types you want to
avoid, and have a plan for three meals and two snacks at basically
the same time every day. Thinking about your day-to-day life,
what kinds of things might get in the way of following this plan?
Jenny: I don’t know. I’m just gonna do it if my mom doesn’t harass me.
P ractitioner: Would it be OK with you if we review some things that
other teenagers have told me get in the way of food plans?
Jenny: Sure, I guess so.
P ractitioner: Some people have a hard time when their mom doesn’t
buy the things on their plan or when she buys a bunch of stuff not
on the plan. Other people have said that eating at the same time
is really hard on the weekend when there isn’t a set schedule. Is
either of these something that might happen, or maybe you have
some other thing?
Jenny: Definitely the mom thing! The weekend maybe too.
P ractitioner: Would it be OK if we did some more planning around
this? Like if this happens, then you’re going to try this.
Â
TIP FOR CHANGE PLANS: GOALS SHOULD BE CONSISTENT WITH LENGTH
OF INTERVENTION
Some behavior change goals require many steps and barriers to overcome
(such as weight loss). Others may be reasonable in a very brief interven-
tion (such as join a gym). For broad behavior change goals, consider more
intensive treatments (see below) and consider guiding the young person to
develop a change plan for engaging in those treatments (either with you or
with another practitioner).
Verbal and Written Change Plans

A change plan can be prepared verbally or via written methods. We suggest
your choice of strategy be based on the young person’s individual needs.
Similarly, we recommend you not limit yourself to one modality or the other
(even during the context of one encounter), as both lead to the same goal of
collaborating with the young person about a specific change plan. In short,
your overall mission is to be flexible, incorporating whichever strategy (or
combination of strategies) the young person best responds to while discuss-
ing the change plan.
Change Plans for Young People Not Yet Ready to Change

You may find you are a better guide when you use the change plan process
at the end of each session, even when the young person is not yet ready
to make major changes in behavior. In this case, options include making a
small change (such as cut back one cigarette a day), thinking about change
(such as talk to a friend, search information on the Internet), or coming back
for another session with you or someone else. However, you should always
offer the young person the option of skipping the change plan discussion
in these cases. It is especially important to tread carefully in this water,
as you may unintentionally create a situation that elicits a decrease in the
young person’s motivation by asking for change when he or she is clearly
not ready. Incorporating reflective statements to demonstrate your under-
standing of the young person’s continued ambivalence can help to guard
against this situation.
Note the balancing of reflections and questions in the next dialogue
with Travis.
P ractitioner: We are about finished with our time today, and this is
when you might consider setting a goal for yourself. I understand
you are not yet ready to make a change. If it’s OK with you, we
can set a goal around something you are ready to do. What do you
think about that? [Ask permission]
T ravis: I am not sure what you mean because I am not going to quit
drinking.
P ractitioner: Well, your goal could be about the Adderall, another
area of your life like school or friends, or to think about our
discussion today, or maybe just to come back next time. [Tell]

What do you think? [Ask for feedback]
T ravis: I guess my goal could be to come back next week to get my
parents off my back.
P ractitioner: You would want to come back next week. [Reflection]
What would it take to get you here? [Open-ended question]
T ravis: Well, we have to set up a time that will work for me, and I have
to figure out a way to get here.
P ractitioner: That’s great you have some thoughts about how to
reach your goal. [Affirmation] If we set up a time that works for
you, how will you get here? [Elaboration]
T ravis: I guess I can ask my parents or take the bus.
P ractitioner: You have some transportation options. [Reflection]
What might get in the way? [Open-ended question]
T ravis: If I am hanging out with my friends, I won’t want to come. Or
if I have a fight with my parents, I may want to skip it to make
them mad.
P ractitioner: If you are with your friends or get mad at your parents,
you might not feel like coming. [Reflection] How could you over-
come these barriers to reach your goal of attending next week?
[Open-ended question]
T ravis: I am not sure. I guess I could make sure I don’t see my friends
before our meeting and maybe not my parents either. Maybe I
should try to come right after school is out.
Additional Strategies to Consolidate Commitment

As noted earlier, in the change planning process itself, the articulation of
specific plans for change and verbalization of implementation intentions
helps to consolidate the young person’s commitment. When summariz-
ing the change plan, you must continue to include reflections of previous
change talk (“As you said, now is probably the best time to do something
about your problem”), and ideally use mainly open-ended questions that
directly elicit commitment language. As described in Chapter 6, there are
several strategies you may adapt for use in eliciting and consolidating com-
mitment language. You can try direct open questions to elicit commitment,
such as “Why do you feel this is something you must do?” or “Why do you
feel now is the time for a change?” You can use a ruler in several ways, such
as guiding the youth to articulate a rating of their commitment score, on a
scale from 1 to 10 (as commitment should not be a 1 or 2 at this stage) or
addressing confidence as in the example below.
P ractitioner: You have lots of ideas about how to make this happen.
How sure are you that you are going to follow through with this
plan? Sort of sure, very sure, or I’m totally in without a doubt
sure?
Sofia: I am pretty sure I will do it.
P ractitioner: You have some confidence in the plan. What makes
you pretty sure?
Sofia: Well, I know my asthma will get worse if I don’t, and I really
don’t want to keep going to the hospital. I have things I want to do.
P ractitioner: This plan is something you are thinking you will follow
through on because you think it is important for your future. It’s
not about what your parents think. What would it take for you to
be even more sure?
Following up with a question, such as the above dialogue with Sofia, can
help to elicit other potential barriers for discussion. Similarly, consolidat-
ing commitment can be enhanced by asking the youth to visualize and
talk about their vision for how the change will occur, along with what their
future might look like (e.g., “What does your future look like after you make
this change?”).
Planning with Values
Guiding the young person to develop a change plan consistent with their
personal values and goals, as well as motivational readiness, is critical to
the planning process. As in the focusing process, autonomy-supportive and
value-respecting statements (such as “Since you are deciding what plan you
want us to make, be sure to make it fit with how important being strong
is to you”) ensure the MI spirit remains a central component that is pres-
ent in the actual planning process. Including values in questions about the
next steps can ensure the plan is consistent with the values identified by
the youth in the engaging process. “I am wondering what steps you want
to take next that fit best with your value of spending time with friends.” If
not previously addressed, you can also check to see if the plan is consistent
with values:
You decided to make a plan to take your HIV meds more consistently, and
wanted your mother to remind you. I want to make sure this plan fits with
your value of being independent. While getting help from family does not
make you dependent, I want to make sure your mom’s help won’t interfere
with your own independence. If it fits, great; if you’re not sure, we can include
other ideas on your list as well.
Summary
We have reviewed how MI spirit and skills are organized into four pro-
cesses: engaging, focusing, evoking, and planning. While there is some logi-
cal order to these processes (engaging is the foundation; planning is nec-
essary for one to maintain), the processes are overlapping and recursive.
Understanding values and developing values–behavior discrepancy have
always been central components of MI, and we have further highlighted
their importance and many of the intricacies involved to incorporate values-
based strategies within each process with young people. Table 7.3 sum-
marizes the processes in terms of dos and don’ts, and Table 7.4 describes
adaptations for specific populations. In the next chapter, we turn to what we
believe is a fifth process, maintaining motivation, and how you might inte-
grate other intervention approaches once motivation is initially established.
TABLE 7.3. MI Processes Dos and Don’ts

Do Don’t
Look before you leap. Explore values Dive straight in without a peek. Jump to
and goals as the foundation of the MI problem solving or other traps promoting
encounter. disengagement.
Focus on values. Create a shared agenda Present your agenda only. Present an
consistent with the young person’s agenda or rationale for the treatment
values. focus based on your values/goals.
Take your time. Always take time to elicit Rush planning. Minimize the evoking
change talk as verbalization of motivation process because you think the young
increases the success of behavior change. person is ready for change.
Steadily guide processes. Elicit Ambush with your expertise. Fall into the
conversation consistent with youth expert trap by offering what you think is
values; present and offer a menu of best without youth’s permission.
options with permission.
Test the waters. Elicit barriers to change Avoid uncomfortable topics. Be afraid
and guide young person to make “if– to bring up potential obstacles (with
then” plans. permission).
Foster hope. Express hope and optimism Be overly enthusiastic. Be overly

about young person’s ideas and abilities to enthusiastic about specific changes in
make specific changes. behavior, as drawing out youth’s own
optimism better maximizes their change
efforts.
TABLE 7.4. Tips for Processes with Special Populations

Criminal justice
Require extra time to establish Highlight “You are tired of feeling taken
rapport when initially placed MI spirit of advantage of by everyone and
in residential/juvenile justice compassion and continue to hang in. What are
placements, and offer examples of elicit strengths. some things keeping you going?”
“deviancy” to make trust issues
with new providers well known: Use of closed- “After everything that is going
“You’re just like my baby’s momma ended questions on you really need some peace. I
and the judge who put me here the and providing am not going to ask you anything
last time. Both of them are liars, information until you help me figure out what
and I’m not ever getting gaslighted (even with you really want.”
again. Twice was enough—you Ask–Tell–Ask)
won’t be my third ‘lucky charm.’ can fall into
When there’s smoke—I run the assessment
quicker than any gas can try to trap and expert
ignite my flame. And—did you read trap. Refrain
my file yet?—you’ll see what I can from these
really do when people piss me off.” utterances until
engagement
Be silent, sullen, and wary, is fully
especially in the face of questions established.
or information/advice: “WTF! Support
I’m so tired of everybody asking autonomy while
me questions and giving me establishing
information. I thought I might get initial focus.
some peace when they locked me
up.”
Eating disorders
Avoid expressing personal fears Develop “Despite what others do, you
about appearance and instead shared focus stay focused on complying with
focus with dislike or distrust of on complaints what you, your parents, and the
the program: “The docs at the against the treatment team have agreed
hospital—they eat all of the time— system and upon. You are frustrated with all
outside of my room—always—like address the eating around you and maybe
it’s a food fest party for them all emotional a little scared about what will be
the time. It’s disgusting. And this reactions to happening while you are here.
system is so stupid. I could figure it weight changes. I wonder if we could talk about
out if I didn’t have all these rules.” Express some options to manage all this.”
empathy
Feel autonomy severely restricting, with gentle “It is really up to you whether
in turn promoting discord— reflections of you follow the treatment plan and
especially in planning process feeling. get out or whether you don’t. I
will be here for you either way.
Be creative I wonder where we could find
in finding some choices in the plan, like
choices within whether you would rather eat
the planning your own food or use some meal
process. replacements.”
(cont.)
TABLE 7.4. (cont.)
Offer ideas about the “whys” Remember that even if “You have many things to
and ideal outcomes of change you evoke seemingly look forward to once you get
efforts you and the treatment “unrealistic” goals, done with speech therapy. If
team may think aren’t realistic: these can still be it’s OK, tell me two things
“I’m going to get the prize at levers for change. You you can do to make sure you
the Scrabble competition with can use more general finish the speech therapy and
a 10-word win and be a sports language if you are are able to do great things in
announcer for the WWE after concerned about the future.”
I’m done with speech therapy!” reinforcing unrealistic
reasons for change. “I am sorry if the plan is
Appear “lost” when new confusing. Maybe you pick
collaboratively agreed-upon Make planning simple one thing to work on for next
schedules and goals are set in with just one or two week. We can find some
an overly detailed and non- concrete steps, and pictures for the different
developmentally sensitive it may be OK to skip steps for this goal.”
manner: “I have no clue what the if–then plans if
you are talking about.” the young person is
not developmentally
ready for that kind
of thinking (can be
done with caregiver
or by providing one
or two ideas with
permission). When
giving a menu of
options, do not provide
too many options.
Apologize if you
created confusion.
Consider visual tools.
Sexual health
Demonstrate incorrect Refrain from “You’re not sure you need

information right away in the correcting to be here. Maybe we can
engaging phase: “I really don’t misinformation too talk more about what’s going
need to hear anything. I heard early. Ethically, you on with you and then we
if you are a top, then you really may need to correct can talk about the safe-sex
aren’t at risk, so I don’t need to before the young information later.”
worry.” person leaves your
office, but you can “You have had a lot of
May want to shock you as a engage first. different experiences in your
way of distracting from target life, and you want to share
behaviors: “I’ve been having Continue to set a them with me. We can add
sex since I was 10. I love it, and collaborative agenda that to the agenda. I also need
I like having sex at least several and reframe the to go over your test results.
times a day. So what did you shocking statements Which would you like to
want to talk about today?” as the young person discuss first?”
wanting to engage.

Opiate addiction
Express desire to revert to “old Engage with empathy, “You have overcome so much,
habits” and reunite with social acceptance, and and it is still a journey. You
connections supporting risking affirmation. could do better if we can
gains made during change figure out a way to make your
processes: “It’s crazy—my Provide action friends stop texting and tempt
buddies texting me all the time reflections to evoke you away from the great
. . . asking when am I going to change. future you have planned.”
start selling again. I’m trying
really hard now to stay clean, Find the change talk “There’s a lot on your plate
but all this pressure is too in the context of right now. Focusing on one
much. It’s making me want to all the pessimism. priority at a time and setting
get high all the time—even Continue to offer hope a planned course of action
more than before. I’d really and optimism but without distractions makes
like to just go back to the not at the expense of most sense to you. You really
community college again and expressing empathy. are thinking this through!”
get my pharmacy degree. I’ve Selectively reinforcing
learned some stuff that might change talk allows
help other kids like me.” affirmations of small
wins to be more easily
Display exaggerated excess heard by the young
of emotions and aggressive person.
behavioral reactions when
experiencing side effects of
opioid use and fears previously
avoided responsibilities that “all
must quickly” be completed in
an unrealistic time frame: “I
can’t believe I have all of this
stuff to catch up on—I only
used for 6 months. My auntie’s
going to kick me out if I don’t
pay my rent by the first of the
month, and I am still in a lot of
pain.”
Practitioner Activity 7.1. MI Processes
Activity Goal: To develop open questions for each process
Activity Instructions: Review the goals for each process in the chapter. Then
review the examples below of open-ended questions for each process and add
your own. Try this toolbox as a general script in a role play, making sure to reflect
change talk and address counter-change talk and discord as it emerges. Balance
reflections and questions so you do not ask two questions in a row.
Your MI Toolbox
Remember to:
• Express empathy
• Emphasize autonomy
• Reinforce change talk
• Summarize every few points and when transitioning between processes
• Use Ask–Tell–Ask if necessary
Open questions that work for engaging:

Example: “What is most important to you right now?”
Example: “What have you been up to since the last time we met?”
Example: “What would you like to get out of this session today?”
Your example:
Your example:
Open questions that work for focusing:

Example: “Of all the different things you mentioned when it comes to [tar-
get behavior], what would you find most helpful to discuss first?”
Example: “If it is OK with you, I want to discuss [target behavior]. Or is
something else more pressing to you at this moment?”
Example: “If you were going to change one thing about [target behavior],
what would it be?”
Your example:
Your example:
Summarize!
Open questions that work for evoking:

Example: “Of all the different things you mentioned when it comes to
[target behavior], what would you find the most helpful to discuss first?”
Example: “What are some reasons for changing [target behavior]?”
Example: “What would be the best thing that would happen to you if you
changed [target behavior]?”
Example: “On a scale from 1 to 10, how confident are you that you can
make this change? Why did you pick that number and not a lower num-
ber?”
Your example:
Your example:
Summarize!
Open questions that work for planning:

Example: “What steps are you willing to take, in the next week, to reach
your goal?”
Example: “When and how will you start your plan?”
Example: “What might get in the way of your plan, and how will you han-
dle it?”
Your example:
Your example:
Remember final summary (using the person’s own statements, in any order):
• Review where client started.
• Review where client ended.
• Emphasize autonomy.
• Reflect commitment language or change talk.
• Include affirmation.
8
Maintaining Change
You have to fight a battle more than once to win it.

—M argaret T hatcher
In this chapter, we discuss how to respond to positive changes, how to

respond when changes have not been maintained, how to integrate other
treatment approaches once motivation to change is established, and how to
address issues around termination. Miller and Rollnick (2013) subsumed
the process of enacting and maintaining change within the planning pro-
cess; however, we consider maintaining to be a process in its own right,
especially as you integrate other interventions (Naar-King, Earnshaw, &
Breckon, 2013).
Following Up on Planning
Change is a journey that one travels throughout the life span, and the old
notion of two steps forward and one step back often prevails. Any progress
the young person makes toward healthy behavior change or goal achieve-
ment, however miniscule it may appear to you, represents movement in a
positive direction. Make sure to reflect this and provide affirmation while
avoiding overenthusiasm. Young people may find it helpful and rewarding
to review situations in which they might have previously engaged in the
problem behavior but avoided it. Reinforce self-efficacy by asking clients to
clarify what they did to cope successfully in these situations. Offer affirm-
ing reflections to reinforce clients for small steps, little successes, and even
minor progress (“shaping”). Consider exploring what contributed to the
success and how to continue those facilitators. Review the client’s goals
and change plan and collaboratively make changes accordingly as needed,
and always in collaboration with the client. Consider reminding or expand-
ing change talk for initial change, eliciting and reinforcing change talk for
maintaining changes, and continuing to refine if–then plans. For example:
128
Maintaining Change 129
• “What are some reasons that it would be important to continue this

process?”
• “Why might you want to continue staying away from smoking after
your asthma gets better?”
• “What positive things have you noticed since you stopped drinking
that you might want to continue after probation?”
• “What new barriers have come up that you might need to plan
around?”
If the change plan was less successful in that goals have not been fully
met, it is especially important to respond to difficulties completing the
change plan with empathy and a nonjudgmental stance. If the client engaged
in a behavior inconsistent with their goal since the last session, discuss how
it occurred. Consistent with the MI style, do not prescribe coping strate-
gies for the client. Rather, use this discussion to renew motivation, eliciting
from the client further change talk statements by asking for the client’s
thoughts, feelings, reactions, and realizations.
Perhaps the most important tenet of the maintaining process is to avoid
the term relapse. Miller and colleagues argued that using the term relapse
assumes there are only two states regarding maintaining change: success
or failure (Miller, Forcehimes, & Zweben, 2019). The true course of mainte-
nance of behavior change is a process of ebbs and flows, with returns to an
ambivalent, preintervention behavior being highly variable in frequency and
intensity. Thus, in MI, the practitioner avoids the terms lapse and relapse.
Instead, the goal of the maintaining phase is to express empathy about the
difficulties of maintaining changes in the context of temporary setbacks or
slips, elicit the client’s perspective on temporary slips, evoke change talk
specific to maintaining change, and support autonomy and choice in making
plans to address triggers. Consider revisiting values clarification if values
have changed following behavior change. As described in the evoking pro-
cess, use values to evoke change talk in the client about maintenance, such
as “I am going to continue to . . . ” or “I am not going to go back to the way
things were.” If slips occur, think about whether the change plan should be
revised to be consistent with current values. Finally, consider key questions
to renew commitment (e.g., “So what does this mean for the future?”; “I
wonder what you could try next time?”).
Integrating MI with Other Treatments
Other interventions may be integrated after the young person is moti-

vated for change to support maintenance. MI provides the platform for
good therapy process regardless of the specific intervention framework
you may be using. Of course you may want to add other ingredients either
by following a recipe (e.g., a manualized treatment) or by adding treat-
ment strategies from whichever theoretical background you practice. The
majority of studies demonstrating the efficacy of MI integrated with other
behavior change methods for young people have focused on behavioral and
cognitive-behavioral treatments (Naar & Safren, 2017; Suarez & Mullins,
2008). Below we provide a summary and examples of applications for how
we believe MI can be integrated within the two predominant behavioral
modalities used with young populations, specifically, cognitive-behavioral
interventions and extrinsic motivation approaches.
Cognitive-Behavioral Treatments and MI

CBT focuses on teaching the young person specific skills (e.g., coping,
problem solving, assertiveness training, self-monitoring, cognitive restruc-
turing, mindfulness, distress tolerance) and incorporates specific assign-
ments to facilitate the acquisition and generalization of skills to the young
person’s natural environment. The underlying premise of CBT suggests
that young persons have a skill deficit, and if they are taught and learn
certain skills, they will then be able to improve functioning and experience
less psychological distress.
Briefly, in CBT the practitioner determines which skills to target by
completing a functional assessment of the antecedent interpersonal and
environmental factors that promote or sustain the young person’s problem-
atic responses (including both intrusive cognitions and behaviors). This is
usually done in an interview format (typically a series of questions). While
the importance of collaboration about goals is an important component of
any CBT, the emphasis on relationship factors is not a central focus for the
practitioner. Rather, the emphasis is on the teaching and use of skills. CBT
can be an important adjunct to MI, particularly in young people who may
not have fully developed the skills necessary for behavior change. Indeed,
when CBT is conducted without MI spirit and skills, the client may not
engage in the work necessary for skill attainment and perhaps will actively
resist such change.
When delivering CBT, you may integrate MI in several ways (see Naar
& Safren, 2017 for more details). You may use MI at the onset of treatment
to elicit motivation for behavior change in general and for treatment partici-
pation. You may use MI to make the assessment less like an interrogation,
using open questions and reflections. You may use MI to collaboratively
develop a treatment plan. You may use MI to build motivation for skills
training and between-session practice (formerly known as homework—
we never use that word with young people). You continue to use MI as a
platform for delivering skills training collaboratively (Ask–Tell–Ask is your

best friend).
MI is especially helpful to address ambivalence that arises during
cognitive-behavioral skills training. For example, consider Sam who pres-
ents with a goal of reducing anxiety but is avoidant of committing to difficult
treatments (i.e., exposure to feared stimuli or the initiation of psychotropic
medications). At the onset of treatment, you might be able to reduce initial
ambivalence to anxiety treatments with the use of MI skills. After eliciting
and reinforcing change talk, the young person may agree to a change plan
that includes further treatment. However, as is common in clinical practice,
you may find after several visits that treatment tasks are not being accom-
plished (e.g., assigned practice for exposure or compliance with a medica-
tion regimen) or counter-change talk reemerged (“I am not sure all this
[exposure treatment] is worth it. It’s too hard”). You may use MI skills such
as stop, drop, and roll, eliciting and reinforcing change talk, and developing
discrepancy between values/goals. When you start to hear change talk of
increasing strength again and can reconsolidate commitment to the change
plan, you may switch back to skills training, still delivered from an MI foun-
dation.
The session outline below is one idea on how to integrate MI with CBT
in the maintenance phase.
• Discuss session agenda.

• Check in on previous week including assessment of outcomes (e.g.,
reviewing change plan and between-session practice completion,
administering objective measures if applicable).
• Complete brief functional analysis of change or lack thereof.
• Discuss rationales for treatment element or module.
• Elicit and reinforce change talk for behavior change and session
tasks.
• Complete session tasks (including expert modeling, guided practice,
behavioral rehearsal, and feedback for skills and evoking motiva-
tion).
• Develop change plan (including implementation intentions and if–
then plans and between-session practice.
Below is one idea for a modular integrated treatment for multiple target
behaviors or symptoms. See Naar and Safren (2017) for examples on how
to deliver such a treatment from an MI foundation.
Module 1: Initial motivational session

Module 2: Assessment and treatment planning
Module 3: Self-monitoring
Module 4: Cognitive skills
Module 5: Skills training (including problem-solving skills, behavioral
activation, distress tolerance, mindfulness and relaxation with or
without exposure, refusal skills and assertiveness training, com-
munication skills, and organization and planning skills)
Module 6: Maintenance of change
Extrinsic Motivation Approaches and MI

Many treatments for young people include strategies to target extrinsic
motivation. Examples include contingency management approaches (i.e.,
the young person receives monetary rewards or vouchers for abstinence
to substance use), token economies (i.e., the young person earns points for
compliance in inpatient or residential settings), and family behavior plans
(i.e., the parent provides rewards or punishments for the adolescent’s com-
pliant or noncompliant behaviors). Contexts and treatment settings operat-
ing from an extrinsic motivational system are often limited in the amount
of choice and decision-making responsibility afforded to the young person.
These typically mandated situations can increase the young person’s resis-
tance to treatment. The integration of MI into these settings holds promise
for improving engagement and personal responsibility.
Historically, extrinsic motivation and intrinsic motivation were
thought to be polar opposites, with the former undermining the latter.
However, Deci, Koestner, and Ryan’s (1999) research suggests otherwise.
That is, investigations about intrinsic and extrinsic motivation in young
persons have shown them to be separate phenomena, and not inversely
related (Lepper, Corpus, & Iyengar, 2005). Other researchers have pointed
to the additive effect of intrinsic and extrinsic motivational approaches (i.e.,
targeting internal motivators, such as achievement of personal goals, and
simultaneously using external motivators, such as offering monetary incen-
tives for goal attainment).
Targeting both aspects of motivation may have a synergistic effect.
You may tip the scale of ambivalence, even if temporarily, with an extrinsic
reward, while simultaneously using MI skills to promote the identification
of internal reasons for doing the new behavior (Carroll et al., 2006; Val-
lerand, 1997). We now give several examples of specific skills needed to
successfully integrate MI with extrinsic reinforcement approaches.
When you offer extrinsic reinforcers (i.e., money or extra time to
engage in planned activities, such as spending time with friends or playing
video games) without offering choice in decisions (i.e., in a controlling man-
ner), intrinsic motivation decreases (Deci & Ryan, 1985). In contrast, if you
offer extrinsic motivators in a more pro-choice fashion (informationally),
the target behavior is more likely to be internalized. We demonstrate this

difference with two examples. Although both begin with a reflection, the
first is a controlling approach while the second offers choice.
Controlling P ractitioner: So we’ve talked a lot about how you

need to finish off your probation hours. If it’s OK with you, I need
to review what I need you to do next.
I nformational P ractitioner: So we’ve talked a lot about finishing
off your probation hours. If it’s OK with you, I’d like to next talk
about options to finish off those hours and how I support you in
your choice.
You will continue to use stop, drop, and roll (see Chapter 5) for decreas-
ing the counter-change talk common in traditional extrinsic reinforcement
treatments, particularly those emphasizing consequences. In this way, MI
not only promotes internal motivation but also addresses the psychological
reactance expected from the young person in contexts that restrict behav-
ior and limit choices.
Examples of Stop, Drop, and Roll

Empathy: “You are really frustrated you have to deal with this point
system in order to be released from the hospital.”
Pros and cons: “What bothers you about this behavior plan? What are
some good things that could happen if you follow it?”
MI to Elicit Change Talk in External Motivation Approaches

Strategies to elicit change talk and solidify commitment may also be used to
build self-efficacy and promote intrinsic motivation in the context of extrin-
sic motivational treatments. Of course, these strategies are best used after
responding to sustain talk and solidifying rapport.
Examples of Eliciting Change Talk

Eliciting strengths: “You were able to complete schoolwork so that you
didn’t lose your PlayStation. How were you able to manage this?”
Looking forward: “I know that right now you are only doing this to get
off probation. What would life be like if you continued this behavior
change?”
Importance ruler: “On a scale from 1 to 10, where 1 is not all important
and 10 is very important, how important is it to earn back your car?
Why did you pick that number and not a lower number?”
Some Thoughts about Termination
We think about the termination session as an extension of the final sum-

mary (where you started, where you ended, change talk, affirming reflec-
tions, review of plans, hope and optimism). Formal termination should be
acknowledged and discussed prior to the last session. This process may
begin by eliciting the client’s perspective on termination. “We’ve been
working together for a little while now, and you have shared a lot in that
time. What are your thoughts as our time together is winding down?” Con-
tinue to elicit and reinforce change talk for maintenance, and express empa-
thy regarding any worries or struggles. Below is a list of components to
consider in the final session:
• Review the most important factors motivating the client for change,
and reconfirm these change talk themes.
• Summarize the commitments and changes that have been made
thus far.
• Affirm and reinforce the client for commitments and changes that
have been made.
• Explore additional areas for change that the client wants to accom-
plish in the future.
• Elicit change talk and commitment statements for the maintenance
of change and for further changes.
• Review if–then plans, and express hope and optimism.
• Address follow-up resources and support services available, and
individualize referral list.
Summary
We believe the process of maintenance is worthy of consideration sepa-

rate from the other MI processes. The key goals of this process include an
ongoing evaluation of the change plan to ensure consistency with values, to
reinforce facilitators of change, and to normalize and plan anew for emerg-
ing barriers. You should recognize, elicit, and reinforce change talk about
maintaining change in addition to behavior change in general. Integration
of other interventions may occur in this process, after you have elicited and
reinforced motivation for initial change with the other four processes. See
Table 8.1 for a summary of dos and don’ts and Table 8.2 for adaptation for
special populations.
TABLE 8.1. MI Maintenance and Integration Dos and Don’ts

Do Don’t
Understand slips by exploring motivation Fall into the blaming trap with “relapse”
for maintenance, values, and realistic language
change plan steps
Use MI skills to ensure MI spirit Move into the expert stance or restrict
and motivation for other treatment autonomy when teaching skills or
approaches implementing extrinsic reinforcers
Elicit and reinforce change talk for Continue to focus on initial motivation to
maintaining changes and continuing to change without exploring maintenance as
reinforce identified facilitators of positive a different process
change steps
Plan for termination and explore Discuss termination only at the last
thoughts, feelings, and behaviors session
TABLE 8.2. Tips for Maintenance with Special Populations

Criminal justice
Struggle with reentry and Provide menu option “It’s important for people to
question your guidance about for maintaining understand the challenges
transitional planning processes: change in less you’ve overcome and the
“You still don’t get what I’ve restrictive setting. next hurdles you face. Since
seen and done. When will Be mindful to focus you are getting released in 2
anyone be happy I’m close to on “biggest bang for days and our time is limited,
getting off probation and just get the buck” if time for what makes better sense to
me? I could jump right back into treatment is shortened focus on first—keeping you
the streets next week—a lot before release and safe from the gang, getting
more money there that would external motivators you squared up with the
pay better for the rent I have to are reduced. social worker, or something
pay my grandmother.” else?”
Use MI stop, drop,
Evidence increases in counter- and roll to emphasize “It’s sometimes easier to
change talk when treatment autonomy and provide just go along with it, whether
setting restrictions are lifted: affirmations for you agree or not. You still
“I did the group talk—said the changes to date. Focus want to be understood and
B.S. in detention and you still on personal choice make decisions during this
want me to do more! Now I and responsibility in transition. What are your
have to get a paper signed by transition to increased thoughts?”
everyone?” freedom.
“What strengths got you
Express counter-change talk Focus on strategies to through this last period that
related to ability: “Maybe it was increase confidence you can take with you when
easier living at the detention for maintaining you leave?”
center—the kids there at least changes in the “real
understood what I was going world.”
through better than y’all do.” (cont.)
TABLE 8.2. (cont.)
Eating disorders
Express concerns with changes Elicit new values “Shifts all around—shifts in
in appearance and buck and reflect novel your appearance, shifts in
practitioners’ advice when change talk. Consider deciding what’s best for your
transitioning to new meal metaphors to address health, shifts in how you
menus, particularly youth on changes in treatment. feel about the changes you
treatment programs increasing are making yourself. All this
caloric intake: “I hate how I Emphasize shiftiness is making you feel
look. Y’all put me on this stupid autonomy and elicit like a shady person. How
diet. Eating almost 1,000 young person’s about we shift too and focus
calories a day. I’m trying—it own commitment on one or two things you can
hurts me—physically to eat language—not what do to help you feel steadier?”
this much everyday. I’m trying everybody else thinks.
not to be disgusted with myself See if young person “You hold the reins in
and remember it’s my health can recognize benefits deciding the next path of
that probably matters more, of improved health. how you will manage your
maybe. I’m shifty all the time Drop it if this query health. Everyone is telling
right now in how I feel.” elicits counter-change you the changes they see.
talk or discord. I am wondering what you
Fear socially valued feedback want in this next phase of
when eating habits and your life.”
physical appearance in weight
changes are noticed by
others: “Everyone says how
much ‘healthier’ I look. I say,
everyone else doesn’t know. I’m
really working on eating every
day and exercising less, but I’ve
gained almost 4 pounds lately—
my period. Is there a pill or
something else that could help
slow this down? I don’t want to
go back to the hospital and that
feeding tube gave me a scar, but
the scale doesn’t lie.”

Express unexpected emotional Express empathy “It’s hard to leave Dr. La
discord when changes in and focus more on when she helped you to
providers who exuded MI spirit managing anxiety build up your leg muscles
occur after therapy treatment than developmental and made physical therapy
gains accomplished in pediatric gains. This is fun. How might you teach
settings: “No! I liked Dr. La. particularly important your new physical therapist
She would make me laugh and when transitioning to work with you—in that
I was the special ‘schamahnah.’ from pediatric to adult special schamahnah way?”
The other kids and even my specialists. Consider
dad—didn’t know what we how the person can “You know you can
were talking about.” take what they liked accomplish anything since
from current services you were able to make all
Withdrawal or overly engage in and bring it to the next your treatment goals. Would
self-stimulating behaviors, or set of practitioner’s it be OK if we focus for 5
distract with random content successes in managing minutes and listen to you?
when changes to treatment transitions and reflect We can talk about what you
routines are being discussed in simply. really want to accomplish
team meetings with caregivers next, like online classes,
and providers: “You all do this Elicit strengths to work training, more speech,
every year—talk about me and increase confidence in or maybe something else.”
keep me stuck in those classes. managing transitions.
Just because I have autism This can focus the
doesn’t mean I’m dumb. I’m not conversation back
a kid anymore like you think. to maintenance in a
Mom—can you finish? You said positive way.
we could stop at the game store
on the way home if I didn’t walk Emphasize autonomy
out this time.” when possible to
promote increased
independence in
decision making.
Provide menu of
options to make
maintenance more
concrete.
Practitioner Activity 8.1. Maintaining Change
Activity Goal: To practice developing evoking questions to elicit change talk

specifically for maintenance. You will then develop a reflection to reinforce the
change talk.
Activity Instructions: For each of the following items, fill in the blanks and
make up additional details of the case as necessary. You will practice complet-
ing each of the three components of the sequences. In the first section, you will
complete one of the three components of the sequence (question/statement to
elicit change talk, client change talk, or reflection of change talk). In the second
section, you will use your creativity to complete two of the three components.
Section A
1. a. Practitioner strategy to elicit change talk: “Why might it be helpful to con-
tinue to tackle these fearful situations, like starting conversations with
people?”
b. Client change talk: “I can get more comfortable with talking to people
that I don’t know. It could get easier for me if I do it more.”
c. Practitioner reinforcement (reflection/question):
2. a. Practitioner strategy to elicit change talk: “You have said before that having
an easier time talking to people is an important goal of yours.”
b. Client change talk:
c. Practitioner reinforcement (reflection/question): “Getting past your fear

of talking to people is an important step toward reaching your other
goals—like having friends to go out with.”
3. a. Practitioner strategy to elicit change talk:
b. Client change talk: “Good question. I think I’d have to start at least two or
three more conversations before I try the next step.”
c. Practitioner reinforcement (reflection/question): “You are getting close, but
you need a little more practice first.”
Section B
1. a. Practitioner strategy to elicit change talk: “You mentioned a few minutes
.
ago that you didn’t have a chance to practice your refusal skills again this
week because you didn’t have time. I’m wondering if we can talk about
that and come up with a solution that would be helpful to you.”
b. Client change talk: “Well . . . since you brought it up, yeah, I guess I do
feel that way. It’s not that I think I can’t do it, because I can. I’m just not
sure it would work, like you said.”
c. Practitioner reinforcement (reflection/question): “You’d like to test out your

skills with others before you use them with family.”
Sample Responses
Section A
1. c. Practitioner reinforcement (reflection/question): “Practicing more could
really build your confidence.”
2. b. Client change talk: “It is. I feel like I could start doing other things, like
making friends and going out to have fun, if I can get over this fear of
talking to people.”
3. a. Practitioner strategy to elicit change talk: “How much practice starting con-
versations do you think you need before you are ready to try the next
step on your list?”
Section B
1. b. Client change talk: “The end of the week just seemed to sneak up on me.
I was planning to practice, but it never happened.”
c. Practitioner reinforcement (reflection/question): “You wanted to try out the
skills we worked on even though life was moving pretty fast.”
2. a. Practitioner strategy to elicit change talk: “Sometimes, when people have
trouble finding time to practice, what they are telling me is that they are
not sure that the skill will be helpful to them—or that they are not sure
they can do it—even when part of them wants to do the practice. I’m
wondering if you’re having thoughts like that too.”
c. Practitioner reinforcement (reflection/question): “That’s really helpful to
hear. I’m glad you can talk to me about it. The practice ideas that we
come up with are meant to be helpful to you, but I can see that you’re
frustrated. You know your situation best, and the steps you take are your
choice.”
3. a. Practitioner strategy to elicit change talk: “We could talk about other
options for practicing your refusal skills, or whether this is the right
time in treatment for you to use refusal skills. Or maybe you have other
thoughts.”
b. Client change talk: “Let’s talk about some other options. I guess I have to
see how it works before I do it with my family.”
9
Maximizing Motivation in Groups
Never doubt that a small group of thoughtful, committed,

citizens can change the world. Indeed, it is the only thing that
ever has.
—M argaret M ead
Working with a group of youth offers opportunities ranging from prevention

to intervention and social support. Group treatments offer a rich history of
philosophical lore of effectiveness that continues to pervade many main-
stream and pop culture treatments (Suarez, 2019). However, evidence-
based group treatments can be separated from the rest of the culture of
groups whose success has never been rigorously tested. Wagner and Inger-
soll (2012) and Sobell and Sobell (2011) provide several examples of such
evidence-based group applications. Group treatment is a primary interven-
tion modality for alcohol and other drug use, criminal justice, and coping
with life stressors such as chronic illness or grief and loss. Group modali-
ties are also increasingly used to deliver acceptance and commitment ther-
apy (Coto-Lesmes, Fernández-Rodríguez, & González-Fernández, 2020)
and Guided Self-Change treatment (Sobell & Sobell, 2011).
According to leaders in the field of MI and adolescent groups (D’Amico
et al., 2015), MI groups differ from other group approaches in that its pri-
mary purpose is to elicit and reinforce conversation that will lead to behav-
ior change, versus other goals such as psychoeducation or social support.
Advantages include cost-effectiveness, social support, and opportunities
for interpersonal skills training. Group treatment may also be particularly
useful for adolescents and emerging adults who rely on social interaction
for information processing and decision making (see Chapter 2). Group
treatment may be less threatening than individual psychotherapy for some
young people.
Â
TIP: BE MINDFUL OF POTENTIAL PITFALLS
There are some disadvantages of group therapy with MI to consider. For

some young people, a group modality may be more threatening. Young
141
people may learn negative behaviors from peers in the group. Social desir-
ability increases with peers in the room, as does response to perceived
social criticism from peers. As Wagner and Ingersoll note in their seminal
text on MI in groups (Wagner & Ingersoll, 2012), from the provider per-
spective there is much more to manage in a group setting. You have to
attend to communication between yourself and multiple group members,
as well as to the communication of group members toward each other. You
may have a natural gravitation toward some members of the group and
away from others. However, following the recommendations in this chapter
and demonstrating MI spirit and skills will help to alleviate some of these
concerns. Finally, you have to attend to different levels of importance and
confidence for behavior change. Thus, you may be reinforcing commitment
language for one member while managing counter-change talk and discord
for another. Feldstein Ewing, Walters, and Baer (2012) recommend smaller
groups of four to six young people with similar ages and experience levels.
MI Spirit and Skills in Adolescent and Young

Adult Groups
A group facilitator is a guide, and the guiding style is the foundation of MI.
As noted in Chapter 3, a guide helps people find their way safely and allows
for the group to determine their goals and direction. In group work, the
role you serve as a guide offers opportunity to be a mediator when there
are conflicting goals between participants. For example, one group member
may want to focus on abstinence while another prefers to address harm
reduction.
Wagner and Ingersoll (2012) suggest several principles of group treat-
ment that are consistent with MI, and Table 9.1 delineates these principles
with their associated MI component to guide your integration of MI in pro-
viding group treatment.
Another way to integrate MI with group treatment is to incorporate
MI spirit into group rules. For young people, we do not suggest you use
the term rules, just as we recommend not using the word homework. Set-
ting forth rules may be interpreted as an autonomy-restricting therapeutic
stance. Instead, consider terms commonly offered in therapeutic language,
such as guidelines or recommendations. Recall from Chapter 3, MI spirit
is defined by partnership, acceptance, compassion, and evocation (PACE).
Acceptance components include affirmation, respect for true worth, and
autonomy support. One guideline could be to avoid labels. As discussed in
Chapter 7, the labeling trap involves using language like addict or alcoholic
and implies the person is the behavior. In MI, we do not believe accepting
a label is critical to the change process; instead, labeling can in fact hinder
Maximizing Motivation in Groups 143
TABLE 9.1. Principles of Group Treatment with Associated MI Components

Group principle MI consistency
Focus on positive growth versus resolving Affirmation
psychopathology.
Address current thoughts and feelings True worth, compassion, focusing

and avoid distal issues that may cause
embarrassment, shame, or anxiety.
Explore perspectives and focus on present Accurate empathy, partnership,

to build group cohesion. engaging
Hear complaints but do not elicit Accurate empathy, compassion

grievances.
Broaden perspectives and focus on the Evoking, planning

future.
Reflect and explore a positive focus on Evoking, eliciting, reinforcing change

desires, needs, plans, and self. talk
Support self-efficacy. Affirmation, exploring past successes
Counteract negative emotions before Emphasize autonomy, managing

session ends. counter-change talk and discord
compassion, evocation, and respect for true worth. Providers, and others in
the group, may present as judgmental and shaming by using such labeling
language.
Another possible group guideline is for members to support autonomy.
Emphasize autonomy by respecting the person’s choice whether the group
members agree or not, avoiding advice until the person has the beginnings
of a goal and plan, and asking permission before offering such advice or
other information. Personal choice and responsibility can also be a group
value (see engaging below for developing group values).
According to the MI spirit of partnership, group rules are collabora-
tively developed. Thus, be sure to ask for permission before offering these
suggestions for group guidelines. The skill of Ask–Tell–Ask for offering
information is critical here as well as other times you might be offering
information such as normative feedback (see Chapter 4) or when incorporat-
ing skills-building activities (see Chapter 8).
The other MI skills of reflections of change talk, including affirmation
and summaries, as well as open questions to elicit change talk, are used at
the individual level for group members as well as at the group level. Open
questions at the group level might still focus on target behaviors: “What are
some things other people have said they are concerned about if people miss
their medications?” However, open questions may be used to increase moti-

vation for positive group processes. For example, “What are some reasons
it might be important to be honest in this group?” when increasing motiva-
tion for the target behavior of honest and open communication. Similarly,
reflections of change talk about the group process reinforce positive group
processes. For example, “When we first started I noticed a lot of interrupt-
ing each other, but now it seems as if everybody has been getting a turn to
speak.” In terms of reinforcing a target behavior, reflections can still be at
the group level, as in this double-sided reflection: “On the one hand, some
of you said that most people drink more than they say they do, but on the
other hand, some people are realizing they drink more than they thought
they did.” Of course, reflections of omission and nonverbal behavior are still
useful. “I noticed nobody mentioned getting into trouble with the law. I am
wondering if that is a reason to change for anybody?” “I noticed that seemed
to make some people uncomfortable.” “Anybody have ideas on how to make
people more comfortable discussing this issue?” These are some ways to
integrate MI spirit and skills into group treatment. We now turn to how to
use the processes at the group level.
MI Processes in Adolescent and Young Adult Groups
The MI processes can be used to guide the flow of the group as they form
the flow of a dyadic interaction, as described in Chapter 7.
Engaging in Groups
Recall the purpose of the engaging process is to develop rapport, explore
values and goals, and understand the client’s dilemma. Several strategies
used in individual interactions can be done with group members, such as
offering an opening statement to emphasize autonomy (see Chapter 4).
Wagner and Ingersoll (2012) note the importance of “decontaminating the
referral process” since members may have been pressured or court ordered
to attend. This process of undoing the restrictions on autonomy when treat-
ment feels forced is especially true for young people when caregivers often
control treatment decisions. This can be done within the opening statement
that emphasizes group autonomy (e.g., “I am not here to tell the group what
to do, or how to do it, and I am here to serve as a guide supporting the group
to be the most useful it can be”), noting that the group facilitator role’s is
not to instill consequences for lack of engagement or attendance but rather
to help with dealing with whatever consequences come up.
The typical day exercise (see Chapter 7) is useful for exploring per-
spectives while focusing on the present. In addition to the labeling trap,
recall the other traps: assessment, expert, premature focus, blaming, and
chat (see Chapter 7). These traps are all things to avoid when engaging in
the group setting as well. Exploring values and goals occurs not only among
individual members but also at the group level as a whole. Along with group
guidelines or recommendations, collaborative development of group goals
and values is useful for promoting group engagement, for fostering group
identity, and later for developing discrepancy between group values and
group behaviors or functioning to increase motivation for positive group
process. A Values Card Sort (see Chapter 7) can be done as a group activ-
ity or individually, and then determined through discussion or a vote that
represents the group values. D’Amico, Osilla, and Hunter (2010) recom-
mend using a wheel of change depicting levels of readiness from not at all
ready to change to making changes and to maintaining changes with slips.
Youth are asked to share where they on in the wheel, normalizing all points
and demonstrating the cyclical nature of the process. Experiential activities
can help with engaging quiet or sullen members. Other strategies include
breaking the group into pairs and taking turns. Wagner and Ingersoll (2012)
note the importance of “inviting rather than expecting” when attempting
to engage each group member (p. 126). When attempting to engage each
member of the group, always allow a “pass” so that a group member may
choose to skip a turn. In fact, the concept of a pass can be a group guideline
that supports autonomy.
Focusing in Groups
The purpose of the focusing process is to set the direction for the conversa-
tion and for treatment in general. Collaborative agenda setting is the core
of this process, and determining the agenda occurs not only for the over-
all group process—what is the group’s general agenda—but also for every
group session. Of course, the challenge in group settings is the negotiation
of agendas among more than just the provider and an individual. Recall the
agenda-setting chart from Chapter 7. This visual tool may be used to map
out, to explore various agendas among group members, and to collabora-
tively prioritize the focus for current and future sessions.
Wagner and Ingersoll (2012) note group facilitation may require the
practitioner to use additional focusing skills. You may need to shift focus
when discord and counter- change talk begin to overwhelm the group
agenda. You may need to accelerate focus when youth continue to explore
perspectives and avoid directly addressing behavior change. You may need
to decelerate focus when members move too quickly to problem solving or
advice giving. You may need to broaden the focus when members are stuck
in the details of the past or present, and you may need to narrow the focus
when young people keep the conversation vague or abstract. Similarly, you
may need to deepen the focus with open questions and reflections of feeling
when members appear to be avoiding emotionally laden discussions. You
may need to lighten the focus when the group is stuck in negative emo-
tion or cognition. Wagner and Ingersoll (2012, pp. 146–147) provide further
detail regarding these strategies. For the purposes of adaptation to young
people, note that lightening the focus may be particularly important to avoid
ruptures in alliance. Also, many of these focusing responsibilities are part
of managing counter-change talk and discord. Using summaries to break
the flow of a conversation and shift focus is critical to ensuring empathy
and a guiding style. Remember, including an open question at the end of
the summary, such as “Did I get that right?” or “Where should we go from
here?”, supports autonomy while you guide the group in a different direc-
tion.
Evoking in Groups
Evoking is about eliciting and reinforcing change talk and commitment lan-
guage. Again, this process can occur at the individual level when having
conversations with individual group members, and it can occur at the group
level when eliciting change talk (e.g., desire, ability, reasons, needs) and
steps for changes in group process queries (e.g., looking forward, if the
group was able to support each of you to reach your goals, what would that
look like?).
You may use the ruler to elicit different perspectives on group process:
“On a scale from 1 to 10, how committed do each of you think the group is
toward respecting each other’s choices? One is like not at all committed,
and 10 is like really committed.”
You can discuss group members’ responses to the question with “Why
did you pick that number and not a lower number?” Transforming open
questions to elicit change talk into group experiential activities is always an
option (see Chapter 6).
You may elicit individual change talk as a group, using statements such
as “Tell me how your picture represents what things would be like if you
cut back on drinking.” You may guide group members to help their peers in
pairs by giving them a list of open questions to ask their partners. As with
any activity with young people, ask permission to engage in the activity,
elicit their reaction to the activity, and allow for a pass.
Note that for emerging adults, motivation for group participation can
focus on group support for managing transitions to adulthood. Reasons for
behavior change can focus on the increase in legal consequences that come
with adulthood.
Normative feedback is often a component of evidence-based group
treatment interventions (D’Amico et al., 2012). As Chapter 6 describes,
providing information about individual behaviors relative to age-specific

norms can often elicit change talk as young people see that their behaviors
and those of their social network may not be representative of the gen-
eral population. You should use this strategy only if such norms exist for a
particular target behavior, as the sharing of personalized feedback without
such norms can suggest that the group itself is representative of the general
population.
It is also critical to demonstrate MI spirit and use Ask–Tell–Ask
when delivering normative feedback to avoid eliciting counter-change talk
and discord. D’Amico and colleagues (2010) also note providing objective
and updated information on the impact of substance use on the brain can
increase motivation for change. Physical consequences of behaviors (such
as reduced blood flow to a part of the brain) are sometimes easier for young
people to accept than cognitive, emotional, or social ones (such as “You will
get bad grades”).
Finally, Wagner and Ingersoll (2012, p. 59) note that increased change
talk is not always an indicator of group progress the way it might be in
dyadic interactions as group members may be making progress without
talking. This is especially true with young people when you are supporting
the autonomy of their choice to observe rather than interact.
Planning in Groups
The planning process occurs when ambivalent conversations begin to tip
toward change and commitment. However, in group settings you may not
always hear individual commitment language. Thus, we recommend that
group members all make plans for change at the end of every session, and
that for those not ready to change the target behavior, their steps may
focus on coming back to the group or for single session groups to simply
think about change or consider other interventions (e.g., meditation, physi-
cal activity). Remember that specific steps and if–then plans to overcome
potential barriers are still developed for these kinds of goals.
If time is short, these plans can be done in pairs or in writing (we pre-
fer using technology such as phone notes or a diary app versus forms). You
may also facilitate the planning process for the group to reach goals such
as less interrupting or being more efficient with time. The same guidelines
regarding developing specific steps, discussing if–then plans, and ensuring
that the plan is consistent with group values still apply.
Maintaining in Groups
Maintaining change and managing slips can be challenging in the
sometimes-rocky road to achieving critical lasting behavioral changes.
Depending on your role and duration of the group, you may or may not have
time to facilitate this process to your clinical satisfaction. If you do not have
time, the group may consider recommendations beyond the group setting
to promote maintenance. If the group has time to address maintenance,
individual plans to prevent and manage slips are developed with group sup-
port. Incorporation of skills building relevant to the whole group (e.g., self-
monitoring) can be included here (always using Ask–Tell–Ask; see Chap-
ter 4). Skills relevant to only one or two members may require referral to
individual treatment. It is critical here to train the group in communication
skills that normalize slips, avoiding the term relapse, avoiding labeling, and
yet affirming any positive steps. In fact, if the duration of the group is longer
term or ongoing, training members in MI skills to support autonomy and
elicit and reinforce change talk could be very productive. Although we have
not been able to find clinical trials in this domain, we know that training
peer health workers in MI has been successful (e.g., Naar-King, Outlaw,
Green-Jones, Wright, & Parsons, 2009; Outlaw et al., 2010) as has training
parents of adolescents (May, Ellis, Cano, & Dekelbab, 2017).
Summary
Group interventions are a commonly used modality for intervention with

adolescents and young adults. Compared to individual treatments, the prac-
titioner must attend to unique issues in the group setting, such as managing
multiple conversational styles, addressing varying levels of importance and
confidence, and handling social influences that can promote or hinder group
process. While MI adaptations for adults in group settings have emerged
during the past decade (Sobell & Sobell, 2011; Wagner & Ingersoll, 2012),
the pace of research to inform practice with youth and young adults con-
tinues to keep up. In addition to the seminal book, Motivational Interview-
ing in Groups, by Wagner and Ingersoll (2012), https://groupmiforteens.org
includes videos and manuals for two interventions to address alcohol and
other drug use in adolescents. Table 9.2 summarizes dos and don’ts for MI
in group settings with adolescents and young adults.
TABLE 9.2. MI and Group Dos and Don’ts

Do Don’t
Guide. Collaboratively develop group Be a stickler. Use unfriendly youth terms
guidelines and values important to like rules or provide suggested use of
youth and contextual goals. MI-friendly companions, such as Ask–Tell–
Ask.
Keep up adventuresome MI spirit. Guide Promote loose boundaries. Let group
and explore present perspectives on meander into the past or miscellaneous
behavior change and group process and details of the present; allow group
avoid “traps.” members to fall into MI “traps.”
Explore opportunities to focus. Consider Lose your focus. Lose track of what is
how you might adapt an MI focus and best for group process and/or side with or
explore roles (e.g., deepen depth of against certain group members.
change talk versus lightening the
group’s mood with idle chat).
Elicit. Elicit and reinforce change talk Forget. Forget behavior change may be
for positive group development. occurring internally for more quiet group
members.
Elicit and guide. Elicit barriers to Assume change is not possible. Assume
changes in group process, and guide the there are no possible plans for change if
group to make “if–then” plans. members are not 100% committed to focus
on discussing behavioral options in change
processes.
Support maintenance. Determine Revert to antiquated therapeutic practices.

how to address maintenance within Allow members to use terms like
the confines of group duration and relapse and forget to both find and affirm
normalize slips (two steps forward, one strengths.
step back).
Practitioner Activity 9.1. MI Groups
Activity Goal: To test your knowledge of adapting MI to group settings with

young people
Activity Instructions: For each process, list three tips regarding adaptations of
MI to groups.
Process Tip 1 Tip 2 Tip 3

Engaging
Focusing
Evoking
Planning
Maintaining
Answer Key (just a few options, there are many more)

Tips for Engaging
1. Be careful not to naturally gravitate toward or away from different group
members.
2. Collaboratively develop group guidelines (don’t call them rules).
3. Allow for “passes” during turn-taking activities.
Tips for Focusing

1. Collaboratively set an agenda for each session.
2. Consider when to broaden focus.
3. Consider when to shift focus.
Tips for Evoking

1. Evoke change talk for group process in addition to individual behavior
change.
2. Recognize that different participants will be at different levels of motivation.
3. Consider experiential activities in pairs, and give partners questions to elicit
change talk.
Tips for Planning

1. Plan for ways to promote group attendance.
2. Allow participants to develop individual change plans.
3. Consider if–then plans for adhering to group guidelines.
Tips for Maintaining

1. Guide group members to avoid the term relapse.
2. Allow for participants to develop individual coping plans.
3. Consider integrating or referring to other treatment modalities such as skills
training.

10
Considering Caregivers
Life affords no greater responsibility, no greater privilege, than

the raising of the next generation
—C. Everett Koop
Research suggests that caregiver involvement in adolescent treatment may

lead to improved outcomes in many domains. Note that we use the word
caregiver to account for the varying family structures you might encoun-
ter. Family-based treatment for substance use has a long history of empiri-
cal support (Hogue & Liddle, 2009). Reviews of caregiver involvement in
adolescent treatment suggest positive outcomes (Dardas, van de Water, &
Simmons, 2018; Haine-Schlagel & Walsh, 2015). A meta-analysis of moti-
vational interviewing interventions for health behaviors that included care-
givers demonstrated positive impact, particularly for diet, physical activity,
and smoking cessation (Borrelli, Tooley, & Scott-Sheldon, 2015). Yet, there
is a significant research–practice gap in this domain. Although family-based
treatments might even be superior, many community practitioners do not
engage caregivers in adolescent treatment. You may be concerned about
confidentiality and potential ruptures in the therapeutic alliance with the
young person. You may not feel you have the skills to effectively manage
both caregiver and youth interactions. Your experience may be that care-
givers typically fail to engage. Regardless of the reason, MI can help. First,
the MI approach will create the atmosphere of trust and nonjudgment with
the young person that will not rupture if you include the caregiver with per-
mission. Second, the MI approach will allow you to collaboratively deter-
mine the rationale and boundaries of parental involvement. Third, an MI
approach with parents will promote appropriate parental engagement.
Negotiating Caregiver Involvement

with the Young Person
When initiating treatment, you have the option of starting with the young
person alone or starting with the young person and the caregiver together.
152
Considering Caregivers 153
We do not have a formal stance on this choice, and to our knowledge there
is no research comparing the two approaches. If you professionally devel-
oped in a family therapy tradition, then meeting with the youth and care-
giver together at the beginning to discuss the purpose and boundaries of
treatment makes sense. If you professionally developed with an individual
adolescent treatment approach, then you may prefer to meet with the young
person individually first and then invite the caregiver. The guidelines to
negotiate caregiver involvement with the young person apply to either sce-
nario. First, the opening statement message still applies. You are there to
help identify what changes the person wants to make and not prescribe any
changes. You then discuss the rationale for caregiver involvement using
Ask–Tell–Ask.
P ractitioner: What are some reasons it could be helpful to include

your parents in some way? [Ask]
Young person: I don’t know, but you could get them off my back.
P ractitioner: Sometimes parents can get in the way of your goals
and getting them off your back might help. Also, you said your
parents control a lot in your life, so it might be important for them
to consider some changes too. [Tell] What do you think of those
reasons? [Ask]
Then it is critical to engage the young person on what boundaries they

would want to set. You can do this with a menu of options, such as this:
Some people like me to work with their parents only when they are in the
room so they know what is being said. Other people want me to work with
their parents without them in the room because they don’t want to deal with
it. Of course, you decide ahead of time what is OK to share and what isn’t. Or
maybe you have another idea?
It can be useful to write down these negotiations in a contract form

to ensure your client of the seriousness of these boundaries and also to
make sure there is no confusion on the plan. Emerging adults who live
with caregivers can use similar rationales. Those who are not in the home
may still benefit from such involvement if they have financial or emotional
caregivers.
Negotiating Engagement with the Caregiver(s)
Treatment engagement includes both attitudes and behaviors. Caregivers

need to believe that the benefits of treatment outweigh the costs (Becker et
al., 2015), thus MI approaches are critical to resolving ambivalence about the
young person being in treatment (as they have to provide consent, possibly
pay for services, and possibly be responsible for transportation). There are
three elements within the behavioral component of engagement: initiating
help, attendance, and active and meaningful participation (Haine-Schlagel &
Walsh, 2015). We now address MI spirit and skills for these target behaviors.
MI Spirit with Caregivers
Just as with individuals and groups, the MI spirit components of PACE

(partnership, acceptance, compassion, and evocation) continue to be the
foundation of interactions with caregivers. The therapeutic stance is one of
collaboration versus expert; however, you must clearly express that your
partnership with the young person is primary. You acknowledge that there
may be times where the young person and the caregiver disagree. Your job
is not to choose sides but to guide each party to make the changes they feel
are best and to help each party consider what compromises are possible.
Acceptance may be difficult when you disagree with the approach to parent-
ing and even more difficult if you believe the caregiver has caused harm to
the young person. However, without being able to identify strengths, sup-
port personal choice, and find compassion, we believe you will be unable to
help the caregiver engage in treatment to help the young person succeed.
Recalling the concept of absolute worth can help here, that humans have an
absolute worth that is not based on thoughts, feelings, and behaviors.
It can be particularly useful when working with caregivers to consider
MI spirit as a foundation for their interactions with the young person. A
recent study of parents of adolescents with diabetes suggested that parents
who received MI-based feedback on their communication skills improved
their demonstration of MI spirit in objectively coded interactions with their
adolescents and then in turn had adolescents who perceived more empathy
and intimacy (May et al., 2017). You may find that more autocratic parents
have particular difficulty with the MI spirit components of partnership and
autonomy support. A few strategies may help here. First, you may present
the research on the success of the MI approach with young people (see
Chapter 1) using Ask–Tell–Ask. Second, we like to ask caregivers if they
believe their current approaches are working. If they believe they are, then
you do not challenge them at this point. However, most caregivers agree
that their current approaches are not working or they would not be in treat-
ment. Then you use that realization as a reason for change. For example,
caregivers might say they have tried curfews, removing privileges, and
adding chores, but nothing works. You may use this as an opportunity to
discuss an alternative MI approach to collaborative rule and consequence
development and autonomy support. Then you assure caregivers that MI

spirit does not mean a nondirective style without structure or responsibili-
ties. Younger adolescents require structure for protection as they are just
beginning to develop executive functions for impulse control and decision
making (see Chapter 2). Older adolescents have to practice managing the
societal constraints they will experience when entering adulthood. Finally,
you elicit from caregivers why collaborative development of things such as
house guidelines (avoid the term rules if possible) and associated rewards
and consequences have a greater likelihood of success.
MI Skills
The skills and strategies used in individual treatment with the young per-
son can be applied to the caregiver target behaviors of initiating treatment,
treatment attendance, and meaningful treatment participation, as detailed
below.
Eliciting and Reinforcing Change Talk

There are two types of change talk you elicit and reinforce to promote
meaningful treatment participation when addressing the caregiver: the
caregiver’s change talk about the young person and the caregiver’s change
talk about themselves. Caregivers’ change talk about the young person’s
behavior can increase the likelihood that the caregiver initiates treatment
for the young person and can improve how they ensure their adolescent’s
treatment attendance. This type of change talk sounds like “She needs to
lose weight”; “He can quit smoking if he tries”; or “I want him to stop
drinking so he stays out of trouble.” However, change talk about the care-
giver’s own behavior may be necessary to increase meaningful treatment
participation and caregiver behavior change. Such change talk sounds like
desire, ability, reasons, need, and commitment for the caregiver’s own
behavior change. See Table 10.1 for examples.
Our group has conducted the only communication study to assess the
practitioner communication behaviors that sequentially predict this type of
caregiver change talk in the context of adolescent treatment (Jacques-Tiura
et al., 2017). We found that caregiver change talk was significantly more
likely to follow counselor’s reflections of change talk and questions phrased
to elicit change talk or commitment language.
P ractitioner: What’s slipped that you want to get back to?

Caregiver: I would like to plan our meals better.
TABLE 10.1. Types of Change Talk When Working with Caregivers

Type of Example of change talk for Example of change talk for
change talk young person’s behavior caregiver’s own behavior
Desire I want her to quit smoking. I want to help her quit smoking.
Ability She can exercise more like she I can start walking with her.
used to.
Reasons He should take his HIV I should set my own phone

medicine so he won’t give HIV reminder to help remember our
to his boyfriend. appointments.
Need He needs to learn how to say I need to cut back on drinking so I

no to his friends. can show him it’s important.
Commitment He will definitely find a way to I will find a way to change my work
make it to sessions. schedule so I can come with him.
When practitioners reflected commitment language or asked question

to elicit change talk or commitment language, caregivers were more likely
to respond with more commitment language.
P ractitioner: Okay, so your plan to support your teen is to keep

doing what you’re doing with the fruits and vegetables.
Caregiver: Right.
P ractitioner: So keep the fruits and you also said vegetables, and
grilling. What else were you going to do to support her?
Caregiver: We’re going to take more walks together.
P ractitioner: Take more walks, excellent. Anything else?
Caregiver: And we are actually going to read the cans and stuff a lot
more.
Emphasizing autonomy was as important for caregivers as it appears

to be for teens (Idalski Carcone et al., 2013). Questions and reflections that
were unrelated to change talk were more likely to be followed by counter
change, suggesting that caregivers may be naturally disengaged without
direct elicitation and reinforcement of change talk.
Â
TIP: MAKE SURE TO ADDRESS CONFIDENCE IN PARENTING
When your child struggles, it is quite common to blame yourself either

consciously or subconsciously. Even a caregiver that notably blames the
child for needing treatment often suffers from shame that their ward is
struggling or not functioning the way society expects. Increasing care-
giver self-efficacy is a key component of promoting engagement. Channon
and Rubak (2011) note that it may be appropriate to use positive refram-
ing skills, such as guiding the parent to discuss situations where the child
demonstrates more prosocial behaviors and the parent similarly can dis-
play effective positive parenting skills. With permission, parents may also
benefit from advice about the normative aspects of children’s misbehavior
as occurring in contexts where they feel safest, such as the home. Present-
ing research on brain development in adolescence and emerging adulthood
(see Chapter 2) can also help to normalize their experience and reduce
self-blame.
Managing Counter-Change Talk and Discord

Counter-change talk about caregiver behavior change is common, and com-
peting priorities are often a realistic barrier. “I didn’t sign up for this . . .
having to meet with you too. You just don’t understand all the stuff I do to
get time off work and get to all these appointments.” Strategies to manage
counter-change talk, such as “stop, drop, and roll” (see Chapter 5) work in
the same way they do with a young person: “You have so much going on, and
this is hard work. You are a hardworking person, and this has helped you
in the past.” You may also reflect prior reasons for caregiver involvement
elicited when discussing the rationale for caregiver engagement. When
managing counter-change talk and discord, we often reflect with empathy
and provide an affirmation. Hence, you may find it useful to explicitly elicit
strengths and past parenting successes to develop affirmations, especially
if the engaging process with the caregiver was time limited.
In this book we note how developing discrepancy between values and
behaviors is a key strategy in promoting behavior change. Here we empha-
size that providing information or advice and creating plans for change that
are counter to the caregivers’ core values will likely engender counter-
change talk and possibly discord. For example, a parent who values hard
work might say, “He just needs to learn the world is a tough place. He has
it too easy. Just fix him.” You might respond with reflecting on the value
and adding an action reflection (see Chapter 6): “It is important to you that
he work for what he gets. Any plan we come up with has to include a work
component where he earns his rewards.”
When you notice ongoing pessimism about engaging in new parenting
practices, it may be that you are pushing too fast for change, sometimes
because of pressure from the young person. Stop whatever is eliciting this
counter-change talk and discord, such as parent education or skills training.
Consider shifting focus to parental support if discord is emerging.
Caregiver: You don’t understand what it is like. You probably never

had a drug addict for a son.
P ractitioner: You’re right—even though a lot of things can work
with teens, not everything works for all parents. What are some
things that help you when you feel this kind of stress?
MI Processes with Caregivers
Again, to what degree you incorporate caregivers and the timing of such
involvement is a personal choice. In the MI processes, below, we present
ideas for each in terms of how we conduct the opening session(s) based on
our research on family-based approaches to improve adolescent health.
Engaging: Young Person and Caregiver Together

The session typically opens with introductions and an opening statement to
demonstrate MI spirit. We then address confidentiality.
Everything we talk about is confidential, so I won’t share anything you tell me

with other people, including each other, unless you give me permission. The
only time I might ever have to “break confidentiality” is if I was concerned
that someone was at risk to harm him- or herself or someone else, and then
we would talk about it first. What do you understand about that?
You then use engaging questions to understand the family’s values and
goals. “How do you think things are going with ?” “What are you
hoping to get out of this program?” “What are some things that are impor-
tant to you? Each family member? To your family?” “What do you see as
your role in treatment?” As in the context of group work, you attempt to get
all perspectives, but you allow for a pass in case the caregiver(s) or young
person prefer to discuss these issues with you individually. After summa-
rizing this exploration, you move to focusing.
Focusing: Young Person and Caregiver(s) Together

In the focusing process, you collaboratively set the agenda for the session
and, for multisession treatments, develop initial treatment goals. First,
you want to understand each family member’s priorities for treatment, and
determine which goals to focus on that will yield the most fruitful results.
You guide the family to determine what has to happen first before other
things can happen. If the caregivers and the young person have completely
different agendas, you will have to map out the priorities and have the fam-
ily determine which to address first or whether the caregivers’ and young
person’s first priority can be addressed simultaneously. Next, you need to
check in on the structure for the rest of the session.
Now that we have gotten to know each other a little bit, I usually spend some
time with each of you separately to figure out what changes you may want to
make and why. We will come together at the end to make a plan. What do you
think about that approach?
Note that while you might want to meet with each caregiver sepa-
rately, you may not have both in treatment or you may not have time. In a
two-caregiver family, we will often begin with the caregivers in the session
together and later determine if there is a rationale to meet separately. After
summarizing the focus, you next meet with the young person alone. We
prefer to meet first with the young person and then with the caregivers to
solidify rapport, build trust, and prioritize any youth concerns that did not
emerge in the joint session.
Evoking and Planning with Young Person

Here you elicit and reinforce change talk with the strategies in Chapter 6
while meeting with the young client alone (this can happen all in the first
session or in separate sessions). You may need to revisit engaging and
focusing, particularly if the young person was not forthcoming in front of
the caregiver(s). For multisession treatments, you should evoke motivation
both for the target behaviors of focus and for ongoing session attendance.
Of course, you use stop, drop, and roll for counter-change talk and discord.
You then summarize and ask a key question, such as “What do you want to
do next?” to move into planning. Recall from Chapter 7 that if the young
person is not ready to make plans for change, you can guide them to make
plans for a preliminary step such as self-monitoring, recording potential
pros of change, or simply think about change and to attend a follow-up ses-
sion. We then use evoke commitment by specifically asking about the plan
(“Why will following this plan make a difference?”) or using a commitment
ruler (see Chapter 7). While we think it is critical for the young person’s
plan to stand alone without caregiver involvement in the event that care-
givers are disengaged, we recommend asking the young person if there is
anything the caregiver can do to support this plan. You may offer a menu of
options with permission if you are unable to evoke a response. Before sum-
marizing and returning to the caregiver, ask the young person to specify
what parts of the conversation are worth sharing with the caregiver and ask
for permission to create a joint plan for change.
Evoking and Planning with Caregiver

Similar to the youth session, you may need to reengage or refocus the con-
versation depending on what transpired in the joint opening. While meeting
with the caregiver alone (in the first session or in subsequent sessions),
you elicit and reinforce change talk not only about the young person’s need
for treatment but also specifically regarding caregiver engagement. Con-
sider that affirming reflections may be most useful here because of the
self-blame and low self-efficacy common when first initiating child treat-
ment. When moving to planning, it is critical that the plan focus on what the
caregiver will change and not the young person. Make sure to include if–
then plans for session attendance as this behavior is so often in the control
of the caregiver, and it can be hard to commit to session attendance if the
young person is not committed to treatment. You can assure the caregiver
that the young person’s change plan will focus on their own behavior and
that you will develop a joint change plan at the end of the session. Finally,
you ask the caregiver if the change plan they developed for themselves may
be shared with the young person. If there are components they prefer not
be shared (such as marital issues), you may need to consider continuing to
meet with caregivers alone or referring them to another provider. Before
moving to a joint closing of the session, summarize with an emphasis on
change talk and steps for caregiver engagement.
Planning: Joint Discussion of Change Plan

We recommend always ending the first session and subsequent with this
component, regardless of what you have covered earlier. If the previous
components above are not possible in one session, move to a joint discus-
sion of planning for continued attendance. You first share the young per-
son’s and the caregivers’ change plan based on the permission you received:
“When I spoke to each of you separately, you said it was OK to share the
goals and steps you developed. Is it OK if we take turn to sharing those
now? Who wants to go first?”
After hearing each person and reflecting the change talk, summa-
rize the connections between each plan. Alternatively, if the family does
not want to each share, you may move right to this summary. You then
address any ambivalence that one family member may express to the other
and refine any specific action steps. Deliver a final summary that reflects
change talk, provide affirmations, review if–then plans, and express hope
and optimism. For example:
When we started, nobody was sure we could communicate enough to make

this work, but you were all very persistent in trying. Mary wants everyone to
stop bothering her about what she eats, but she agreed that she would try to
exercise with one or both of you by taking an evening walk. This was impor-
tant to your family value of staying healthy. Mom, you agreed to be the pri-
mary person to walk with Mary. You all agreed that you would give Mary one
reminder, and if she doesn’t want to walk, you would simply try the next day.
You all agreed you would save any concerns for the next time we meet instead
of trying to talk about it in the moment. What else do you want to add to this
plan?
You may then end the session by reviewing if–then plans for attending the
next appointment.
A Word About Maintenance
We often integrate cognitive-behavioral treatments into ongoing sessions.
We typically begin with the family together, reviewing between-session
practice activities and exploring barriers and facilitators to change over
the previous week. We then meet with the young person alone to further
explore these issues. If skills-building activities are part of the treatment
plan, we typically address these with the young person individually (see
Chapter 9) and then elicit ideas for caregiver support for the change plan,
including any between-session practice over the next week. We finish with
the young person and caregiver together to review the plan. When focusing
on preventing and managing slips, we follow the same format.
When to Consider Family-based Treatment

as the Primary Modality
Channon and Rubak (2011) delineate several considerations for conducting

sessions primarily as a family unit instead of primarily individually with
some additional conjoint interactions. First, family work may be indicated
when the problem is truly a whole family issue, in that other family mem-
bers struggle with the same concerns. This is especially common in pedi-
atric obesity when other family members have obesity, unhealthy eating
patterns, or sedentary lifestyles. It is also common in the area of alcohol and
other drug use when other family members use substances.
Second, family-based interventions may trump individual work when
the process of change requires the engagement of other family members,
sometimes because of the child’s age, disability, or interactive nature of
behavior. Third, when difficulties occur mostly at home and not in other
environments, such as school or work, family sessions may be indicated.
Finally, individual changes in the young person can have rippling effects
throughout the family. When these cause significant disruption (such as

marital difficulties or parental depression in response to increased adoles-
cent autonomy), family sessions, couples sessions, or individual caregiver
sessions may be warranted. Alternatively, you might want to avoid fam-
ily sessions (and possibility refer out) when the individual caregiver issues
warrant individual treatment, when there are high levels of family conflict
that will interfere with the young person’s progress, when managing care-
giver disengagement will take too much time away from the young per-
son’s needs, and when family members are in very different stages of the
change process.
Summary
We have reviewed potential adaptations of MI for caregivers, noting the

importance of specifying target behaviors on caregiver initiation of treat-
ment, caregiver attendance in treatment, and caregivers’ meaningful par-
ticipation in treatment. The overall framework is to address caregiver
motivation for their own behavior versus their motivation for the child’s
behavior change. We provide some ideas for the timing of individual ses-
sions, caregiver sessions, and family sessions but note that with little evi-
dence on comparative effectiveness to guide us, youth preference, care-
giver preference, and your personal experience and comfort should guide
these decisions. Table 10.2 summarizes dos and don’ts with caregivers.
TABLE 10.2. MI with Caregiver Dos and Don’ts

Do Don’t
Explore family values in addition to youth Make plans that are inconsistent with
and caregiver values those values
Discuss the rationale for the MI approach Assume caregivers will be comfortable
with all aspects of MI spirit
Affirm caregiver strengths, normalize Ignore the possibility of low caregiver

concerns, and elicit past successes efficacy and feelings of shame
Elicit and reinforce change talk for Mistake change talk about the young
caregiver behavior change person to mean that the caregiver is
motivated for treatment
Make plans for caregiver support Forget to elicit youth permission for this
support
Practitioner Activity 10.1. MI with Caregivers
Activity Goal: To consider how strategies for MI in groups might be used in ses-
sions with caregivers and young people together
Activity Instructions: Record your tips from Chapter 9 in the middle column
below. Note how they might be used as-is or adapted for conjoint sessions. (We
note our group tip examples below if you prefer to use those.) Then, adapt each
of the tips for work with caregivers and young people, noting each in the third
column.
Process Tip for groups Adaptation for family sessions

Engaging 1.
2.
3.
Focusing 1.
2.
3.
Evoking 1.
2.
3.
Planning 1.
2.
3.
Maintaining 1.
2.
3.
Group Tip Examples

Tips for Engaging
1. Be careful not to gravitate toward or away from different group members.
2. Collaboratively develop group guidelines (don’t call them rules).
3. Allow for “passes” during turn-taking activities.
Tips for Focusing

1. Collaboratively set an agenda for each session.
2. Consider when to broaden focus.
3. Consider when to shift focus.
Tips for Evoking

1. Evoke change talk for group process in addition to individual behavior
change.
2. Recognize that different participants will be at different levels of motivation.
3. Consider experiential activities in pairs, and give partners questions to elicit
change talk.
Tips for Planning

1. Plan for ways to promote group attendance.
2. Allow participants to develop individual change plans.
3. Consider if–then plans for adhering to group guidelines.
Tips for Maintaining

1. Support group members to avoid the term relapse.
2. Allow for participants to develop individual coping plans.
3. Consider integrating or referring to other treatment modalities, such as skills
training.
11
Your Motivational
Interviewing Journey
You must be the change you want to see in the world.

—M ahatma Gandhi
As with any change process, incorporating MI into your clinical repertoire

involves thoughtful consideration and practice. We hope you will view the
pyramid as a roadmap for learning and as a skill set you will continually
refine over time. Similar to playing an instrument, a few lessons are not
sufficient to become proficient, and even skilled musicians often seek addi-
tional training. In addition, we hope we have conveyed to you the idea that
the process of change can be as hard for practitioners as it is for young peo-
ple. The goals you set for yourself for learning MI will be individualized, and
we hope you use this book as a guide rather than as a prescription. You may
choose to focus on small goals within each level of the pyramid, attend to a
single skill, tackle all the skills in the order presented, or choose the skills
most relevant for you. Of course, we hope you will carry the MI spirit into
all your work with young people. We next review options for further training
to highlight the next steps you might take in your own journey of change.
Now that you know the steps involved in MI, how might you practice
these skills and further develop your clinical repertoire? Over the last two
decades, exponential growth has taken place in opportunities for learning
MI and in methods for measuring practitioner competence. Research stud-
ies on what it takes to effectively learn MI are beginning to emerge. We
next review several of these learning possibilities and hope this review will
provide further guidance as to how you can continue to become more adept
in your use of MI with young persons and families.
What Does It Take to Learn MI?

The art of becoming a skilled MI practitioner involves a learning process,
much akin to becoming proficient in any complex musical instrument or
165
sport. The last decade has seen a significant increase in MI training stud-
ies. We knew from previous literature that attending at least a 2-day train-
ing resulted in a beginning level of MI proficiency, and practitioners with
less training, across many different disciplines, have often not been able to
demonstrate basic skills (Brug et al., 2007; Chossis et al., 2007; Lane, John-
son, Rollnick, Edwards, & Lyons, 2003; Madson, Loignon, & Lane, 2009;
Martino, Haeseler, Belitsky, Pantalon, & Fortin, 2007; Miller, Forcehimes,
O’Leary, & LaNoue, 2008; Miller & Mount, 2001; Moyers et al., 2008;
Rubak, Sandbæk, Lauritzen, & Christensen, 2005; Schoener, Madeja, Hen-
derson, Ondersma, & Janisse, 2006; Söderlund, Madson, Rubak, & Nilsen,
2011).
A few randomized trials have shown the value of follow-up coach-
ing after workshop training. In a seminal randomized controlled trial of
MI training, Miller, Yahne, Moyers, Martinez, and Pirritano (2004) found
that an in-person workshop only was better than self-teaching methods in
increasing MI competency on an objective outcome (session recordings
that are coded for competency ratings). Yet, a workshop plus standardized
feedback of coded sessions or a workshop plus clinical supervision resulted
in greater competency. Feedback and supervision conditions did not differ
from each other. Of note is that practitioners’ self-ratings were not related
to objective coding, suggesting that review of actual sessions or role plays,
ideally with an objective coding tool, is critical to improving MI compe-
tency.
One study (Forsberg, Ernst, & Farbring, 2011) randomized staff in
prisons to three conditions: 5-day workshop only training, workshop train-
ing plus group coaching with feedback on audio recorded sessions (mean
of 16 group sessions), or usual care. Content analysis of recorded sessions
suggested that staff in the workshop plus group coaching had improved MI
skills compared to the usual care group, but the workshop-only group did
not differ from usual care.
Another study in child protection settings (Forrester et al., 2018) ran-
domized social workers to no training or an MI skills development package
of 3 days of workshop training, eight coaching sessions, and a 1-day booster.
Coaching sessions were both individual and group and included reflective
practice but did not appear to include feedback on objectively coded sessions.
The training resulted in improvements in MI skills among social workers.
However, this improvement did not translate into improved outcomes in par-
ents (who were randomized to trained and untrained workers). The authors
reported that even after training, most practitioners were not sufficiently
competent in MI skills and thus parent outcomes were not improved.
In a cluster randomized trial (Darnell, Dunn, Atkins, Ingraham, &
Zatzick, 2016) in a trauma center focused on alcohol screening and brief
intervention, medical providers were randomized to no training or an
Your Motivational Interviewing Journey 167
on-site workshop followed by feedback on four standardized patient role

plays and 30-minute coaching sessions over the next 6 months. The major-
ity of participants (13 of 16) completed at least two coaching calls. Provid-
ers in the workshop training group had significantly improved Motivational
Interviewing Treatment Integrity (MITI) scores over the course of 2 years;
however, high proficiency was only achieved for global scores.
In a randomized trial of rehabilitation counselors (Torres, Frain, &
Tansey, 2019), half received a 4-hour MI training workshop followed by
four weekly coaching sessions. Only 7 of the 32 counselors in the train-
ing group attended any coaching session. On average (regardless of coach-
ing) counselors in the training group improved MI competence based on
self-ratings and their clients had increases in perceived engagement and
alliance compared to controls. A significant weakness of the study is the
reliance on self-report.
These studies, conducted in different contexts, all suggest that work-
shop plus coaching and/or feedback yields improvements in MI skills, most
likely beyond the impact of workshop only. However, studies suggest that
achieving high levels of competency is difficult within the confines of lim-
ited training and supervision. We know little about how much coaching is
necessary to achieve proficiency. In our pilot study of a motivational inter-
viewing intervention tailored for HIV-related behaviors in young people
(Naar, Pennar, Wang, Brogan Hartlieb, & Fortenberry, in press), longitu-
dinal data were collected from 19 community health workers (CHW) at 16
youth HIV agencies. Workers from eight sites were assigned to the tailored
MI training intervention per the funder’s request. The remaining eight
sites were randomly assigned to tailored MI training services as usual.
Training included a 3-day workshop followed by phone coaching based on
feedback of coded standard patients and practice to improve low ratings.
The training group completed one pretest standard patient interaction; then
after the workshop, they completed coded interactions and coaching ses-
sions biweekly for 3 months, monthly for 3 months, then quarterly for a
total of 15 sessions over 2 years. Control CHWs completed one pretest
standard patient interaction and then monthly for 6 months resulting in a
total of seven competence scores. Competence scores in the tailored MI
group significantly increased, while the scores of the control group signifi-
cantly decreased. Further analysis of the intervention group demonstrated
that scores significantly increased in the first 3 months of biweekly coach-
ing and then showed no significant increases subsequently. Although gains
were not evident beyond the first 3 months, at no point did MI competence
significantly decrease between successive time points and the baseline, and
final competence scores were still significantly different. These data sug-
gest that an initial workshop followed by six biweekly sessions increases
competency, and then booster sessions can be delivered to maintain gains.
The data showed variability across worker’s skill, suggesting that some
workers could benefit from more training while some need less.
To address this need, Martino et al. (2011) piloted a criterion-based
stepped approach to training addictions counselors. Counselors first
received a web course and then submitted self-selected recordings of real
sessions that were coded to determine additional training. Those with less-
than-adequate skills (rated as average or above on at least half of items
per the author’s measure) then received four 2-hour in-person workshops
before they were assessed again. Those with less-than-adequate skills
were then offered two monthly supervision sessions that included feedback
on scores and practice. The results showed that counselors who performed
adequately after the web course maintained their skills over 24 weeks, and
counselors who received follow-up training improved their adherence to MI
strategies. This pilot study requires replication but suggests that tailoring
training based on objective skills coding may improve skills while saving
resources.
The research on training from Miller and colleagues (2004) and oth-
ers demonstrates that the process of gaining proficiency in MI requires
your time: time to learn, time to practice, and time to receive feedback.
How much time is required? The verdict is still out. Consider if you were
to walk down a path for 5 minutes versus 5 hours. Either way you make
progress, but with a greater time investment you will get farther along the
trail. The same idea holds true when learning MI. Proficiency in MI, like
most skills, is a lifelong journey. In our own work we have found that with
a high-quality workshop, about six coaching sessions that include role-play
practice or review of actual sessions with objective feedback and practice
are necessary to achieve at least intermediate competency. Future studies
are needed to address how much coaching is needed to maintain skills over
time, and how to promote adherence to MI training requirements in real-
world settings (see implementation science in Chapter 13).
Your Own MI Development
There are several methods to promote your own MI development at differ-

ent stages.
Learning to Crawl: Self-Study
Books in Guilford’s Applications of Motivational Interviewing series offer
content tailored to mental health, health care, and training, and several MI
videos are available (see https://motivationalinterviewing.org). Observing
MI encounters is helpful to bring texts to life. An excellent practitioner
“self-help” book is Rosengren’s Building Motivational Interviewing Skills: A

Practitioner Workbook (2017), complete with self-training quizzes and exer-
cises for each level of the pyramid. These methods can surely increase your
understanding of MI and expose you to how MI might be used with young
persons. Many videos are available online, and we have developed video
of examples of MI sessions, traps, and specific skills with young people
(Naar, Parsons, & Stanton, 2019). However, these methods will never sub-
stitute for practice. Books and videos provide a “ground school for flying”
(Miller, Sorensen, Selzer, & Brigham, 2006), but you cannot get a flying
license without a flying instructor. We recognize time constraints often
limit practitioners from moving beyond self-study. The difficulty in becom-
ing proficient in MI through only these passive methods is they leave you
disengaged and nonactive in the learning process (reading about MI is not
doing MI).
Learning to Walk: Attend a Training Workshop

When first introduced to MI, many of us are drawn to the core humanistic
qualities of the style. The openness, respect for autonomy, and overall valu-
ing of the young person’s journey often resonate with our own professional
values of caring for this often-neglected population. Similarly, when initially
learning MI, it is common to believe MI is easy to do—just listen, ask cer-
tain questions, and use the skills. However, when practitioners begin to try
out MI with young persons after initially reading a text or watching videos,
they often quickly gain a deeper appreciation of the level of difficulty in
implementing even seemingly simple tasks (such as reflections). Typically,
the more you grasp MI, the more you recognize what more you need to
learn. If you are at this point, attendance at a 2- or 3-day training workshop
is often a good next step in the learning process.
So what can you expect from a general training MI training workshop?
In general, by attending an initial workshop, you will have a greater under-
standing of the underlying spirit and basic style of MI, practice recognizing
and reinforcing change talk, learn to respond to counter-change talk and
discord, and understand the processes of MI. In addition, with the increase
in training workshops tailored to practitioners working with young persons,
it is our hope that issues of development and family processes, as well as
use of video analysis and real-time role plays designed with the issues cen-
tral to the young person, will also be incorporated into these trainings.
Learning to Dance: Access Coaching and Feedback

After initially learning MI in an introductory workshop, research has
shown that to achieve any significant gain in MI skills, participation in a
combination of ongoing personal feedback and performance coaching is cru-

cial (Miller et al., 2004).
So what can you expect from these coaching and feedback sessions?
First, be sure to work with someone who is more skillful in MI than you.
They will have more experience and likely also have undergone their own
supervision when learning MI. Coaches also serve as learning tools, with
some examples including observing role plays with other supervisees and
structuring feedback from the group, teaching you to code your own and
other taped MI encounters, and helping to coordinate and supervise peer-
mentoring groups (both are discussed in the next section). Also important
in your work with a coach is the emphasis on receiving feedback and prac-
ticing skills for effectively monitoring and responding to the young person’s
developmental needs, as well as the contextual familial issues that often
present during an MI encounter.
In order to give you feedback, your coach will need to hear you do
MI. This often involves listening to your recorded sessions or role plays
(much the way a dance teacher would need to watch you dance to know if
you have learned the proper steps), receiving feedback, and then practicing
necessary skills. There have been some efforts to automate this process
with coded recordings, automated feedback with suggested practice activi-
ties, and video examples (Naar et al., 2019), but this approach has yet to be
empirically tested. Often, standardized coding systems are used to assess
progress and monitor the motivational interviewer’s fidelity.
Below, we briefly discuss the most common MI coding system typi-
cally used with adult populations, the Motivational Interviewing Treatment
Integrity (MITI) coding system (Moyers, Rowell, Manuel, Ernst, & Houck,
2016), and the only coding system developed for young populations, the MI
Coach Rating Scale (MI-CRS; Naar, Chapman, et al., in press). Both share
the use of audio- or videotaping of sessions and at minimum a 20-minute
review of the encounter for coding. The MI-CRS allows for a standard client
interaction instead of an average 50-minute therapy session. We offer this
brief review of coding systems (Table 11.1), not as something you should
bank in memory, but rather as a resource to help you master your MI dance
steps. Your use of coding systems can also facilitate your understanding
of what skills you may need to refine, as well as allow for a more detailed
analysis of the MI encounter that can be obtained from just listening to a
session.
The MITI 4.0
The MITI has undergone extensive development and updating by Moyers
and colleagues (2016), and the most recent version is available at https://
casaa.unm.edu. The purpose of the MITI is to provide a fidelity measure
TABLE 11.1. Overview of the Motivational Interviewing Coach

Rating Scale (MI-CRS)
Item Definition
1. The counselor cultivates The counselor understands or makes an effort to
empathy and compassion grasp the client’s perspective and feelings, and
with client. conveys that understanding to the client.
2. The counselor fosters The counselor negotiates with client and avoids an
collaboration with client. authoritarian stance. A metaphor for collaboration is
dancing instead of wrestling.
3. The counselor supports The counselor emphasizes client’s freedom of choice
autonomy of client. and conveys an understanding that the critical
variables for change are within the client and cannot
be imposed by others.
4. The counselor works to The counselor conveys an understanding that

evoke client’s ideas and motivation for change and the ability to move toward
motivations for change. that change reside mostly within the client and
therefore focuses efforts to elicit and expand it within
the therapeutic interaction.
5. The counselor balances The counselor maintains appropriate focus on a

the client’s agenda with specific target behavior or concerns directly tied to it
focusing on the target while still addressing the client’s concerns.
behaviors.
6. The counselor The frequency of reflective statements is in balance

demonstrates reflective with questions.
listening skills.
7. The counselor uses The quality of the reflections—low-quality reflections

reflections strategically. are inaccurate, lengthy, or unclear. High-quality
reflections are used to express empathy, develop
discrepancy, reinforce change talk, reduce resistance,
and generally strategically increase motivation.
8. The counselor reinforces The counselor affirms personal qualities or efforts
strengths and positive made by the client that promote productive change or
behavior change with that the client might harness in future change efforts.
affirmations/affirming
reflections.
9. The counselor uses Summaries are used to pull together points from
summaries effectively. two or more prior client statements. At least two
different ideas must be conveyed, as opposed to two
reflections of the same idea. Summaries are a way to
express active listening and reflect back to the client
the “story.” Summaries are also used to structure the
session as well as to guide clients in the direction of
change.
(cont.)
TABLE 11.1. (cont.)
Item Definition
10. The counselor asks An open question is one that allows a wide range of
questions in an open- possible answers. Closed-ended questions may be
ended way. answered with a one-word response. Multiple-choice
questions are considered open, particularly with
clients who struggle with open and more abstract
questions.
11. The counselor solicits The counselor asks clients for their response to
feedback from client. information, recommendations, feedback, etc. This is
analogous to the Ask–Tell–Ask or elicit–provide–elicit
strategy in motivational interviewing.
12. Counselor manages The counselor responds to discord and sustain talk
counter-change talk/ (i.e., counter-change talk) either reflectively or
sustain talk and discord. strategically. Client may make statements against
change directly about the target behaviors, about
engaging in the treatment program, or about discord
in the relationship. Discord refers to tension between
the client and counselor (wrestling).
for clinical trials, to provide a structure for formal feedback to providers,

and to assist with selection of candidates for hire. The MITI includes global
scores and behavior counts during a randomly selected 20-minute segment
of a recorded interaction (not a transcript). The global score is rated on a
five-point scale based on impressions of the overall interaction: Cultivating
Change Talk, Softening Sustain Talk, Partnership, and Empathy. Behavior
counts are frequencies of provider behaviors and include giving informa-
tion, persuade, persuade with permission, questions, reflections, empha-
size autonomy, affirm, seek collaboration, and confront. The MITI requires
formalized training and a clearance process for coders to be considered
reliable to code.
Motivational Interviewing Coach Rating Scale (MI-CRS)

The MI-CRS uses measurement development methods based on Item
Response Theory (Wolfe & Smith, 2007) to produce an instrument for
measuring the competency of provider MI delivery with adolescents and
adults. The resulting 12-item measure of MI competency (see Table 11.1)
was designed to be rated on a four-point scale (poor, fair, good, and excel-
lent) in one pass of real or simulated encounters. MI-CRS showed excel-
lent psychometric properties in diverse settings and samples of primarily
youth and parents (Naar, Chapman, et al., in press). Some items are akin to
MITI global scores, while others are rated with a behavior count estimate.
Like the MITI, a 20-minute segment of a session can be coded. Unlike
the MITI, the MI-CRS does not use a randomly selected 20-minute seg-
ment, but instead uses the first 5 minutes, the middle 10 minutes, and the
last 5 minutes to ensure a sampling across the session for each trainee.
Finally, an objective standard-setting procedure defined criterion scores for
MI competence to facilitate its use in provide feedback to providers. The
categories, based on average scores, were named based on feedback from
trainees and supervisors as beginner (< 2.0), novice (2.0–2.6), intermediate
(2.7–3.3), and advanced (> 3.3). Thus, the MI-CRS can be used to measure
fidelity (Naar, Pennar, et al., in press) and can be used as an implementation
outcome (Naar et al., 2019) when rated by coders trained to reliability. How-
ever, the measure can be used by coaches to guide feedback or hire provid-
ers with just a short half-day training (see https://behaviorchangeconsulting.
org).
How Do I Find a Dance Instructor?

If you or your agency is interested in pursuing training, there is currently
no formal certification for becoming an MI trainer. However, the interna-
tional Motivational Interviewing Network of Trainers (MINT) promotes
quality MI training by offering Train the Trainer workshops. We recom-
mend seeking training from members of MINT who are actively aware of
updates in MI research and training approaches. MINT operates an infor-
mational website (https://motivationalinterviewing.org) offering information
about MI and providing a geographical listing of MINT members. To date,
training has been provided internationally in at least 27 languages. If you
are seeking a trainer with expertise in MI and young people, the MINT
listing includes information about trainers’ specialty areas. We recommend
you ask potential trainers how much expertise they have in MI with young
people and families and request references or evaluations from prior train-
ing workshops.
Learning to Dance with Others: Establish a Community

of Practice
One of the pitfalls of having a coach outside your organization is that he
or she is not always available. Establishing your own MI learning group
with peers provides an alternative if having a coach is not possible, yet the
core goals of strengthening MI skills remain the same. Communities of
practice (CoPs) are another strategy to promote uptake and sustainability
of motivational interviewing skills. CoPs were developed in the context of
education and management and more recently in mental health and health
care contexts (Kothari, Boyko, Conklin, Stolee, & Sibbald, 2015). A CoP is
a group of people who learn together and create common practices based on
(1) a shared domain of knowledge, tools, language, and stories that creates
a sense of identity and trust to promote learning and member participa-
tion; (2) a community of people who create the social fabric for learning
and sharing, inquiry, and trust; and (3) shared practice made up of frame-
works, tools, references, language, stories, and documents that community
members share. CoPs can vary in level of formality, membership (shared
discipline or across disciplines), and method of communication (such as
face-to-face or virtual). They are supposed to be nonhierarchical and can
change their agenda to suit the needs of members. While the study of CoPs
to promote fidelity to evidence-based practices is in its infancy, preliminary
findings are promising (Barwick, Peters, & Boydell, 2009) and we are com-
pleting a study comparing CoPs to coaching (Naar et al., 2019).
Rosengren (2017) has offered the following recommendations as a
guide for CoPs:
Schedule Routine Meetings
Offer times that are conducive to the group members’ work schedule.
Rosengren advises selecting times that are frequent (i.e., biweekly) but
not overly intrusive as to make them cumbersome to work schedules (i.e.,
weekly), or too minimal to maintain group goals (i.e., monthly). Also impor-
tant in structuring your meetings is taking care of practical matters (e.g.,
coordinating taping of reviews and agenda setting).
Use an Agenda, but Don’t Be Rigid

Much akin to the menu of options you might offer to the young person dur-
ing an encounter, the use of an agenda in your group meetings can help par-
ticipants to know what will happen and the best way to learn from the group
meeting. A second option involves structuring the groups to coincide with
the stages of learning MI processes, such as in this book, and emphasizing
skills accordingly. The third option proposed by Rosengren involves using
meetings (especially those at the initial stage) as a vehicle for learning more
about MI. For example, include time to review and discuss articles relevant
to MI with young persons and/or families, or the MINT Bulletin.
Practice
If there is one golden rule in learning MI, we believe it is practice. Review-
ing training exercises and practicing them in your group with peers can be
particularly helpful. Discuss challenges, skills you are learning, and skills
to focus on next.
Review Available Videos for Expert MI Practice

Observing practitioners that do MI can be an excellent model for learning.
A list of training videos can be found on the MINT website, https://motiva-
tionalinterviewing.org. We have developed our own series of youth-specific
videos, available from Behavior Change Consulting (https://behaviorchange-
consulting.org).
Code Your Own and Others’ Sessions or Role Plays

Listening and coding tapes can enhance your knowledge of MI as you listen
for links between practitioner skills and client language. Coding systems
can range from the simplistic (e.g., counting client change talk exchanges
and practitioner responses) to the more formalized (e.g., MITI). Of course,
you must first ensure that the young person has agreed to be audiotaped
and to have tapes reviewed for training purposes. We have found that most
young persons are generally agreeable to being taped when you tell them
you are interested in learning how you might be a better practitioner and
you are evaluating yourself, not them. When listening to the tapes of others,
remember to respond in an MI fashion by expressing empathy and support-
ing self-efficacy.
Consult about Challenging Situations

When you are experiencing frustration or feeling stuck, group members
often have valuable and creative suggestions about how to use MI in these
situations. Ideas can not only be discussed but also develop into helpful role
plays. You may play the young person and have another practitioner dem-
onstrate a unique approach. Then, you may follow by trying out alternative
responses to the difficult interaction in a subsequent role play.
Consider Additional Targeted Training

When particular challenges arise, such that peers feel similarly stuck, or
when difficulties common to the group arise in several peer sessions, it
may be helpful to seek targeted training. Approaching an MI trainer with a
specific request (e.g., a coaching session about negotiating change plans or
how to handle chronic ambivalence) can lead to a valuable consultation that
can move your peers and you forward in learning MI.
Summary
We have provided a menu of options to learn MI. The literature is clear

that something is better than nothing, that practice beyond initial learning
is critical, and that we do not have enough data to determine how much
is enough. We do have objective assessments that can give you an idea of
where you are at with MI proficiency. If you already have tools that work,
please keep using them. Perhaps this text has helped you specify the tools
you already use. We simply ask that you consider adding any additional tools
from this text into your toolbox.
Practitioner Activity 11.1. Your MI Journey
Activity Goal: To evaluate different options for learning MI that will work best
for you
Activity Instructions: List the pros and cons for each option and determine
which option(s) might be best for you.
1. Using textbooks, practitioner workbooks, and video examples
Pros Cons
2. Completing online learning modules
Pros Cons
3. Listening to and self-rating recordings
Pros Cons
4. Finding a group training
Pros Cons
5. Finding an MI coach
Pros Cons
6. Finding someone to code your sessions and give written feedback
Pros Cons
7. Finding a peer to review each other’s sessions and practice
Pros Cons
8. Developing a community of practice
Pros Cons
Based on this analysis, what options are you considering? (You will have an
opportunity to develop steps and if–then plans in Chapter 13.)
12
Ethical Considerations
Relativity applies to physics not ethics.

—A lbert Einstein
A general review of ethics and MI has been previously described (Miller

& Rollnick, 2013; Miller & Rollnick, 2002; Rollnick et al., 2008), and we
encourage you to review these sources. Our focus in this chapter involves
how the general ethical principles these earlier writers delineated can be
extended and incorporated in your work with young persons and families.
Influence, Values, and Goals
Although MI spirit encapsulates the four ethical practice principles of

autonomy, justice, benevolence, and nonmaleficence (Beauchamp & Chil-
dress, 2001), the issue of influence is always present in any behavior change
intervention. Your role as a guide by definition involves exerting influence
on another person no matter how collaborative the goal may be. When the
person’s values and goals are associated with what you believe to be positive
change, your influence is consistent with what the person already wants.
However, when you believe the person’s values or goals do not maximize
his or her potential or are in fact harmful, you may experience what Miller
and Rollnick (2002) coin ethical itches. These are the nagging concerns you
may feel when guiding the person toward goals you consider healthy but
inconsistent with the person’s choices. In MI with young people and fami-
lies, your influence in the change process can become even trickier than in
work with adults, in that you are balancing the goals of the young person,
other family members, and sometimes multiple treatment providers. Each
may have his or her own agenda for behavior change, and figuring out what
and whose goals you are targeting can be a feat in and of itself!
As Miller and Rollnick (2002) note, there is nothing wrong with these
179
itches, and it is a tribute to your own ethics that you can feel the itch. To
help soothe you, we next offer a guide, based on the ethical guidelines of
Miller and Rollnick, to help you maintain your focus on maximizing the
young person’s potential and not falling into a trap of your own or of others’
biases and values. The first step is to clarify each player’s values and goals
in order to pave the way for open and honest communication about behavior
change.
Values and Goals of the Young Person:

Is This Always Most Important?
Ideally, your use of MI with young people targets their behavior change
goals. The young person would present with a goal in mind, request your
help, and the change process would roll. Often however, as we note through-
out the text, the young person’s aspirations for change aren’t always clear.
Sometimes, they are even counter to what you can offer. For example, a
common frustration reported by pediatricians and child psychiatrists occurs
when young people come in asking or demanding certain medical services
the physician does not deem to be medically indicated: the college student
who wants a stimulant to help him stay awake to study, or the high school
student who heard that benzodiazepines would help her be less anxious
during exam time. When these occasions occur, it is appropriate to ask the
young person not only what he or she wants but also, as Miller and Rollnick
(2002) suggest, “What do you want from me?”
Values and Goals of the Family:

How Much Do They Matter?
Make sure you consider the values and goals of the family that is seeking
your help, not only because you bear an obligation to the legal guardians of
the young person but also because family members’ values and goals can
both help and hinder the young person’s changes. For example, consider a
young female wanting to lose weight. She identifies the nightly family meal
as her biggest obstacle to reducing caloric intake, although the mealtime
is the family’s valued tradition. Your consideration to invite the young per-
son’s parent(s) into this discussion (with her permission) can powerfully
affect how changes in her behavior could take place, as well as affect how
the family is (or is not) willing to support her changes. As a general rule,
how you encourage family members to voice their concerns and goals for
young people can clearly enhance what and how change is supported in the
natural environment outside of your clinic office.
At the same time, family goals for the young person can sometimes
Ethical Considerations 181
offer challenges. Family members can often present with a treatment

agenda that differs from what the practitioner wants or has to offer. In the
case of a young person seeking stimulants to help him study, the family
members may have differing ideas, be supportive of this goal, not know of
the young person’s wishes, or be against this decision. Again, be sure you
frankly discuss with family members, as well as the young person, not only
what they want from treatment but also what they want from you as the MI
practitioner.
Values and Goals of the Practitioner:

Does What You Want Matter?
Miller and Rollnick (2002) discuss three types of values practitioners may
have in doing MI: compassion, opinion, and investment. Compassion refers
to a selfless and caring concern for the other person’s welfare and his or
her best interest. For example, a mother demonstrates compassion when
she listens without offering advice while her daughter cries on her shoulder
after her first relationship breakup. With young people, your compassion
may evolve into a strong caregiver instinct to protect the young person
from engaging in risk. You must take extra care to ensure this instinct does
not cloud your respect for autonomy and personal choice.
Opinion involves a professional judgment as to which decision serves
the young person’s best interest. Young people may ask for a professional
opinion, and family members and other treatment providers will often do
so. In rendering an opinion, Miller and Rollnick (2002) suggest you con-
sider what the outcomes would be for the young person in resolving their
own ambivalence in one direction or the other if an opinion is given. Would
this help or hinder, and how will you know? When working with young
people, you must take extra care to identify generational or cultural gaps
in terms of what you believe are appropriate behaviors, responsibilities,
and environments for a young person versus what may be normative in
their contexts.
Investment describes a personal gain or loss to you, depending on the
young person’s ultimate decision. Investments can take several forms. For
example, a practitioner working in a private, for-profit agency may have a
material investment in the young person enrolling in treatment. A practitio-
ner who has experienced similar life issues as the young person or family
member, such as substance abuse, may have a symbolic investment in the
young person engaging in change. Again, we do not provide a foolproof oint-
ment for these itches. Rather, we believe that your awareness and thought-
ful balancing of these concerns will result in the best outcome for the young
person.
Values and Goals of Other Treatment Providers:

How Do They Play a Role?
Young people spend their lives in multiple contexts (school, relationships
with peers and family, work, religious settings, and with other treatment
providers, etc.) where other adults have their own agendas for the young
person’s goals and values. You may find it challenging to coordinate your
work with other treatment providers, especially those providers who are
taking a more directive approach (e.g., legal system) or those who instill a
sense of urgency due to the life-threatening nature of the young person’s
behavior (e.g., health care system). Common examples include young peo-
ple struggling with substance abuse who are told by the treatment pro-
vider they must remain abstinent from all alcohol and drugs, but the parents
expect only moderation in use, or the young person who is medically frag-
ile and may be considering a break from the treatment regimen, although
these changes are not supported by their medical practitioner or family.
In these situations, we again believe the best interest of the young per-
son is served by asking other practitioners not only their treatment aspira-
tions but also what they would like from you as a collaborator in helping the
young person to change. It may also be helpful to elicit from providers how
directive approaches and/or threatening stances have not worked with the
young person thus far. In these situations, your use of MI skills can demon-
strate empathy for the other providers’ point of view and assure them that
you hear their concerns.
Managing Multiple Agendas: How Is It Possible?

As you can see, values and goals are not always congruent in your work
with young persons and families. In the times when all partners are danc-
ing to the same tune and goals for change are in agreement, you are well on
your way to behavioral activation. In contrast, when agendas differ and each
of the dancing partners wants to do a different dance, questions of how to
set goals for change often arise. Here are some examples.
A young girl struggling academically wants her pediatrician to pre-
scribe her a stimulant to help her focus because she thinks she has attention
problems. The pediatrician does not believe she has a diagnosis to justify
the use of medication, while the girl’s counselor is in support of this diag-
nosis and originally recommended the consult for services. The parent is
against the girl taking medication but does not want to create conflict in the
relationship with her daughter and will support whatever decision is made.
A young adult male convicted of driving while under the influence
is referred for court-mandated counseling and is advised by the judge to
remain abstinent from alcohol. The counselor would like to pursue a goal
of controlled drinking. The young man is not interested in selecting a goal,

does not want to stop drinking, and only wants to attend counseling to com-
plete his probation.
The values and goals of young persons and other adults often diverge.
When these divergent perspectives are still ultimately about maximizing
the young person’s potential, MI is ethically appropriate as long as you are
honest about the behavior change goal. Miller and Rollnick (2002) posit that
the ethical principle of benevolence prevails during these occasions, as the
other person holds objective value and judgment in what is in the young
person’s best interest. We agree that the issue of benevolence holds merit
under these circumstances, particularly when the young person is engag-
ing in risk behaviors (i.e., substance abuse or not complying with medically
necessary treatments), and when he or she lacks the insight to stay free
from harm. Of course, if the young person is truly at risk of immediate
harm, MI is not appropriate, and you may need to violate autonomy to keep
the patient safe.
You should use MI with caution when others have a personal invest-
ment in the young person changing beyond maximizing the young person’s
potential. An example would be a parent who wants the young person to
be the first in the family to attend college when the young person seeks to
obtain vocational skills. Another example is the young person who seeks
to learn controlled drinking skills but whose parents or medical provider
wants to set a goal of abstinence owing to their own history of alcohol mis-
use. You may still want to engage the young person in MI sessions during
these situations, but you will need to be very clear to other adults that the
goals you set will be collaborative with the young person.
Finally, if you as the practitioner are in a position of power and the
young person can experience consequences as the result of what they tell
you, MI is not appropriate. For example, if you are a probation officer inter-
viewing a young person suspected of selling marijuana and the information
you obtain could lead to further involvement with the law, you should not
use MI.
Guidelines for Ethical Practice:

Doing the Right Thing
We have discussed what not to do when using MI with young persons and
families, and next conclude with some helpful examples and guidelines ini-
tially proposed by Miller and Rollnick (2002). In considering how you can
balance ethics and MI, we suggest you continue to follow the ethical stan-
dards of your profession as well. Furthermore, when you feel an ethical
itch, don’t ignore or avoid it: Scratch it some, but make it go away and heal.
Do something about it, and don’t let it fester. As in the journey of learning
MI, dealing with ethical issues is a process. Once you think you know how
to play the game, a curve ball can get thrown at you. What we hope is that
you will be able to be flexible when these occasions arise and use these
additional guidelines as a resource to facilitate a more productive encounter
focused on the young person’s engagement in change.
Guideline 1: When you perceive disagreement in the therapeutic

relationship or an area of ethical malaise, clarify everyone’s agenda
(including your own).
Example
A counselor working with a young male was referred for substance abuse
treatment by the legal system. The judge has mandated 20 visits and
requires weekly urinalysis testing (other’s aspiration). When the youth
comes to the clinic, he states he does not want to talk about his marijuana
use but instead wants the counselor’s help in learning to be less anxious
around new people (young person’s aspiration). The counselor only focuses
on the youth’s substance misuse and decides that because he is court-
mandated and it is what the judge aspires for treatment, this focus is the
only viable option. The counselor proceeds to use MI only on topics he
deems pertinent to substance misuse.
Our Opinion: Unethical Use of MI

While the young person is referred for substance abuse treatment, the
counselor does not clarify with him whether his goals for treatment are in
accord with the goals of the judge or counselor, and disregards his aspira-
tions. A more ethical approach to using MI would have been to clarify the
discrepancy among the aspirations of the young person, the judge, and the
counselor, explore how the young person’s aspirations for change might be
related to his substance misuse, and then set an agenda for the focus of
treatment.
Guideline 2: When your opinion as to what is in the young person’s best

interest is in disagreement with what the young person wants, reevaluate
and collaborate about your agenda, making known your own concerns
and goals for the young person.
Example 2
A pediatrician is asked by a young teen to prescribe a stimulant (young
person’s aspiration). Although she has not been formally evaluated, the girl
believes she has attention problems, and her counselor agrees she needs
medication (other’s aspiration). The mother of the girl is ambivalent and will
agree to whatever decision is made (other’s aspiration). As a diagnosis has
not been made, the pediatrician is not willing to ethically prescribe medica-
tion without proper evaluation (other’s aspiration). The pediatrician listens
to the young person and others’ aspirations, and then asks permission to
discuss them collaboratively. With permission from the youth, she explains
to her the ethical concerns about prescribing at this time, and together, the
young person and pediatrician set up a plan for her to complete an evalua-
tion and return for follow-up with the results. The next course of treatment
will be discussed at that time. The young person, counselor, pediatrician,
and mother all end in agreement.
Our Opinion: Ethical Use of MI
The pediatrician incorporated the spirit of MI, asked permission to dis-

cuss her concerns, and explored each person’s aspirations. A collaborative
agenda was set, and options for follow-up were provided. Each person’s
aspirations were validated, while the pediatrician maintained an ethical
stance in providing appropriate care.
Guideline 3: The greater your personal investment in the young person’s

outcome, the more unacceptable it is to use MI. When your personal
investment is not in accord with the young person’s best interests, MI
is inappropriate.
Example 3
A medical resident working on an inpatient unit is working with his first

patient hospitalized for juvenile diabetes. The young male is 75 pounds
overweight, does not maintain proper glucose levels, and is hospitalized
at least monthly for his poor self-care regimen. The resident suspects that
if the youth continues to neglect his health, he may meet death by the age
of 21. Each day, the resident thinks about ways to help the young male,
and checks on him regularly during the day, even though the youth is not
on his service. The resident has recently learned MI and decides to try to
use it with the young man to help him become more compliant with his
health regimen. He structures the consultation to include specific strate-
gies, such as the looking forward and rulers’ exercises. However, when the
young man tells him he isn’t ready to talk about the future—it’s just too far
away—the resident becomes upset and tells the young man he is going to
die if he doesn’t change.
Our Opinion: Unethical Use of MI

The medical resident is more invested than the youth in altering his health
habits, and the manner in which MI was used in this case is unacceptable.
Rather than offering the young man opportunities to voice his own goals
and values about health, the resident is the one doing all of the work and,
in effect, elicits only sustain talk. Moreover, the resident overextends his
professional obligations, visiting with the young man when he is not on his
service, and spends his own free time considering options he deems are
best for the youth. A more ethical approach to using MI in this example
would have been first for the resident to consult with the young man only
when he was on his service. Second, the resident should have used the MI
spirit and allowed the young man to select his own valued topics and goals
to discuss. Last, by displaying a neutral stance in the young person’s deci-
sion to discuss health behavior change options, the resident would have
enhanced the youth’s autonomy and created a more open path for him to
explore his motivation to change.
Guideline 4: When your role involves coercive power to influence the

young person’s behavior and outcomes, a higher degree of caution is
warranted. If coercive power is combined with personal investment in the
young person’s behavior and outcomes, MI is inappropriate.
Example 4
After being arrested for selling marijuana, a 16-year-old male was brought
to his first visit with his probation officer by his adoptive mother. The
probation officer recently underwent an agency-wide training in MI and
decides to incorporate it into her assessment. She immediately begins her
interaction with the youth by conveying the spirit of MI while balancing her
goals of assessment. During the interview, she often mentions to the young
person that she “likes to keep my caseload light” and expects he “will do
everything as he is told to get off probation as quickly as possible.” She
“really doesn’t like to send kids to juvenile detention.” As the interview
continues, the youth becomes less communicative and the probation officer
attends to this feedback, realizing she has not been truly using MI. With
this realization, she returns to using MI and again notices a shift in the
young person’s response to her. She proceeds to set a collaborative agenda,
asks permission multiple times throughout the rest of interview, continues
to convey the spirit of MI, and also includes the mother’s aspirations for her
son into the probation goals. At the end of the interview, specific goals are
set, with the probation officer, youth, and parent stating agreement to the
plan.
Our Opinion: Ethical Use of MI

The probation officer in this scenario is placed in a difficult situation. She
has to set clear limitations with the young person and holds a high level of
coercive power. Throughout the majority of the interaction, the probation
officer effectively incorporated MI and met the goals of the visit. While she
did briefly broach the unethical, by touting her power and reminding the
young person that she has authority to place him in juvenile detention if he
is noncompliant with his probation plan, she was able to respond accordingly
to the young person when he began to disengage, and she did not breach
ethics. Situations that place providers in such power-yielding roles often
increase the likelihood of venturing off the MI path. However, by staying
present and responding to the best teacher of MI, the young person, return-
ing to the path can efficiently result in remaining ethical when using MI.
A Few Words about Self-Disclosure
Is self-disclosure a therapeutic strategy or a clinical mistake? The origins of

psychotherapy rest in the psychoanalytic tradition that unequivocally con-
sidered self-disclosure to be counterproductive (Peterson, 2002). Human-
istic approaches countered this tradition as self-disclosure was considered a
natural part of an authentic and genuine relationship between therapist and
client and a catalyst for therapist trust and intimacy (Farber, 2006; Rogers,
1951a, 1951b). The research evidence on self-disclosure with adults seems
to be favoring this approach (supportive). A meta-analytic review demon-
strated that clients perceived counselors who self-disclosed more favorably
and were more likely to disclose themselves to those counselors (Henretty,
Currier, Berman, & Levitt, 2014).
One study found that the number of self-disclosures was less relevant
than the type of self-disclosure (Levitt et al., 2015). Self-disclosures that
humanized the counselor and that demonstrated similarities between coun-
selor and client were associated with fewer clinical symptoms than other
types of disclosures. There is some evidence to suggest that immediate or
self-involving disclosures (such as disclosure of real-time feelings) may be
more beneficial than historical content disclosures, but this line of research
is in its infancy.
Much of this research has been conducted with adults, and there is
very little data on self-disclosure with adolescents (see Gaines, 2003 for
a conceptual discussion). Of course, self-disclosure of similarities is more
difficult with young people if you are not close to the age of your client.
For example, we know that the influence of social media has created a
dramatically different landscape for young people today, one that many of
us cannot fully comprehend. However, normalizing the adolescent experi-
ence with self-disclosure may still be beneficial if you have not experienced
discord that sounds like “you don’t know what it’s like.”
Thus, from a clinical standpoint, self-disclosure can be beneficial, but
from an ethical standpoint, the devil is in the details. We are all bound
by the ethical principles of our profession, which regardless of profession
include principles related to professional boundaries and conflict of interest.
In addition to these professional requirements, Koocher and Keith-Spiegel
(1998) suggest nine ethical principles, two of which are directly related to
self-disclosure (Peterson, 2002), nonmaleficence (do no harm), and benefi-
cence (help others).
The questions to consider below demonstrate these two principles and
are adapted from a recent set of guidelines for practitioner self-disclosure
(Sadighim, 2014).
Here are some questions to consider before disclosing personal infor-
mation to an adolescent:
• How will the young person or their caregiver(s) benefit from this
information? Am I considering cultural and developmental context
when answering this question?
• Is there a way that I can express empathy without self-disclosure?
• What are the reasons behind my decision to self-disclose? Are they
to express similarity? (And will that work?) Are they to express
my reactions to the current interaction? (And can that be done in a
reflection instead?)
• Am I being triggered by these discussions in some way, and is that
affecting my decision to self-disclose?
• Am I drawn to self-disclosure more or less often with this particular
client?
• Will self-disclosure negatively affect the young person or caregiv-
ers’ view of my professionalism or competence?
• What would my supervisor or mentor or colleague say or think about
this situation?
• Am I concerned that if I don’t share this information, the client will
be upset with me (particularly if client is asking)?
• How will my client interpret my self-disclosure?
Because nondisclosure can have negative consequences in terms of deper-

sonalizing the relationship or promoting client reticence, consider the same
questions for nondisclosure as well!
The Ethics of Social Media
As we have stated earlier, the proliferation of social media is perhaps the

greatest cultural shift since the first edition of this book. Social media has
triggered a host of ethical questions to consider. What do you need to con-
sider when you market your services on social media? Is it OK to search
information about a young person or their caregiver online? What do you
do if a young person “friends” you? What are your boundaries regarding
text messaging and email communication? What do you need to consider
when offering online therapy? These are just some of the questions to con-
sider. We do not attempt to answer all these questions but provide a list
of available online resources from professional organizations to help con-
sider these questions:
www.goodtherapy.org/blog/therapists-guide-to- e thical-s ocial-media-

use-0304197
www.apa.org/monitor/2014/02/ce-corner
www.onlinetherapyinstitute.com/ethical-f ramework-for-the-use-of-
social-media-by-mental-health-professionals
www.zurinstitute.com/ethics-of-telehealth
Summary
We hope we have provided a foundation for you to recognize ethical itches.

Your first job is to clarify and understand the agendas of all parties (youth,
family, other providers, and yourself). The next steps are variable, depend-
ing on the unique situations and your use of MI. You may find it helpful to
discuss any ethical issues with your supervisor or peers to assist in clarify-
ing your own agenda as well as a course of action. What do you think you
will do the next time you experience an ethical itch?
Practitioner Activity 12.1. Ethical Issues
Activity Goal: To consider the application of ethical principles to your own work
and integration of MI with young people
1. Reflect on the primary principles of practice (Beauchamp & Childress, 2001).
2. List three vignettes from your own practice with adolescents and young
adults.
3. Explain how you would respond according to these four principles.
Principle Description
Autonomy Respect for the young person and their right to make
decisions about their own health and future
Justice Maximizing benefit to young people and society while
showing equality, equipoise, and compassion
Nonmaleficence Do no harm; avoid harm
Beneficence Doing and promoting good and removing harm
Vignette 1:
Ethical Response:
Vignette 2:
Ethical Response:
Vignette 3:
Ethical Response:
The website below has a collection of vignettes to consider as well as additional

resources.
www.ethicalpsychology.com
13
Future Directions
If you can’t fly then run, if you can’t run then walk, if you can’t
walk then crawl, but whatever you do you have to keep moving
forward.
—M artin Luther K ing, Jr.
The beauty of the MI community of practitioners, trainers, researchers,

organizational leaders, and clients lies not only in the interdisciplinary
approach but also in the process of evaluating, reevaluating, and improving.
We are committed to the ongoing quality improvement of MI strategies and
would like to share what we and our colleagues in the field are thinking
about for the future. These findings are based not only on our own experi-
ence and scientific inquiry but also on the perspectives of trainees, young
people, and their caregivers whom we and our colleagues actively elicit and
highly value. We discuss how MI might be a transdiagnostic treatment to
fuel good practice and where we need more evidence. We review how the
new research focus on implementation science will assist ongoing quality
improvement in how best to not only deliver MI to young people but also
train upcoming practitioners in MI and promote uptake in various service
delivery settings. We review advances in using technology to deliver MI
and new science to elucidate the mechanisms of why MI works. We end
with the encouragement to plan your own change journey in any of these
domains.
MI as a Transdiagnostic Treatment
Over the last two decades, the field of behavior change has encouraged
the integration of different forms of evidence-based treatments by identi-
fying their general factors and shared elements and applying them across
191
multiple behaviors (Abraham & Michie, 2008; Chorpita, Becker, Daleiden,

& Hamilton, 2007; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005).
General factors, sometimes called “common factors,” refer to the personal,
interpersonal, and other processes that are shared among all psychosocial
treatments—for example, therapeutic alliance, empathy, and optimism.
These account for much of treatment outcome beyond specific treatment
techniques. Similarly, scientists have advocated for the study of processes
that cut across diseases, a paradigm that fits nicely with the general factors
approach to treatment (Bickel & Mueller, 2009; Norton, 2012). By integrat-
ing these “common” factors that specify good behavior change guidance,
adding shared elements from other approaches such as cognitive and behav-
ioral therapy, and applying them across different behaviors and symptoms,
we can promote more widespread dissemination of evidence-based treat-
ments and improve the ease of implementation and training. This approach
can also more easily address common comorbidities and address multiple
behavior change.
Transdiagnostic or unified treatments are defined as those that apply
the same underlying treatment principles across conditions or behaviors
instead of delivering different specific treatments for different conditions
(McEvoy, Nathan, & Norton, 2009). Transdiagnostic protocols are indi-
vidualized during the treatment planning process. The term unified has
also been used to refer to unified treatment plans that address mental and
physical health (comorbidities in the diagnostic arena) such as depression
and chronic illness management or obesity and substance use. We believe
that motivational interviewing, with the integration of additional shared
treatment elements from evidence-based approaches when necessary (e.g.,
skills training), can serve as a unified treatment approach to improve men-
tal and physical health. In addition to demonstrating MI spirit as the foun-
dation for good behavior change practice, Moyers and colleagues (2007)
have found that change talk is related to behavior change across differ-
ent treatment approaches, suggesting that evoking change talk may be an
important key to success across different treatment approaches (Miller &
Moyers, 2021).
To ensure that a unified treatment will work with young people across
different target behaviors, symptoms, and contexts, more research is nec-
essary. Despite the growth of MI research with adolescents and young
adults described in Chapter 1, more evidence is needed as there are still
many fewer studies, reviews, and meta-analyses compared to MI research
on adults. The research on MI with caregivers of young people is par-
ticularly scarce, and there is very little evidence to determine if MI with
younger adolescents is very different or efficacious compared to MI with
older adolescents or young adults.
Future Directions 193
Multiple Behavior Change and Comorbidity
When considering MI as a transdiagnostic treatment, the dilemma arises

regarding how to handle multiple behavior change. Targeting two or more
related behaviors may increase providers’ ability to help individuals make
more meaningful changes with fewer costs and resources than if each
behavior was targeted separately (Prochaska, Spring, & Nigg, 2008). In
our own work on brief interventions with young people, we have found that
two behaviors over four sessions was the maximum number to consider
(Naar et al., 2020; Naar-King, Parsons, et al., 2009). You can choose how to
extrapolate that guideline to multisession treatments. We have traditionally
handled the initial MI sessions for each behavior in a sequential manner and
then linked the behaviors together to address simultaneously in subsequent
sessions.
A 2011 review found only four studies that directly compared simul-
taneous and sequential approaches to multiple behavior change, all with
adults (Prochaska & Prochaska, 2011). Three studies targeted tobacco and
diet (Spring et al., 2004), tobacco and alcohol (Joseph, Willenbring, Nugent,
& Nelson, 2004), and physical activity and diet (Vandelanotte, De Bourde-
audhuij, Sallis, Spittaels, & Brug, 2005). There were no differences between
simultaneous and sequential interventions on long-term outcomes. In one
study targeting physical activity, smoking, and salt intake, the simultaneous
intervention was superior to the sequential intervention (Hyman, Pavlik,
Taylor, Goodrick, & Moye, 2007). Most of the studies used skills-building
interventions but not necessarily MI. However, in synthesis of meta-
analyses and reviews of physical activity and nutrition target behaviors,
single behavioral treatments (activity only or nutrition only) were superior
to interventions targeting both simultaneously (Sweet & Fortier, 2010). We
found one additional study published since that review (King et al., 2013)
comparing simultaneous targeting of nutrition and physical activity with
two sequential plans—physical activity first and nutrition first—and a con-
trol condition matched for length of treatment. After 4 months of treatment,
the physical activity-first condition resulted in greater changes in activity
compared to the other three conditions. Both sequential and simultaneous
interventions were better than the control condition in changing nutrition.
However, long-term outcomes (12 months) were not different by condition,
with one exception. The nutrition-first sequential condition seemed to sup-
press physical activity changes; thus, the authors recommended a simulta-
neous approach based on the findings overall.
Similar concerns arise when treating “comorbid” conditions, such
as depression and alcohol use or anxiety and attention-deficit concerns.
Options include sequential treatment, parallel treatment, and integrated
treatments. Historically, sequential treatment has been the most common,

and in the case of comorbid mental health and substance abuse conditions,
the patient may engage in one treatment system and then the other with
separate treatments and practitioners. In the parallel treatment approach,
treatments are provided separately but simultaneously. If different prac-
titioners are providing treatments, adequate coordination becomes espe-
cially critical. Integrated treatment is also simultaneous, but both condi-
tions are treated by the same practitioner and the interrelationship between
conditions is explicitly addressed. The same treatment strategies may be
used to target similar symptom clusters. Again, there is limited data on the
best approach with adults, and even less with young people.
Clinically, we have found that many young people feel overwhelmed
trying to make too many behavior changes at once. Until the data clearly
suggest how to address multiple behavior change, we believe the best
approach is to allow the client to choose as part of agenda setting and col-
laborative treatment planning by providing a menu of options.
Translating Research to Practice:

Training Research and Implementation Science
How does research evidence move out from the academic world and into
the world of service settings? There are three ways that differ in the effort
involved (Glasgow et al., 2012). Diffusion is the passive process that occurs
when evidence is used in the real world without promotion efforts. Dissemi-
nation includes the formal, planned efforts to spread knowledge or infor-
mation about evidence-based practices. Implementation science studies the
methods and strategies used to promote the adoption and integration of
evidence-based practices into different settings. The last decade has seen
a burgeoning of implementation science funding, methodologically rigor-
ous implementation trials testing different implementation interventions
or packages of implementation strategies, and the increasing impact of a
dedicated journal, Implementation Science. The MI training trials reviewed
in Chapter 11 are examples of one component of implementation science as
they focus on how to train practitioners to deliver evidence-based practice
and the outcomes address quality of dissemination. However, as noted in
Chapter 11, there are very few randomized controlled trials of training of
practitioners serving young people. There are also many unanswered ques-
tions including training dose, predicting and managing variability in train-
ing response, and understanding the inner and outer organizational barriers
and facilitators of quality implementation in different service settings. We
describe our current implementation trial of MI in adolescent HIV clinics
as an example of future directions in MI and implementation science.
The Tailored Motivational Interviewing (TMI) protocol is part of

the Scale It Up Program within the Adolescent Trials Network for HIV/
AIDS. TMI is a type 3, hybrid implementation-effectiveness trial. This
means the study tests the effect of implementation strategies on a pri-
mary implementation outcome (MI competence) and on secondary effec-
tiveness outcomes (retention in HIV care and viral suppression). Using
an innovative randomized design, 10 clinical sites in the United States
(150 multidisciplinary providers) are randomized two at a time every 3
months to receive the implementation package. After 1 year, sites are re-
randomized to [two different sustainment conditions, a dedicated local MI
coach and a communities of practice model]. In addition to assessing MI
competence with coded standard patient interactions using the MI Coach
Rating Scale (see Chapter 11), we assess the context of implementation
with a series of practitioner and key stakeholder qualitative interviews and
surveys.
The implementation intervention strategies follow the phases of the
EPIS implementation science model (exploration, preparation, implementa-
tion, and sustainment; see https://episframework.com).
Exploration Phase
The exploration phase involves a multilevel assessment of system, organi-
zation, provider, and client characteristics, including the following:
1. Anticipated barriers and facilitators of adoption and use of MI and

proposed implementation intervention strategies within the inner
(provider, clinic, and organization) and outer (system) contexts.
2. Ideas to promote sustainability in terms of integration into program
and clinic policies.
3. Identification of key stakeholders for the local implementation
teams (iTeam). In addition to these data, baseline quantitative data
on provider competency is collected in this phase.
Preparation Phase
In the preparation phase, a continuous information feedback loop is cre-
ated such that information gathered during the assessments are used by the
iTeam to make adjustments to the implementation strategies while main-
taining fidelity to mandatory implementation intervention components.
The iTeam has monthly conference calls during this period to review and
amend the barrier and facilitator data and iteratively draft locally custom-
ized implementation strategies.
Implementation Phase
The implementation begins with a 12-hour skills workshop delivered by
members of the Motivational Interviewing Network of Trainers. The work-
shop was tailored for adolescent HIV in our prior studies (Bartlett, Cheever,
Johnson, & Paauw, 2004; Outlaw et al., 2011). There are two mandatory
individual phone coaching sessions in the 3 months following training.
Subsequently, practitioners complete a quarterly competency assessment
and receive automated emailed feedback listing strengths and weaknesses
and suggested practice activities. This report includes a recommendation
for mandatory coaching for scores below intermediate competency and
optional maintenance coaching for scores in the intermediate or advanced
range. The duration of coaching sessions is 45–60 minutes, and they are
delivered by a member of the Motivational Interviewing Network of Train-
ers. The standardized coaching includes a brief interaction to elicit change
talk on MI implementation, feedback on two highest and two lowest ratings,
and review of the audio-recorded standard patient interactions and specific
coaching activities based on the low scoring item ratings. The iTeam con-
tinues to monitor adaptations at the provider and inner and outer organiza-
tional contexts as well as any fidelity drift and plan for sustainability. The
iTeam is encouraged to obtain youth perspectives and is offered the Cli-
ent Evaluation of Motivational Interviewing (Madson et al., 2013) to obtain
anonymous, postvisit “satisfaction” ratings.
Sustainment Phase
In the sustainment phase, the iTeam is encouraged to keep meeting with-
out external facilitation to review practitioner competency data and adher-
ence to coaching sessions and address barriers and facilitators to ongoing
MI fidelity. The iTeam is given a communities of practice manual that
includes recommendations for Rosengren’s Building Motivational Inter-
viewing Skills: A Practitioner Workbook (Rosengren, 2017). The sites ran-
domized to a dedicated local coach receive the equivalent of 10% funding
for the coach, who must achieve advanced competency ratings and complete
a five-session coach training. At the time of this writing, data collection is
complete and analysis is underway. From these findings, we will refine the
implementation strategies and also adapt strategies for public health and
community-based settings, as opposed to the academic medical centers in
the current trial.
While our own work has focused on implementation of MI in service
settings, another future direction is the study of implementation of MI in
educational settings such as psychology, social work, medicine, nursing,
pharmacy, and paraprofessional certification programs. Another growing
area is the use of MI with staff and organizational leaders to promote orga-
nizational change (Grimolizzi-Jensen, 2018; Marshall & Nielsen, 2020).
The Motivational Interviewing Network of Trainers (https://motivation-
alinterviewing.org) is also undergoing organizational changes and is con-
sidering how to implement more formalized certification for practitioners
and trainers. We expect to see more about this in the future. Finally, we
hope to see more MI training studies that use technology to extend training
reach, particularly to resource-limited settings that provide alternatives to
in-person trainings in light of recent pandemics and that promote evidence-
based self-learning.
Using Technology to Deliver MI
The last decade has seen enormous growth of technology-delivered behav-

ioral interventions. In addition to new studies of MI telehealth and videocon-
ferencing (e.g., Schumacher, Madson, & Norquist, 2011), there have been a
few studies of MI-based text messaging, emailing, and online chatting (e.g.,
Armstrong et al., 2018; Jorayeva, Ridner, Hall, Staten, & Walker, 2017).
Several studies have demonstrated the efficacy of computer-delivered MI
as a way of increasing reach, replicability, and potentially cost-effectiveness
(see Shingleton & Palfai, 2016, for a review), but with limited studies com-
paring computer-delivered with face-to-face treatments. One study (Mar-
tino et al., 2018) found that computer-delivered screening, brief interven-
tion, and referral had an advantage over the same approach delivered by
reproductive health clinicians in reducing substance misuse in pregnant
women. The computer-delivered intervention was also more cost-effective
(Olmstead et al., 2019).
As an example of a computer-delivered MI intervention with young
people, we describe our work using the Computer Intervention Author-
ing Software (Ondersma, Svikis, & Schuster, 2007) to develop and test
the Motivational Enhancement System for Adherence (MESA), designed
to prevent adherence problems in youth newly beginning HIV medications
in two 30-minute sessions delivered 1 month apart. The intervention is
tailored in several ways (Naar-King et al., 2013; Outlaw et al., 2014): (1)
youth choose an avatar that serves as a virtual counselor; (2) the interac-
tive intervention is individualized based on MI principles (e.g., the avatar
reflects participants’ motivational language and affirms behave change
intentions); (3) participants are routed through arms of the program based
on their ratings of importance and confidence, and choices for goal setting;
(4) participants receive personalized feedback and HIV education (with per-
mission) based on their recent medical information and response to an HIV
treatment knowledge questionnaire; (5) participants may choose to read
through the intervention screens or be read to, based on their literacy level
and choice; and (6) all intervention content was reviewed by youth advisory
groups across the country as well as medical, nursing, and psychosocial
providers to ensure appropriate tailoring for the cultural context of adoles-
cent HIV in the United States (such as age appropriateness of language, and
appropriateness for ethnic and sexual minority youth). In a pilot randomized
trial (Naar-King et al., 2013) comparing MESA to a comparison condition of
a similar computer program targeting nutrition and physical activity, effect
sizes for adherence and viral load suppression were medium to large at 3-
and 6-month follow-up. MESA is currently being tested in a multisite full-
scale trial. Figure 13.1 demonstrates the flow of the computer-delivered MI
session.
Machine Learning
In the last decade, advances in computational approaches have analyzed

behavior change interactions to develop tools for automatic evaluation of
quality and to understand the nature of relationships between practitioner
and client (Pérez-Rosas et al., 2018). The first approach has the potential
for autocoding transcripts or recordings of interactions for automated feed-
back to the counselor, reducing time and cost of current coding procedures.
The second approach will allow us to continue to refine MI skills, but iden-
tifying practitioner language most associated with client behavior change
language. In our own pilot work, we were able to identify such sequences
in a sample of African American youth using machine learning trained on
sequentially coded transcripts (Hasan et al., 2019). Using the TMI project
above and three other projects with MI interactions with young people, we
will now develop a deep neural network-based model for automated coding
of youth and practitioner language from MI transcripts. We will then com-
pare two methods of automated annotation and compare accuracy to tradi-
tional coding methods. And last, we will identify communication sequences
to determine which autocoded practitioner communication behaviors pre-
dict youth change talk and commitment language. Transcript coding and
computational analysis is underway and is expected to be disseminated by
the end of 2021.
Final Words: Your Future Directions
We maintain that the best way to practice, train, or conduct research in MI

is to listen to the feedback and guidance you receive from the young per-
sons and families you serve. They will be your best teachers. Remember
Importance of adherence
Low High
Pros and cons Reasons it’s important
No feedback
Feedback Feedback
(options to select feedback (options to select feedback
on VL, CD4, knowledge) on VL, CD4, knowledge)
Confidence for adherence
Low High
My strengths and abilities My abilities and plan

• Past successes • Past successes
• My personal strengths • My personal strengths
• How I’ve done it
• Developing a plan
• Review skills and resources

available
• Developing a plan My great Putting Getting myself
plan more prepared
(100% thought (practice
adherence) into it steps)
A great Putting Getting
plan some prepared
(100% thought (practice
adherence) into it steps) Wrapping
My wrap-up Summarizing
it up
Summary Wrapping Wrap-up

up
Thank you!
FIGURE 13.1. Example of computer-delivered MI.
that the process of your learning and doing MI is much akin to a young
person’s journey of development and change, and one that will be unique to
you. What we hope you will take from this is that there is no one right way
“to do” MI. It takes two to tango to MI, and when you are working with
young people, it often takes three, four, or more, depending on the size of
the family! Recall also that practice over time with guided feedback is the
key to becoming proficient. This mantra applies even once you are well
down the path of having learned MI. If you stop playing your instrument,
your skills will fade. After initially acquiring MI skills, the final and ongoing
step involves the generalization and continued refinement of these skills.
We have provided several suggestions for continuing your own journey of
change, including workshop attendance, coaching and supervision, review
of taped sessions, peer supervision, and most important, listening to the
talk of young people. These are all paths for you to choose in your journey
of learning MI. Which one will you choose next?
Practitioner Activity 13.1. Future Directions
Activity Goal: To develop your own change plan
Activity Instructions: Consider your future directions with MI practice, training,

or research with adolescents and young adults. Complete the change plan steps
for your goal(s) and share with a colleague.
My Change Plan
Changes I would like to make related to MI practice, training, or research

with adolescents and young adults:
These changes are important to me because:
I plan to take these steps (what, where, when, how):
If this gets in the way, then try this:

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Index
Note. f or t following a page number indicates a figure or table.
Ability type of change talk. See also Change Affirmation. See also Acceptance
talk agreement with a twist strategy and,
activity/questions to explore, 99 66–67
caregiver involvement and, 156t compassion and, 33
DARN (desires, abilities, reasons, and complex reflections and, 81–83, 82f
needs) acronym and, 75–76, 75t group delivery of MI and, 143–144
open questions to elicit, 86t OARS acronym and, 8–9
Absolute worth, 29–31, 154. See also overview, 32, 60
Acceptance reinforcing change talk and, 78f, 96t
Acceptance. See also Absolute worth; stop, drop, and roll strategy and, 60
Accurate empathy; Affirmation; Affirmation Card Sort activity, 89–90
Autonomy; Spirit of MI Affirming reflections, 81–83, 82f. See also
caregiver involvement and, 154 Complex reflections
group delivery of MI and, 142–143, 143t Agenda setting. See also Goals
overview, 29–32 caregiver involvement and, 158–159
Acceptance and commitment therapy (ACT), ethical considerations and, 182–183,
103, 107, 141 184–187
Accurate empathy, 31, 58–60, 59t. See also focusing processes and, 107–109, 109f
Acceptance; Empathy group delivery of MI and, 145–146
Action reflections, 83. See also Complex multiple agendas and, 182–183, 184
reflections values and, 109–110
Active listening skills, 5. See also Listening Agreement with a twist strategy, 66–67
Addiction, opiate. See Opiate addiction; Alcohol use. See also Substance use
Substance use Ask–Tell–Ask strategy and, 49
Adolescent groups. See Group delivery of MI evidence that supports the use of MI and,
Adolescent stage. See also Developmental 7
processes research support for training in the use of
brain development and, 23–24 MI and, 166–167, 168
identity formation and, 20 using MI with, 11–13
overview, 2, 25, 26t Alienation, sense of, 2
Adolescent Trials Network for HIV/AIDS, Ambivalence. See also Counter-change talk;
194–197 Discord; Sustain talk
Adulthood, emerging. See Emerging agreement with a twist strategy and,
adulthood stage 66–67
Advice. See also Feedback; Providing amplified reflection strategy and, 63–64
information behavior change and, 5–6
ambivalence regarding, 2–3 caregiver involvement and, 154, 159
Ask–Tell–Ask strategy and, 46–50, 50t change plans and, 119–120
comparing MI to other approaches and, 37t complex reflections and, 83
evoking processes and, 33, 110 group delivery of MI and, 147
group delivery of MI and, 145–146 integrating MI with other treatments and,
planning processes and, 116, 118 131
215
216 Index
Ambivalence (continued) roadblocks to accurate empathy and, 59t

overview, 2–3, 4 you and your statements and, 44
planning processes and, 112 Brain development, 23–24, 26t. See also
pros and cons strategy and, 64–66 Developmental processes
reinforcing change talk and, 77
stop, drop, and roll strategy and, 56–62,
59t Caregiver involvement
Amplified reflection strategy, 63–64 activity/questions to explore, 163–164
Anxiety, 13, 49–50 negotiating with the caregiver(s), 153–154
Apology, 60–61, 67t negotiating with the young person,
Asking for permission 152–153
agenda setting and, 108 overview, 11, 33, 152, 162, 162t
caregiver involvement and, 159 processes of MI and, 158–161
group delivery of MI and, 143 skills of MI and, 155–158, 156t
Ask–Tell–Ask strategy. See also Elicitation spirit of MI and, 154–155
autonomy and, 50t when to consider family-based treatment
caregiver involvement and, 153, 154–155 as the primary modality and, 161–162
evoking processes and, 110–111 Change. See also Change plan; Change talk;
group delivery of MI and, 143, 147, 148 Counter-change talk; Maintaining
overview, 46–50 change
planning processes and, 116 ambivalence regarding, 2–3
pros and cons strategy and, 66 multiple behavior change and, 193–194
stop, drop, and roll strategy and, 61 Change plan. See also Planning processes
using to provide feedback, 92, 96t caregiver involvement and, 157, 160–161
Assessment, 104–105, 130 components of, 116–119, 117t
Assessment trap, 104–106, 105t, 145 following up on in order to maintain
Assumption, 37t change, 128–129
Autonomy. See also Acceptance; Choice group delivery of MI and, 147
activity/questions to explore, 54 overview, 115–116
Ask–Tell–Ask strategy and, 46–50 when the youth is not ready for change,
caregiver involvement and, 155, 156 119–120
choice and, 45 Change talk. See also Commitment language;
complex reflections and, 79 Counter-change talk; If–then plans
evoking processes and, 33 activity/questions to explore, 99–100
group delivery of MI and, 143, 144, 148 caregiver involvement and, 155–158, 156t
overview, 9f, 10, 30–31, 42–43, 50, choice and, 45
50t–53t complex reflections and, 79–83, 80f, 81f,
reinforcing change talk and, 77, 78f 82f
roadblocks to accurate empathy and, 59t eliciting, 84–94
social and emotional development and, evoking processes and, 110–112
21, 26t extrinsic motivation approaches and, 133
special populations and, 51t–53t following up on in order to maintain
spirit of MI and, 37t change, 128–129
stop, drop, and roll strategy and, 61–62 group delivery of MI and, 142, 143–144,
supporting, 42–43, 50, 50t–53t 147
you and your statements and, 43–46 listening for, 113
Avoidance, 58, 60, 110 overview, 4, 4f, 9f, 10, 74–75, 93–94,
95t–98t
recognizing, 75–76, 75t
Behavior. See also Criminal behavior; reinforcing, 76–83, 78f, 80f, 81f, 82f, 93–94
Health behaviors; High-risk behaviors ruler strategy and, 90–91
ambivalence regarding change and, 5–6 simple reflections and, 77–79, 78f
impulsive behavior, 23–24, 155 with special populations, 96t–98t
multiple behavior change and, 193–194 transitioning from evoking to planning
social and emotional development and, 21 and, 114–115
Behavioral autonomy, 21. See also Autonomy types of, 86t, 99, 156t
Between-session practice, 130–131 Chat trap, 105t, 145
Biological factors, 2, 23–24 Child protection settings, 166
Blame Choice. See also Autonomy
blaming trap, 105t, 145 activity/questions to explore, 54
caregiver involvement and, 156–157 agenda setting and, 107–109, 109f
Index 217
Ask–Tell–Ask strategy and, 46–50 Communities of practice (CoP), 173–175. See

caregiver involvement and, 154 also Training in the use of MI
extrinsic motivation approaches and, 132 Comorbidity, 193–194
group delivery of MI and, 143 Comparison, 37t
overview, 42–43, 50, 50t–53t Compassion. See also Spirit of MI
special populations and, 51t–53t caregiver involvement and, 154
spirit of MI and, 37t ethical considerations and, 181
stop, drop, and roll strategy and, 56 group delivery of MI and, 142–143, 143t
you and your statements and, 45–46 overview, 32–33
Chunk–Check–Chunk approach, 47. See also spirit of MI and, 37t
Ask–Tell–Ask strategy Competency, 32
Client feeling reflection, 80–81. See also Complex reflections, 76, 79, 80–83, 80f, 81f,
Complex reflections 82f. See also Reflections
Closed questions, 78–79, 78f. See also Computer Intervention Authoring Software,
Questions 197–198, 199f
Coaching in MI, 169–173, 171t–172t. See also Computer-delivered MI, 197–198, 199f
Training in the use of MI Confidence in parenting, 156–157
Cognitive control, 23–24 Confidentiality. See also Ethics and MI
Cognitive coping strategies, 5–6 Ask–Tell–Ask strategy and, 47
Cognitive development. See also caregiver involvement and, 158
Developmental processes Consequences
activity/questions to explore, 27 autonomy and, 50t
developmental neuroscience and, 23–24 caregiver involvement and, 154–155
overview, 18–19, 26t evoking processes and, 34
social and emotional development and, group delivery of MI and, 147
19–23 Contingency management approaches,
social media and, 24–25 132–133
Cognitive-behavioral interventions Control
caregiver involvement and, 161 ethical considerations and, 186–187
integrating motivational interviewing into, spirit of MI and, 37t
4, 130–132 Convincer role
processes of MI and, 102 autonomy and, 50t
Collaboration. See also Partnership; Spirit comparing MI to other approaches and, 36t
of MI Coping skills, 5–6
agenda setting and, 107–109, 109f Core skills of MI. See Skills of MI
caregiver involvement and, 154–155 Counter-change talk. See also Ambivalence;
group delivery of MI and, 145–146 Change talk; Discord
overview, 28–29, 37t agreement with a twist strategy and,
partnership and, 28–29, 142–143, 143t 66–67
you and your statements and, 43–44 amplified reflection strategy and, 63–64
Come alongside strategy, 64 caregiver involvement and, 157–158
Commitment language. See also Change talk choice and, 45
caregiver involvement and, 155–157, 156t comparing MI to other approaches and, 36t
components of a change plan and, 117t evoking processes and, 110
group delivery of MI and, 142, 147 group delivery of MI and, 142, 145–146,
listening for, 113 147
overview, 10, 113 listening for, 113–114
planning processes and, 118, 120–121 overview, 9f, 55–56
reinforcing change talk and, 76 pros and cons strategy and, 64–66
transitioning from evoking to planning responding to, 55–56, 67, 67t–70t
and, 114–115 special populations and, 68t–70t
types of change talk and, 86t, 156t stop, drop, and roll strategy and, 56–62,
Communication. See also Language factors 59t
accurate empathy and, 31 training in the use of MI and, 8–9
amplified reflection strategy and, 63–64 Criminal behavior. See also Juvenile
caregiver involvement and, 154, 156 delinquency
group delivery of MI and, 142, 144 eliciting and elaborating change talk with, 96t
stop, drop, and roll strategy and, 61–62 maintaining change and, 135t
traps that promote disengagement and, processes of MI and, 123t
104, 105t research support for training in the use of
you and your statements and, 43–46 MI and, 166
218 Index
Criminal behavior (continued) Dissemination, 194

stop, drop, and roll strategy and, 68t Distraction, 59t
supporting autonomy and, 51t Distress, 33
Double-sided reflection, 80, 81f. See also
Complex reflections
DARN (desires, abilities, reasons, and Drug use. See also Substance use
needs) acronym, 75–76, 75t. See also Ask–Tell–Ask strategy and, 49
Ability type of change talk; Change talk; eliciting and elaborating change talk with,
Desire type of change talk; Need type 98t
of change talk; Reasons type of change ethical considerations and, 186–187
talk evidence that supports the use of MI and, 7
Decisional balance strategy, 64–66 processes of MI and, 125t
Decision-making processes research support for training in the use of
autonomy and, 21, 50t MI and, 168
caregiver involvement and, 155 spirit of MI and, 39t
developmental processes and, 19 stop, drop, and roll strategy and, 70t
evoking processes and, 110 supporting autonomy and, 53t
extrinsic motivation approaches and, 132 using MI with, 11–13
family relationships and, 21–22
peer relationships and, 22–23
you and your statements and, 45–46 Eating disorders
Denial label, 36t eliciting and elaborating change talk with,
Denial of problems, 59t 97t
Desire type of change talk. See also Change maintaining change and, 136t
talk processes of MI and, 123t
activity/questions to explore, 99 spirit of MI and, 38t
caregiver involvement and, 156t stop, drop, and roll strategy and, 68t
DARN (desires, abilities, reasons, and supporting autonomy and, 51t
needs) acronym and, 75–76, 75t Elicitation. See also Ask–Tell–Ask strategy;
open questions to elicit, 86t Change talk; Evoking processes;
Developmental processes. See also Questions
Adolescent stage; Cognitive activity/questions to explore, 99–100
development; Emerging adulthood stage Ask–Tell–Ask strategy and, 46–50
activity/questions to explore, 27 caregiver involvement and, 155–157, 156t
caregiver involvement and, 155 examples of, 93–94
developmental neuroscience and, 23–24 extrinsic motivation approaches and, 133
overview, 10, 25, 26t group delivery of MI and, 143–144,
puberty, 2, 23–24 146–147
social and emotional development and, overview, 93–94, 95t–96t
19–23 pros and cons strategy and, 64–66
stage theory and, 18–19 with special populations, 96t–98t
Diagnostic focus, 36t spirit of MI and, 37t
Diffusion, 194 Elicit–provide–elicit strategy. See Ask–Tell–
Direct questions, 84–88, 86t. See also Open Ask strategy
questions; Questions Elimination strategies, 19
Directive approach, 36t Emerging adulthood stage, 2, 20–23, 25, 26t,
Disbelief, 44 180. See also Developmental processes
Disconfirmatory strategies, 19 Emotion reflection, 81, 81f, 146. See also
Discord. See also Ambivalence; Counter- Complex reflections
change talk Emotional autonomy, 21. See also Autonomy
agreement with a twist strategy and, Emotional context. See also Social–emotional
66–67 development
amplified reflection strategy and, 63–64 emotion regulation, 23–24
caregiver involvement and, 157–158 emotional intensity and, 115
comparing MI to other approaches and, 36t social and emotional development and,
group delivery of MI and, 142, 145–146 21, 26t
overview, 9f, 10, 55–56 you and your statements and, 44
pros and cons strategy and, 64–66 Empathy
responding to, 55–56, 67, 67t–70t agreement with a twist strategy and,
special populations and, 68t–70t 66–67
stop, drop, and roll strategy and, 56–62, 59t amplified reflection strategy and, 63–64
Index 219
comparing MI to other approaches and, Feedback. See also Advice; Providing

37t information
maintaining change and, 129 Ask–Tell–Ask strategy and, 46–50, 50t
overview, 31 comparing MI to other approaches and, 37t
spirit of MI and, 37t eliciting and elaborating change talk with,
stop, drop, and roll strategy and, 58–60, 92–93, 96t
59t group delivery of MI and, 143, 146–147
Emphasizing autonomy. See Autonomy Feedback in using MI, 169–173, 171t–172t.
Engaging processes. See also Processes of See also Training in the use of MI
MI Feelings reflection, 81, 81f, 146. See also
activity/questions to explore, 126–127 Complex reflections
caregiver involvement and, 158 Focusing processes. See also Processes of
group delivery of MI and, 144–145 MI; Shifting focus
overview, 9f, 102–103, 102f, 104–107, 105t, activity/questions to explore, 126–127
122, 122t–125t agenda setting and, 107–109, 109f
with special populations, 123t–125t caregiver involvement and, 158–159
traps that promote disengagement and, group delivery of MI and, 145–146
104, 105t overview, 9f, 102–103, 102f, 107–110, 109f,
values and, 106–107 122, 122t–125t
Ethics and MI with special populations, 123t–125t
activity/questions to explore, 189–190 stop, drop, and roll strategy and, 61–62, 67t
confidentiality and, 47, 158 values and, 109–110
guidelines for, 183–187 Friendships. See Peer relationships
influence and, 179–180 Functional assessment, 130
multiple agendas and, 182–183 Future directions for MI
overview, 179, 189 activity/questions to explore, 200
self-disclosure and, 187–188 comorbidity and multiple behavior change
social media and, 189 and, 193–194
values and goals and, 180–182 implementation science and, 194–197
Evoking processes. See also Elicitation; overview, 191, 198–200
Processes of MI; Reinforcing change technology in the implementation of MI
talk; Spirit of MI and, 197–198, 199f
activity/questions to explore, 126–127 transdiagnostic treatment, 191–192
caregiver involvement and, 159–160
group delivery of MI and, 142–143, 143t,
146–147 Goal-oriented skills, 5, 34
overview, 9f, 33–35, 102–103, 102f, Goals. See also Agenda setting; Change plan;
110–112, 122, 122t–125t Planning processes; Values
with special populations, 123t–125t autonomy and, 50t
spirit of MI and, 37t caregiver involvement and, 158–159
transitioning from evoking to planning comparing MI to other approaches and, 36t
and, 114–115 complex reflections and, 83
Executive functions, 23–24 components of a change plan and, 117t
Expectations, 32 developing a change plan and, 118–119
Expert role, 36t, 50t ethical considerations and, 180–182,
Expert trap, 105t, 145 184–187
Exploration, 44 following up on in order to maintain
Exploration phase of implementation, 195. change, 128–129
See also Implementation group delivery of MI and, 145
External consequences. See Consequences multiple agendas and, 182–183, 184
Extrinsic motivation, 5, 132–133. See also multiple behavior change and, 193–194
Motivation partnership with the young person and, 29
visual tools and, 108–109, 109f
when the youth is not ready for change,
Family behavior plans, 132–133 119–120
Family relationships, 21–22, 23, 26t. See also Group delivery of MI
Relationships activity/questions to explore, 150–151
Family values and goals, 180–181 engaging processes and, 144–145
Family-based treatment, 152, 161–162. See evoking processes and, 146–147
also Caregiver involvement focusing processes and, 145–146
Faults, emphasizing, 59t maintaining change and, 147–148
220 Index
Group delivery of MI (continued) following up on in order to maintain

overview, 11, 141–142, 148, 149t change, 128–129
planning processes and, 147 group delivery of MI and, 147
processes of MI and, 144–148 Imagining questions, 88–90. See also Open
spirit and skills of MI and, 142–144, 143t questions; Questions
Guiding style Implementation, 194–198, 199f
comparing MI to other approaches and, Implication reflection, 80, 80f. See also
36t–37t Complex reflections
group delivery of MI and, 142 Impulsive behaviors, 23–24, 155. See also
guide role, 43–44, 50t Behavior
partnership with the young person and, Inadequacies, emphasizing, 59t
28–29 Incorporating MI. See Learning MI
planning processes and, 116 Inflection, 78, 95t
spirit of MI and, 37t Influence, 179–180
Information, providing. See Providing
information
Health behaviors. See also Behavior; High- Information processing, 19, 26t
risk behaviors; Sexual health Information–motivation–behavior skills
Ask–Tell–Ask strategy and, 48–49 model, 5
decision-making processes and, 19 Integrative approach. See also Group delivery
eliciting and elaborating change talk with, 98t of MI
ethical considerations and, 184–186 maintaining change and, 129–133
evidence that supports the use of MI and, MI as, 9
7–8, 167–168 transdiagnostic treatment and, 191–192
evoking processes and, 111–112 Interpretation biases, 19
group delivery of MI and, 147 Intrinsic motivation, 5–6, 34. See also
maintaining change and, 136t Motivation
overview, 2 Investment, 181, 185–186
processes of MI and, 123t–125t
stop, drop, and roll strategy and, 69t–70t
supporting autonomy and, 52t–53t
training in the use of MI and, 167–168 Juvenile delinquency, 38t, 186–187. See also
using MI with, 11–14 Criminal behavior
Higher-order thought processes, 19
High-risk behaviors. See also Behavior;
Criminal behavior; Health behaviors
ambivalence regarding changing, 2–3 L abeling trap, 105t, 142–143, 144–145, 148
brain development and, 23–24 Labels, 36t
decision-making processes and, 19 Language factors. See also Communication
emerging adulthood and, 20–21 comparing MI to other approaches and,
overview, 2 36t
using MI with, 11–14 complex reflections and, 79
HIV management. See also Health behaviors processes of MI and, 103
implementation science and, 194–197 stop, drop, and roll strategy and, 61–62
research support for training in the use of Lapse, 129
MI and, 167–168 Learning MI. See also Training in the use
technology in the implementation of MI of MI
and, 197–198, 199f activity/questions to explore, 176–178
using MI with, 14 future directions for MI and, 198–200
Homework. See Between-session practice implementation and, 194–197
Hope overview, 165–168, 176
affirmation and, 32 promoting your own MI development,
caregiver involvement and, 160–161 168–175, 171t–172t
compassion and, 33 Listening
components of a change plan and, 117t accurate empathy and, 31
active listening, 5
planning processes and, 113
Identity, 19–23, 26t Long-term values/goals, 111–112. See also
If–then plans. See also Change plan Goals; Values
caregiver involvement and, 160–161 Looking-backward strategy, 89
components of a change plan and, 117t Looking-forward strategy, 88–89
Index 221
M achine learning, 198 Negative feelings, 56–62, 59t

Maintaining change. See also Change; Neurodevelopmental conditions
Processes of MI eliciting and elaborating change talk with,
activity/questions to explore, 138–140 97t
caregiver involvement and, 161 maintaining change and, 137t
following up on planning and, 128–129 processes of MI and, 124t
group delivery of MI and, 147–148 spirit of MI and, 38t
integrating MI with other treatments and, stop, drop, and roll strategy and, 69t
129–133 supporting autonomy and, 52t
overview, 11, 101–103, 102f, 128, 134, Neuroimaging research, 24, 26t
135t–137t Neuroscience, 23–24, 26t
special populations and, 135t–137t Nondirective approach, 37t
termination and, 134 Normative feedback. See also Feedback
training in the use of MI and, 8–9 eliciting and elaborating change talk with,
Media, social. See Social media 92–93
Medication management, 48, 184–185. See group delivery of MI and, 143, 146–147
also Health behaviors
Menu of options
autonomy and, 47, 48–50, 50t OARS (open questions, affirmations,
caregiver involvement and, 159 reflections, and summaries), 8–9, 74–75.
complex reflections and, 79 See also Affirmation; Open questions;
planning processes and, 116 Reflections; Summaries
stop, drop, and roll strategy and, 61 Offering information or advice. See Advice;
Minimizing statements, 63–64 Providing information
Motivation Open questions. See also Questions
comparing MI to other approaches and, activity/questions to explore, 99–100
36t–37t direct questions, 84–88, 86t
evoking processes and, 34 eliciting and elaborating change talk with,
extrinsic motivation, 5, 132–133 84–90, 86t
extrinsic motivation approaches and, 132 imagining questions, 88–90
intrinsic motivation, 5–6, 34 OARS acronym and, 8–9, 74–75
theories of, 5 reinforcing change talk and, 76, 78f
Motivational Enhancement System for Opiate addiction. See also Drug use
Adherence (MESA), 197–198, 199f eliciting and elaborating change talk with,
Motivational Interviewing Coach Rating 98t
Scale (MI-CRS), 170, 171t–172t, processes of MI and, 125t
172–173 spirit of MI and, 39t
Motivational interviewing (MI) overview stop, drop, and roll strategy and, 70t
activity/questions to explore, 17 supporting autonomy and, 53t
comparing MI to other approaches, 35, Opinion, 181
36t–37t Optimism. See also Change talk
evidence that supports the use of MI, 6–8 affirmation and, 32
future directions for MI, 191–200, 199f caregiver involvement and, 160–161
learning and practicing, 8 compassion and, 33
overview, 3–6, 4f, 8–14, 9f, 15t–16t components of a change plan and, 117t
Motivational Interviewing Network of eliciting and elaborating change talk and,
Trainers (MINT), 173 90
Motivational Interviewing Treatment spirit of MI and, 37t
Integrity (MITI) coding system, 170, Ownership. See also Responsibility
172 autonomy and, 30–31
Multiple behavior change, 193–194 you and your statements and, 46
N eed, statements of, 76 PACE acronym. See Acceptance;

Need type of change talk. See also Change Compassion; Evoking processes;
talk Partnership; Spirit of MI
activity/questions to explore, 100 Parents. See also Caregiver involvement;
caregiver involvement and, 156t Family relationships; Relationships
DARN (desires, abilities, reasons, and compassion and, 33
needs) acronym and, 75–76, 75t parent–youth relationships, 21–22
open questions to elicit, 86t values and goals and, 180–181
222 Index
Partnership, 28–29, 142–143, 143t. See also Pressure from outside sources, 2, 144
Spirit of MI Problem solving, 33, 145–146
Paternalistic salesperson role, 37t Processes of MI. See also Engaging
Peer relationships. See also Relationships processes; Evoking processes; Focusing
emotional contexts of, 23 processes; Maintaining change;
social and emotional development and, Planning processes
22–23, 26t activity/questions to explore, 126–127
social media and, 25 caregiver involvement and, 158–161
Permission, asking for. See Asking for group delivery of MI and, 144–148
permission overview, 4f, 10–11, 102–103, 102f, 122,
Personal responsibility. See Responsibility 122t–125t
Personality development, 20. See also with special populations, 123t–125t
Developmental processes Progress, 128–129, 134. See also Maintaining
Personalized feedback. See also Feedback change
eliciting and elaborating change talk with, Pros and cons strategy, 64–66
92–93 Providing information. See also Advice;
group delivery of MI and, 147 Feedback
Person-centered skills, 5, 76 Ask–Tell–Ask strategy and, 46–50, 50t
Persuasion, 50t, 57–58 eliciting and elaborating change talk and,
Persuasive convincer role, 36t 92–93, 96t
Pessimism about change. See Counter- group delivery of MI and, 146–147
change talk planning processes and, 116, 118
Planning processes. See also Change plan; Psychological reactance, 56–62, 59t
Goals; Processes of MI Psychosocial personality development, 20.
activity/questions to explore, 126–127 See also Developmental processes
additional strategies for, 120–121 Puberty, 2, 23–24. See also Developmental
autonomy and, 50t processes
caregiver involvement and, 159–161 Punishment, 132–133
developing a plan, 115–120, 117t
following up on in order to maintain
change, 128–129 Questions. See also Closed questions; Open
group delivery of MI and, 147 questions
listening and, 113–114 activity/questions to explore, 99–100
overview, 9f, 102–103, 102f, 112–121, 117t, caregiver involvement and, 156
122, 122t–125t eliciting and elaborating change talk with,
with special populations, 123t–125t 84–90, 86t
transitioning from evoking to planning group delivery of MI and, 146
and, 114–115 reinforcing change talk and, 78f, 95t–96t
values and, 121 with special populations, 96t–98t
when the youth is not ready for change,
119–120
Power, 186–187 R eactance, psychological, 56–62, 59t
Practice between sessions. See Between- Reasoning, 110
session practice Reasons type of change talk. See also Change
Practitioner learning of MI. See Learning MI; talk
Training in the use of MI activity/questions to explore, 100
Practitioner traps that promote caregiver involvement and, 156t
disengagement. See Traps that promote DARN (desires, abilities, reasons, and
disengagement needs) acronym and, 75–76, 75t
Practitioner values and goals, 181–182 open questions to elicit, 86t
Premature focus trap, 105t, 145 Reflection of feelings. See also Accurate
Preparation phase of implementation, 195. empathy
See also Implementation amplified reflection strategy and, 63–64
Preparatory change talk, 75–76, 75t. See also stop, drop, and roll strategy and, 58–60,
Change talk 59t
Prescriptive approach Reflections
compared to a guiding style, 29 activity/questions to explore, 99–100
comparing MI to other approaches and, caregiver involvement and, 156
36t–37t complex reflections, 79–83, 80f, 81f, 82f
spirit of MI and, 37t group delivery of MI and, 143–144, 146
Index 223
OARS acronym and, 8–9, 74–75 Self-determination theory, 5, 30–31, 32

overview, 5 Self-disclosure, 187–188
reinforcing change talk and, 76–83, 78f, Self-efficacy
80f, 81f, 82f, 95t–96t caregiver involvement and, 156–157
simple reflections, 77–79, 78f complex reflections and, 79
Reinforcing change talk. See also Change spirit of MI and, 37t
talk; Evoking processes Self-governance, 30–31
activity/questions to explore, 99–100 Self-study, 168–169. See also Training in the
caregiver involvement and, 155–157, 156t use of MI
examples of, 93–94 Setbacks, 129, 145
group delivery of MI and, 146–147 Sexual health. See also Health behaviors
overview, 76–83, 78f, 80f, 81f, 82f, 93–94, eliciting and elaborating change talk with,
95t–96t 98t
with special populations, 96t–98t processes of MI and, 124t
Relapse, 129, 148 spirit of MI and, 39t
Relationships. See also Family relationships; stop, drop, and roll strategy and, 69t
Peer relationships supporting autonomy and, 52t
social and emotional development and, Shifting focus, 61–62, 67t. See also Focusing
21–23, 26t processes
social media and, 25 Short-term needs, 111–112. See also Goals
Relative worth, 30 Simple reflections, 76, 77–79, 78f. See also
Research supporting MI, 6–8 Reflections
Resistance label. See also Counter-change Skills of MI
talk caregiver involvement and, 155–158, 156t
comparing MI to other approaches and, 36t group delivery of MI and, 142–144, 143t
overview, 55–56 overview, 4f
stop, drop, and roll strategy and, 56–62, 59t Skills training, 6, 130–132
Respect Slips, 129, 145
absolute worth and, 30 Smoking, 12–13. See also Substance use
autonomy and, 30–31 Social anxiety, 13, 49–50
comparing MI to other approaches and, Social cognitive theories, 5
36t–37t Social media
spirit of MI and, 37t ethical considerations and, 189
Responding to counter-change talk and impact of, 24–25, 187–188
discord, 9f, 10. See also Counter-change Social–emotional development, 19–23, 26t,
talk; Discord 27. See also Developmental processes
Responsibility. See also Ownership Spirit of MI. See also Acceptance;
autonomy and, 43, 50t Compassion; Evoking processes;
extrinsic motivation approaches and, 132 Partnership
group delivery of MI and, 143 activity/questions to explore, 40–41
spirit of MI and, 37t caregiver involvement and, 154–155, 158
you and your statements and, 43–46 change talk and, 94
Reward systems, 23–24, 132–133 comparing MI to other approaches, 35,
Righting reflex, 33, 110 36t–37t
Risky behaviors. See High-risk behaviors group delivery of MI and, 142–144, 143t,
Role formation, 19–23 147
Rolling with resistance, 56. See also Stop, overview, 4f, 8, 9f, 10, 28, 35, 37t–39t
drop, and roll strategy special populations and, 38t–39t
Ruler strategy Stage theory, 18–19
eliciting and elaborating change talk with, Statements of need, 76
90–91, 95t Stems, 64, 79
group delivery of MI and, 146 Stop, drop, and roll strategy
planning processes and, 120–121 activity/questions to explore, 71–73
Rules for group work, 142. See also Group caregiver involvement and, 157
delivery of MI examples of, 62
overview, 56–62, 59t, 67, 67t
with special populations, 68t–70t
Scale It Up Program, 194–197 Strengths
Self-compassion, 32–33. See also Compassion ambivalence regarding change and, 5–6
Self-concept, 19–23 caregiver involvement and, 154
224 Index
Strengths (continued) Transtheoretical model of change (TTM), 5

listening for, 113 Traps that promote disengagement. See also
questions regarding to elicit change talk, Engaging processes
89–90 group delivery of MI and, 144–145
you and your statements and, 45–46 overview, 104, 105t
Substance use. See also Alcohol use; Drug planning processes and, 112
use True meaning reflection, 80, 80f. See also
Ask–Tell–Ask strategy and, 49 Complex reflections
ethical considerations and, 184, 186–187 Typical day exercise, 105–106
group delivery of MI and, 147
research support for training in the use of
MI and, 166–167, 168
stop, drop, and roll strategy and, 70t
Unified treatments, 191–192
supporting autonomy and, 53t
using MI with, 11–13
Summaries
Validation, 66–67
Values. See also Goals
components of a change plan and, 117t
autonomy and, 30–31, 50t
group delivery of MI and, 143–144
caregiver involvement and, 157, 158
OARS acronym and, 8–9
changes in, 129
Summarizing reflections, 82–83, 96t. See
engaging processes and, 106–107
also Complex reflections
ethical considerations and, 180–182
Sustain talk. See also Ambivalence
evoking processes and, 111–112
amplified reflection strategy and, 63–64
focusing processes and, 109–110
overview, 10
group delivery of MI and, 143, 145
maintaining change and, 129
pros and cons strategy and, 64–66
overview, 9f, 10
responding to, 55–56, 67, 67t–70t
special populations and, 68t–70t
processes of MI and, 102–103
stop, drop, and roll strategy and, 57–58
you and your statements and, 45–46
Sustainment phase of implementation,
Values Card Sort activity, 106–107, 145
196–197. See also Implementation
Video-based delivery of MI, 197–198, 199f
Sympathy, 37t, 59t
Visual tools
agenda setting and, 108–109, 109f
Tailored Motivational Interviewing (TMI) group delivery of MI and, 145
protocol, 194–197
Technology in the delivery of MI, 197–198,
199f Weight loss, 13–14. See also Health
Telehealth delivery of MI, 197–198, 199f behaviors
Termination, 134. See also Maintaining Wheel of change, 145
change Workshops, training, 169. See also Training
Token economies, 132–133 in the use of MI
Training in the use of MI. See also Learning Worth, absolute. See Absolute worth
MI
activity/questions to explore, 176–178
future directions for MI and, 198–200 You and your statements
implementation and, 194–197 activity/questions to explore, 54
overview, 8, 15, 15t–16t, 165–168, 176 autonomy and, 43–46, 50t
promoting your own MI development, choice and, 45
168–175, 171t–172t clarifying guide role with, 43–44
research support for, 165–168 complex reflections and, 79
Training workshops, 169. See also Training in promoting personal responsibility with,
the use of MI 45–46
Transdiagnostic treatment, 191–192, Young adult groups. See Group delivery of MI
193–194 Young adulthood stage, 20–24, 25, 26t, 180.
Translational research, 24, 26t See also Emerging adulthood stage

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Motivational Interviewing

with Adolescents and Young Adults

Motivational Interviewing in Diabetes Care

Motivational Interviewing in Nutrition and Fitness

Motivational Interviewing in Schools:

Motivational Interviewing with Offenders:

Motivational Interviewing and CBT:

Building Motivational Interviewing Skills:

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Motivational Interviewing for Leaders in the Helping Professions:

Motivational Interviewing in Social Work Practice, Second Edition

Motivational Interviewing with Adolescents and Young Adults,

Sylvie Naar | Mariann Suarez

Series Editors’ Note by Stephen Rollnick, William R. Miller,

THE GUILFORD PRESS

All rights reserved

No part of this book may be reproduced, translated, stored in a retrieval

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-­P ublication Data is available

ISBN 978-1-4625-4698-5 (hardcover)

Sylvie Naar, PhD, is Distinguished Endowed Professor in the Department

Mariann Suarez, PhD, ABPP, is Associate Professor in the Department

1 Why Motivational Interviewing with Adolescents 1

2 Developmental Challenges and Opportunities 18

3 Getting the Spirit Right 28

4 Highlighting Choice at Every Turn 42

5 Stop, Drop, and Roll 55

7 Processes of Motivational Interviewing 101

8 Maintaining Change 128

9 Maximizing Motivation in Groups 141

10 Considering Caregivers 152

11 Your Motivational Interviewing Journey 165

12 Ethical Considerations 179

13 Future Directions 191

Don’t laugh at a youth for his affectations. He is only trying on

It is a beautiful thing when career and passion come together. We have

Incorporating motivational interviewing (MI) into your practice can

not be viewed as a technique, a trick, or something to be done to people to

Adolescence and Emerging Adulthood:

In the latest edition of Motivational Interviewing, Miller and Rollnick

interviewing is a collaborative conversation style for strengthening a per-

Motivational interviewing is a collaborative, goal-­oriented style of commu-

Figure 1.1 demonstrates the elements of MI, and in our adaptations

Four Components of Spirit: Partnership,

While MI is a learnable and effective method for enhancing motivation for

MI Is Not a Theory or School of Psychotherapy

impeding behavior change. Incorporating skills training, such as in cognitive-­

MI Is Not a Bag of Tricks and Techniques

MI was developed as a brief intervention for problem drinkers and debuted

MI, MI combined with other treatments, or MI as a pretreatment. We could

What Does It Take to Learn MI?

We have organized the book in terms of how we train. In a typical 2-day

change, a process in which you are likely to consider integrating other

FIGURE 1.2. New conceptualization of MI for adolescents and young adults.

• A fifth process. While Miller and Rollnick (2013) subsume mainte-

Finally, we updated chapters on developing MI proficiency (Chap-

The Five Unique Developmental–­Contextual Journeys

Travis: “Polysubstance use—I’ll worry about health later”

it was OK, just don’t say the stuff I told you.”

Sofia: “Trying to work on my smoking, but my inhaler keeps

able to once in a while smoke—I’d come back to see you. The

Sam: “Part of me wants to be more social and part of me doesn’t”

Library of Congress Cataloging-in-P ublication Data is available

Motivational interviewing is a collaborative, goal-oriented style of commu-

impeding behavior change. Incorporating skills training, such as in cognitive-

The Five Unique Developmental–Contextual Journeys

control,” we concur some degree of risk-taking behavior may be neces-

Another need youth have that motivates behavior according to self-

mechanism of resolving distress. In fact, a meta-analysis across 19 studies

Promote behavior-specific optimism Undermine self-efficacy by setting