Motivational Interviewing: the change YOU can’t make

It doesn’t take a genius to work out that you can’t make a teenager do what he or she doesn’t want to do. You can’t make them change. You dig your heels in, they’ll dig theirs in further. You shout at them, they’ll shout louder.

Coercion can get short term results, but as a long term strategy it is fundamentally flawed. It is not only exhausting, but in the end resentment will build and as soon as they sense you no longer have control, they will revert to their preferred behaviour which is the exact opposite of what you want for them.

Respect for one another and real change cannot thrive in a purely coercive environment. We must remember that teens are on the pathway to independence and if you do not recognise and respect this inevitability and deal with them as cogniscent, thinking people with their own opinions, then you are eventually going to come unstuck.

This doesn’t mean that you are powerless, far from it. With the right tools at your disposal you can address their behaviour and help them navigate the difficulties of teen life in a supportive, respectful way. To help a teen change their behaviour, their education or employment circumstances, anything where a change is to be made, the core principle that needs to be recognised is that only they have the power to make their own decisions and as a result only they can decide to change. You can advise, erect signposts, even write what you want them to do in the sky, but only they can decide to listen and engage. In the end, teens will always go their own way; it’s just a matter of how much their way coincides with your way. But it is always up to them.

So you can’t change a person and least of all a teen. What you can do however, is maximise their willingness to listen to you, and even more importantly, maximise their willingness to really dig down and listen to themselves so that they can come to the best decisions for themselves.

But how? In my experience the best way to achieve this is to use a Motivational Interviewing approach.

 

The Spirit of the Method

The Motivational Interviewing method originated in the field of alcohol abuse therapy (Miller & Rollnik 1991) but has now spread far and wide into all areas where change is desired. It is now used in health, social care, criminal justice and education settings. It is a gentle, non-confrontational, positive, collaborative method for working with clients that acknowledges and brings to the fore the fact that they are the best experts on themselves. So rather than sessions being something that is ‘done to’ them, it is something that they are central in shaping, and it starts very much from where they are in terms of readiness to change. Some will be wanting to change but haven’t successfully achieved this, others won’t even feel they want to.

At its core, as its name suggests, is the idea that rather than ‘piling in’ with loads of strategies on how to ambivalencecope with a problem and ‘dishing out’ advice, it ensures that a client is actually wanting to change first and aims to get them to that point by helping them explore and resolve their ambivalence to change and find their intrinsic motivation for change. In short, it recognises that you can’t change someone who doesn’t want to change.

And even when they do get to the point where they want to change, it is about helping them make personal decisions about how they wish to accomplish that change. Instead of preaching or providing unsolicited advice which they will invariably resist, you evoke and elicit. You draw out of them their reasons for wanting to change and any concerns they might have about it. You provide them with information and resources that might help them change and you elicit from them their opinion on that approach and how they think it could apply to them and what their concerns are about it. You also establish whether they have better ideas about how to deal with their problem.

It’s all about drawing out their motivation from within themselves and engaging them in the process, helping them to visualise where they want to be and how to get there and how to avoid the pitfalls and hurdles on the way. This way they retain their autonomy, they retain control and you collaborate with them in finding the best way to change and the best way to maintain that change. You make it clear that they are the ones with the power to decide and that you are the guiding guest in this process- they own it. It’s about helping them to help themselves by minimising reasons for them to resist the change and maximising their reasons for making the change.

This spirit of Motivational Interviewing is nicely summarised with the acronym ACE: Autonomy (only they have the power to change their lives), Collaboration (work together rather than just dishing out unsolicited advice), and Evocation (evoke and elicit reasons for and concerns about change).

 

The Practical Application

But how do you actually, practically deliver this Motivational Interviewing style of interaction?

There are four main techniques (OARS) for guiding conversation towards change.
1. Open-ended questions
2. Affirm
3. Reflect
4. Summarise

Open-ended questions draw out far more information from a client than closed questions and cause them to really reflect on their lives, their thoughts and their actions. They also can provide you with valuable information on what might motivate them to change. For example, it is easy to see that the closed questions light bulbquestion, “Do you think your offending is a problem?” will garner far less reflection and information than the question, “What problems has your offending caused for you?” In addition, closed questions can lead to a client feeling like you are trying to trick them into accepting your way of thinking or a particular treatment. Open questions are far better for increasing internal motivation to change.

Compare this interaction…


Agent: You don’t think your drug use is a problem?

Offender: Not really. When I used to use, I would just do it every once in
a while, and I can’t see how it really hurt anything.

A: How about your kids? Don’t you think that your drug use has a negative impact on them?
O: No, because they didn’t see me use.
A: Even if you don’t use in front of them, aren’t you afraid that it might put them at risk? I mean, how can you care for your kids if you’re high?
O: It doesn’t really affect them. Because when I used to use a neighbor always took care of them. She just kept them overnight.

…with more open questions like these:
A: What concerns do you (does your wife, girlfriend, children etc.) have about your drug use?
■ How has this caused trouble for you?
■ What do you think might happen to your kids if you overdosed?
■ If you did go ahead and finish this class, how would that make things better for you?


(adapted from Walters et al 2007, p.31)

Affirmations build rapport, provide feedback and make positive behaviours more likely. Affirmations can be given for something a client has done, e.g. “Well done for getting here on time”, or can point towards something admirable or interesting about the person, e.g. “You really look out for your sister don’t you?”. They can also increase a client’s appreciation of their own thinking skills. e.g. “How did you know that would work?”. It goes without saying that offering affirmations will build self-esteem, will further strengthen your relationship with your client, will build trust and more open conversations will ensue which will aid you in guiding them towards contemplating and achieving change.

Reflections are statements of what you believe a client is saying (and thinking). They show the client that you are listening to what they are saying and are really trying to understand them. It also helps in actually gaining an accurate understanding of what has been said. This might consist of stripping what has been said down to its bare bones, “So you’re angry” and also paraphrasing what has been said and guessing what would come next if the client had continued to talk, “So your teacher didn’t listen to you… and that made you angry”.

Using reflections gives real momentum to conversations as the client can correct misunderstandings and elaborate mirror reflectionfurther. In addition, hearing what they have said helps clients to process their thoughts more easily. Just like when you might read something aloud to help understand it, so the same goes with reflecting clients statements. By hearing their thoughts repeated aloud it better enables them to make links between what they have said and to notice any discrepancies, which is an important step in beginning to contemplate change.

A key use of reflection is in ‘Rolling-with-resistance’. If your client states something that you disagree with, rather than entering a debate with them where they end up giving arguments against change and being more resistant, you avoid challenging them and ‘roll with the resistance’. To do this you reflect back what they have said and thereby use the client’s momentum to further explore their views.

For example if they state, “I wouldn’t be in this care home if my stupid foster carer hadn’t been such a cow.” you can respond with, “You’re upset with your foster carer” [reflects the emotion] or “The reason you are in the care home is because of your foster carer” [restates their statement]. You aren’t agreeing or disagreeing with them and thereby stalling the conversation. Instead, you are inviting them to say more. In the course of further discussion and with appropriate open-ended questions you can often end up with the client changing their own mind after fully exploring their opinion and the context and noticing any discrepances in their thinking.

Summarising is central to the goal-oriented aspect of Motivational Interviewing. Summarising what has been said is an important tool as it helps to confirm what has been achieved and gives future discussion and action a direction. Summaries highlight the major discussion points, help to clarify any agreed action plan and helps to confirm for both you and the client why they have decided to take action and what the consequences may be of succeeding or not. In addition summarising enables the emphasis on positive steps forward that have been made that you wish to positively reinforce and affirm.

For example:
“OK, so it looks like we’re about out of time. We’ve been covering some of the conditions of your supervision.You thought that the fees would not be a problem, and we’ve agreed on a fee schedule.You thought it would just be easier to get the drug assessment out of the way, but at this point, you have some real mixed feelings about completing the batterer intervention class.You’re aware that it’s one of your conditions, but it’s kind of costly, will take several weeks, and seems like it might be a waste of your time. That’s certainly understandable, since it’s a supervision order. We can revisit that next session if you want to take some time to think about it, and we can also talk about your community service options. I know this is a lot to cover in 20 minutes, but it I do appreciate your willingness to work with me. Is there anything else I need to know?” Walters et al 2007, p.42)

 

Handing over

The above synopsis of Motivational Interviewing is the absolute bare bones of what it is and I hope that it has piqued your interest if you have not come across it before. I will be covering more elements of this style of interaction in future posts but if you are hungry for more right now I can highly recommend the resources listed at the bottom of this post.

With Motivational Interviewing you need to be very mindful that to get it right requires a lot of practice and a lot of reflection on your sessions, particularly in the early days. It is very easy to forget certain techniques or misapply them, so keeping up your reading in this area is strongly advisable. The Motivational Interviewing website is really good for this.

Motivational Interviewing is a highly rewarding method when working with people when trying to change their lives for the better. It really does work. Two relatively recent reviews of more than 70 Motivational Interviewing outcome studies in different areas strongly supported the effectiveness of this approach (Hettema et al 2005; Rubak et al 2005). I have personally found that it actually makes engaging with the most difficult and challenging young people a lot less hard work than any other method I have used. If you get off your professional power-trip (which we all have from time to time!) and hand over the reigns to teenagers their capacity for change will surprise you. Yes, you do need to guide them, but their astounding inner potential when properly harnessed is what will ultimately change them, not you.

 

Recommended further reading

I highly recommend the book, ‘Motivational Interviewing with Adolescents and Young Adults’. This is an extremely accessible and engaging book that is very practice-oriented and geared directly towards working with adolescents. It shows a wide range of applications for the method, with excellent strategies and phrases to employ. If you really want to understand the Motivational Interviewing method and how to practically apply it in your work with teens, buying a copy of this book is highly recommended. Amazon has ‘Look Inside’ so you can take a look without purchase- click on the links here.

Walters, S.T. et al (2007) Motivating Offenders to Change: A Guide for Probation & Parole (Washington DC:US Department of Justice)
An excellently written book that is extremely accessible and provides a huge number of practical scripted scenarios and exercises. Cannot recommend highly enough, even if you are not in the criminal justice field. AND it’s free to download!(pdf)

Motivational Interviewing website has many valuable resources and also an 8 minute video on the background to MI.
 

References

Hettema, J., Steele, J., and Miller, W.R. (2005). Motivational interviewing. Annual Review of Clinical Psychology 1(1): 91–111.
Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change (New York: Guilford Press)
Rubak, S. et al (2005) ‘Motivational interviewing: A systematic review and meta-analysis’, British Journal of General Practice 55(513): 305–312.
Walters, S.T. et al (2007) Motivating Offenders to Change: A Guide for Probation & Parole (Washington DC:US Department of Justice)

1 comments On Motivational Interviewing: the change YOU can’t make

  • WAS JUST PUT IN A POSITION AS THERAPIST AT A VOCATIONAL SCHOOL WORKING WITH HIGH RISK TEENS. I’VE WORKED WITH YOUNGER KIDS SO THIS IS NEW TO ME. I APPRECIATE ANY HELP ALONG THE WAY.

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