Session 3.

Motivational
Interviewing
Session Topics

Definition of Motivational Interviewing

The MI Spirit

The MI Principles

The MI Process

The MI Skills & Strategies

Motivational
Interviewing
Adolescence is a critical period;
a second window of opportunity.

During adolescence, physical, cognitive/mental, emotional, social

and sexual changes are happening.
These changes, along with exposure to poverty, abuse or
violence and other social determinants, can make
adolescents vulnerable to mental health problems.
Many mental health disorders have their beginning in
adolescence.
Supporting the cognitive
development of adolescents
During adolescence, dynamic neurological transitions take place in
particular regions of the brain that often continue until children reach
their early 20s.
The brain's prefrontal lobe represents the seat of logic and
reason. Its function is to enable people to use good judgment when
solving problems or making decisions. It serves to balance impulsive,
instinctive, emotional reactions with rational thought.
Because the prefrontal lobe is still maturing during the adolescence
stage, adolescents may act without thinking about the
consequences of their actions.
Pubertal hormones: reproductive maturity & reorganizing neural circuitry; processing of emotions, risks,
rewards & social relationships ➔ evolving capacities ➔ second window of opportunity to improve life chances
How can adults support cognitive
development of adolescents?
Adults can support by talking to adolescents in a safe
environment.
Adults can provide a safe environment by respecting the
autonomy and supporting the evolving capacity of adolescents.
Adolescents respond better when their growing capacity and
ability to do things independently are recognized and respected.
All forms of abuse (verbal, emotional, physical, sexual or
neglect), alcohol and drugs harm the development of the brain.
ACTIVITY: Real-Play Round 1
Each one will be assigned to a triad. In the triad, choose a Speaker, a
Care Provider and an Observer.

If you are the Speaker: identify a change that you are considering.
✓ It should be something you are thinking about
changing in your life but have not definitely decided.

✓ It should be something you feel two ways about -- a

change that would be “good for you” that you “should”
make for some reasons but have been putting off.
✓ Tell the Care Provider about this change you are
considering. It should be something you feel
comfortable sharing.
If you are the Care Provider: Your task is to try as hard as you can to
convince and persuade the Speaker to make the change she/he is
considering.
Once you find out what the change the Speaker is considering, do these
five things:
✓ Explain why the person should make this change.
✓ Give at least three specific benefits that would result
from making the change.
✓ Tell the person how they could make the change.
✓ Emphasize how important it is for them to make the
change. This might include the negative
consequences of not doing it.
✓ Tell/persuade the person to do it.
✓ And if you encounter resistance, repeat the above,
perhaps more emphatically.
For the Observer: Take note of the
facial gestures, body language and
voice tone of both the Speaker and
the Care Provider.

You have 10 minutes to do the real-play.

Let us hear from everyone…

Speakers: What did you feel while

doing your part?
Care Providers: What did you feel
about persuading the Speaker?

Observers: What did you observe

from both the Speaker and Care
Provider in your triad?
Everyone: What are your reflections
on this activity?
ACTIVITY: Real-Play Round 2
You will return to your respective triad.
Triad members will retain the same role as Speaker, Care
Provider and Observer.

Speakers:
Tell the Care Provider about the
same change he or she used in
the previous activity.
Care Providers: Don’t try to persuade or fix anything this time. Don’t offer
advice. Instead ask these four questions one at a time, and listen carefully to
what the person says:

✓ Why would you want to make this change?

✓ If you did decide to make this change, how might you go about it in order to
succeed?
✓ What are the three best reasons for you to do it?
✓ How important it is for you to make this change, on a scale from 0 to 10,
where 0 is not at all important, and 10 is extremely important
✓ Why are you at _____ rather than on any of the numbers?
After you have listened carefully to the answers to these questions, give back a
short summary of what you heard, of Client’s motivations for change.
Then ask one more question: So, what do you think you’ll do? and listen with
interest to the answer.
Care Providers: Don’t try to persuade or fix anything this time. Don’t offer
advice. Instead ask these four questions one at a time, and listen carefully to
what the person says:

Why would you want to make this change?

If you did decide to make this change, how might you go about it in order to
succeed?
What are the three best reasons for you to do it?
How important it is for you to make this change, on a scale from 0 to 10,
where 0 is not at all important, and 10 is extremely important
Why are you at _____ rather than on any of the numbers?

After you have listened carefully to the answers to these questions, give back a
short summary of what you heard, of Client’s motivations for change.
Then ask one more question: So, what do you think you’ll do? and listen with
interest to the answer.
For the Observer: Listen to the
conversation between the Client and
Care Provider. Take note of any
changes in the facial gestures, body
language and voice tone from the
previous activity.

You have 10 minutes to do the real-play.

Share your reflections …

Speakers: How did you feel this time?

Care Providers: How did you feel this time?

Observers: What have you observed from

both the Client and Counselor this time?
Share your reflections …

Personally, in which Speaker situation would you rather be in?

The Client in the first or second activity?

In which Care Provider would you rather be in? The Care

Provider the first or second round?

Based on your experience in the first and second round, can you
distinguish which experience is Motivational Interviewing? Was it
your experience in the first or second round?
What is Motivational Motivational Interviewing (MI) is a
collaborative, goal-oriented style of
Interviewing? communication that builds on intrinsic
motivation.

Developed by psychologists William

R. Miller and Stephen Rollnick in the
late 1980s.

MI is about “looking and seeing

together from the patient’s
perspective” rather than probing to
extract information for diagnosis and
management.
MI has been successfully applied to many
types of behavioral goals (e.g., diet and
exercise, contraception, smoking, and drug
use).

MI is suitable when talking to adolescents. It

enables them make use of their brain’s
prefrontal lobe and make decisions in a
safe and nurturing space. This can lead to
positive mental health outcomes.

It is founded on the MI spirit (a prescribed way of being with

people), principles, process, skills and strategies.
MI can be time consuming, however,
certain key strategies have shown
promise for helping teens modify
risky or unhealthy behaviors.

Working collaboratively with teens

can actually be rewarding and fun.
Adolescents can be very resourceful
when their opinions are elicited and
lecturing is eliminated.
MI is like riding in a car
where the client takes the
driver’s seat and stirs the
wheel.

The MI practitioner sits

beside the driver, supporting
and encouraging the driver in
her/his journey to change.
The MI Spirit
 Collaboration is working in partnership
with adolescents. It positions the
The essential spirit adolescent as an expert about his/her own
of MI consists of experiences, values, beliefs, and goals.
three elements, Evocation is helping the adolescent
namely, identify his or her intrinsic motivation for
collaboration, change.
evocation, and Autonomy is honoring the adolescent’s
autonomy. capacity to change his or her behavior
and decide if, how, and when changes
will occur.
The MI Spirit is an openness to way
of thinking and working that is:

✓ Collaborative rather than

prescriptive

✓ Respectful of adolescent’s
autonomy and self-direction

✓ More about evoking than fixing

Photo credit: https://media.gettyimages.com/photos/happy-teenage-
patient-with-doctor-in-doctors-office-picture-id154953823
The MC Spirit involves at
least a willingness to:

✓Suspend an authoritarian
or expert role

✓Explore client capacity

rather than incapacity

Photo credit: https://thumbs.dreamstime.com/b/female-doctor-questioning-teen-

patient-office-professional-physician-consulting-concerned-teenage-clinic-
69967287.jpg
The MI Principles
MI adheres to these
principles:
1. Expressing empathy:
Communicating with respect and
acceptance
Encouraging a non-judgmental,
collaborative relationship
Complimenting rather than degrading
Listening rather than telling
Persuading but allowing the
adolescent to decide for the change
Photo credit: https://www.naturalnews.com/wp-content/uploads/sites/91/2017/04/med-
e1486990115473.jpg
2. Developing discrepancy:
Recognizing inconsistencies
between the adolescent’s
current behavior and
important values or goals in
life.
3. Rolling with resistance:
Recognizing that it is normal
to feel ambivalent/conflicted
about behavior change.
Resistance usually occurs
when a person feels pushed
to do something she/he is
not yet ready to do.
Arguing and persuading in
the face of ambivalence are
counterproductive.
Change is most likely to occur
when a problem is recognized and
the person believes in her/his
ability to do something about it.
The MI Skills
The MI core skills can be summarized
as OARS, which stand for:

O for Open Questions or asking

questions that encourage adolescent to
talk about their thoughts and feelings, or
to tell their story.

A for making Affirmations or

expressing appreciation for actions or
decisions made by the adolescent.
The MI core skills can be summarized
as OARS, which stand for:

R for Reflective Listening, or

restating, clarifying or enhancing
what the adolescent said in a
warm & nonjudgmental way.

S for Summaries or bringing

together the thoughts and/or
feelings that the adolescent has
shared.
Asking Open Questions
Asking questions are a way of getting information from adolescents.
There are several types of questions and these are:
Closed questions - ask for a restricted answer such as a “yes”
or a “no” answer or a short answer. Place your sentence here.
Leading questions - are actually a form of closed questions as
they lead the clients to a desired answer.
Open questions – invite the clients to elaborate, say more, or
tell a story. They allow a wide range of possible answers
including surprises.
Let’s try… Do you eat vegetables?

What kind of vegetables do you

love to eat?
Which of the two questions encouraged
you to elaborate?

What was your feeling when you were asked

to answer the first question? How about when
you were asked to answer the second
question?
Is it an open, close or leading question?
You are always feeling sad, right? Answer: Leading
What makes you feel sad? Answer: Open
You should tell your mother about how you Answer: Leading
You are always feeling sad, right?
are feeling, shouldn’t you?
What do you do when you’re feeling sad? Answer: Open

Do you know why you are feeling sad? Answer: Closed

Do you do something to keep you from Answer: Closed
feeling sad?
Have you ever received support from your Answer: Closed
friends?
Transform them into open questions…
You are always feeling sad, right? Answer: Leading
You should tell your mother about how you Answer: Leading
areYoufeeling,
are alwaysshouldn’t you?
feeling sad, right?

Do you know why you are feeling sad? Answer: Closed

Do you do something to keep you from Answer: Closed

feeling sad?
Have you ever received support from your Answer: Closed
friends?
 Broad open questions to build engagement
with the client and explore potential topics
of interest or importance

When do I
Probing questions for better
use which understanding, to build focus
and to elicit motivations for
question? change

Closed questions
to clarify
specific
points
Making affirmations…
• Close your eyes and think of a time
when you received a deeply
meaningful compliment from
someone you trusted and respected.
• How did it go? What was the
compliment you received and how did
it make you feel?
Affirmations

Affirmations are statements and

gestures that highlight the clients’
inherent worth as a person.
They recognize and validate the clients’
strengths, feelings or experiences, and
acknowledge positive behaviors that lead
to the direction of positive change, no
matter how big or small.
Photo credit: https://www.mikemichalowicz.com/wp-
content/uploads/2013/10/Employee-Recognition.jpg
Affirmations can help…

✓Engage clients
✓Build confidence in one’s ability to
change
✓Reduce defensiveness
✓Increase openness to potentially
threatening information
Making or offering affirmations

✓ Comment on something positive

about the clients, their intentions
or actions:
▪ Be specific
▪ Describe rather than evaluate
✓ Recognize clients’ actions or
situation in a positive light
✓ Highlight interesting qualities of
clients
Examples of affirming response

✓You are clearly a very resourceful person.

✓You handled yourself really well in that
situation.
✓That’s a good suggestion.
✓You are taking charge of your life and
making tough decisions.
✓You got discouraged, but you decided to try
again. You’re persistent.
Let’s practice!

Scenario 1: After carefully explaining to a patient the benefits of

seeing/talking to a mental health specialist, the client replied, “I
got it, a mental health specialist can help me understand and
manage my anxiety attacks. I certainly would want to see a
specialist but I fear that people around me will think I have a
mental health condition and will stay away from me.”

What are the client’s strengths?

How will you state your affirmation?
Let’s do another practice!

Scenario 2. A 15-year-old girl approaches you, “I feel I am a

boy even if I have the body of a girl and I want to tell my parents
about this. But I am so afraid that they will disown me. What
must I do?”

What are the client’s strengths?

How will you state your affirmation?
Reflective Listening

Reflective listening involves listening

carefully, taking interest in what
clients say, and understanding what
clients say by repeating,
rephrasing or offering a deeper
guess about what they are trying to
communicate.

A good reflective listening response

asks, in a way, “Is this what you
mean?”
If done effectively, reflective listening helps:

✓ Build clients’ trust

✓ Clarify misunderstanding
✓ Make clients become aware of
their thoughts and feelings
✓ Encourage clients to provide more
information
Remember that MC is a communication style!

There are at least three ways that MI can go

wrong. These are:

❑ The client (speaker) does not say exactly

what he or she means.
❑ The MI practitioner (listener) does not
hear the words correctly.
❑ The MI practitioner (listener) gives a
different interpretation to what the client
means.
Dr. Thomas Gordon’s listening model

What speaker What listener

SAYS! HEARS

Reflective Listening

What speaker INTERFERENCE! What listener

means interprets
Reflective listening response:

A good reflective listening response is

a statement that is delivered in a tone that
goes down at the end.

For example:
❑ "You're angry about what I said?" (up)
❑ "You're angry about what I said."
(down)
Some helpful phrases:

Some people find it helpful to use certain

words or phrases to get them started in
making a reflective listening statement.
Examples are:
❑ So, you feel . . .
❑ It sounds like you . . .
❑ You're wondering if . . .
❑ You . . .
 Ways of making reflective listening responses

Repeating. This is the simplest form of reflection. The listener simply

repeats what the speaker has said.

Rephrasing. The listener stays close to what the speaker said but
substitutes synonyms or slightly rephrases what was offered.

Paraphrasing. The listener assumes a meaning in what the speaker said

and uses new words to convey that meaning to the speaker.

Reflection of Feeling. Regarded as the deepest form of reflection. This

involves paraphrasing and emphasizing the emotional dimension of what
the speaker said by using statements that describe feelings.
Double-Sided Reflections

Reflect a client’s mixed feelings (against and for

change).
Examples:
• On one hand, you want to…. But on the other
hand, you don’t want to…
• You want to… yet you don’t want to…

Reflect statements against change first. Then

reflect statements which favor change.
Let’s try… “I had an unprotected sex last
night."

“I don’t understand what’s

happening to me.
Sometimes I feel joyful, the
next minute I feel sad…”

“I know I need to take the HIV

test and know my HIV status. I
just don’t know when.”
Summarizing
Making a summary or summarizing is a special
application of reflective listening.
It can be used throughout a conversation but is
particularly helpful when it is used during transition
points.
It can be used after a client has spoken about a
particular topic, recounted a personal experience,
or when the conversation is about to end.
Summarizing helps to ensure that the speaker and
the listener clearly communicates with each other.
How to make summaries:
Begin with a statement that indicates you are
making a summary. For example:
❑ Let me see if I understand so far...
❑ Here is what I’ve heard. Tell me if I’ve missed
anything.
Give special attention to “change statements.” These are
statements made by the client that point towards a willingness to
change.
If the person or client expresses ambivalence, it is useful to
include both sides in the summary statement.
For example: “On the one hand…, on the other hand…”
It can be useful to include information in summary
statements from other sources (e.g., your own
clinical knowledge, research, courts, or family).

Be concise.

End with an invitation. For example:

❑ Did I miss anything?
❑ If that’s accurate, what other points are there
to consider?
❑ Anything you want to add, or correct?
Let’s practice!
First statement: “I am not sure which one should I be worried
about: HIV or COVID infection. Before my place was placed under
ECQ, I had the chance to go out of the house and met someone
who I had an unprotected quick sex with.”

Second Statement: “I am afraid to go out and take the HIV test. I

might get infected with COVID.”

Third Statement: “I am not feeling quite well these days.”

Final Statement: “I know I need to take the HIV test and know my
HIV status. I just don’t know when.”
The MI Strategies
Establishing rapport and
engaging adolescents
Once an adolescent comes to
you, start with making
affirmations or expressing
appreciation for taking the time
and making the effort to see
you.
Example: Welcome to ____
and thank you for reaching
out to me…
Engage the adolescent in a
conversation by talking in a
low, gentle and warm tone,
and by giving an assurance
that the conversation is a
safe space and will be
treated with utmost
confidentiality.
Encourage the adolescent to talk or tell his/her story by using
open-ended questions and offering reflective statements in a
warm, gentle and non-judgmental way.

Examples: Reflective statements:

Open questions: ✓ You are feeling confused
✓ What is it that you want to and you want to talk about
talk about? what makes you feel that
✓ What do you have in mind way.
right now? ✓ You think it is best for you
✓ What is it that you feel? Tell to tell someone about how
me about it… you feel.
Use affirmations, although
sparingly, to express
appreciation for what the
adolescent has shared with
you.
Examples:
✓ That’s great, thank you for
telling me about that!
✓ I really appreciate your
being honest with me.
At certain points of the
conversation and to ensure that
both of you are on the
same page, summarize or put
together the thoughts or feelings
that the adolescent has shared
with you.
Examples:
✓ Let me see if I understand
so far...
✓ Here is what I’ve heard. Tell
me if I’ve missed anything.
Providing information through the
Ask-Tell-Ask technique
MI practitioners get the chance The Ask-Tell-Ask technique:
to speak when:
Ask: finding out what the
a) the adolescent asks for
information adolescent already knows
b) the adolescent seems to lack Tell: providing additional
information
information when appropriate
c) the adolescent appears and with permission from the
misinformed
d) they think of an idea that
adolescent
might be useful to the Ask: getting the adolescent’s
adolescent
reaction to the new information
Examples:

✓ What do you know about….?

ASK
✓ Have you heard about…?
✓ Would you like to know more about…?
TELL
✓ Would it be okay if I tell you what I think or
what I know about…?
✓ What do you think of the information I just
ASK
shared With you?
✓ How does it help you?.
Adolescent: Online schooling has become stressful! I am feeling tired
all the time.

Ask: What do you know about managing stress?

Adolescent: One of my teachers told us to engage in some forms of

exercise. But I can’t exercise regularly. I feel I don’t the energy to
exercise and there is a lot of school work to do.

Tell: Keeping a regular exercise routine can be difficult, but there is

one simple thing that you can do without exerting so much effort.
Would you like to hear about it?

Adolescent: Yes, sure I’d love to hear about it!

Tell: You can do deep breathing every time you’re feeling very
tired. In deep breathing, you inhale through your nose and exhale
through your mouth. Would you like me to show you how to do it?

Adolescent: Yes, please show me how to do it. Tell: Okay follow

me. Here’s how to do it…

Ask: How did you find deep breathing? Will you be able to do it on
your own?

Adolescent: It’s very simple and easy. I can do it anytime I am

feeling tired or stressed.
Avoiding Communication Traps

Playing the expert role Giving unsolicited advice or

✓ “I know better than you…”
✓ “This is how you must do it.”
✓ “Don’t do that.”
✓ “Listen to me, this is how it
works.”
Arguing the positive side or
fixing
✓ “The reason you need to
change is…”
ordering the client
✓ What you need to do is…”
✓ You have to…”
Premature focus on change
✓ “I really need you to make a
commitment to...”
Video 1: The Ineffective Physician
In what instances was the
provider:
Playing the expert role?
Giving unsolicited
advice?
Lecturing/blaming the
client?
Pushing the client
prematurely for change?

The Ineffective Physician: Non-Motivational Approach - YouTube

Video 2: The Effective Physician

From the second video,

how was this
discussion different?

Pick out dialogues that

show the provider used
the following MI skills.

The Effective Physician: Motivational Interviewing Demonstration - YouTube

Be REAL!
RESPECT every learner’s autonomy, self‐determination, and
freedom to make his or her own choices.
EMPATHIZE with learners. They are more likely to make change or
participate actively in the interactions if they feel understood.
COLLABORATE. Learners are experts on themselves. They
have their own strengths, resources, and motivations for change.

LISTEN. Reflective listening is the essential communication skill

that enables an MI practitioner to get REAL, to extend respect,
have empathy, and collaborate actively.
Thank you