A deep dive into a form of therapy that helps teens change unhealthy behaviors
Writer: Faith Wilkins
Clinical Expert: Christine Morrissey, LCSW, MSEd
What You'll Learn
- What are the core principles of motivational interviewing?
- How does motivational interviewing work?
- What are the benefits to using motivational interviewing as a form of treatment?
- Quick Read
- Full Article
- What are the core principles of MI?
- What is the process of treatment?
- What are the benefits of MI?
Motivational Interviewing (MI) is a form of therapy that helps patients build the confidence and self-motivation they need to change unhealthy behaviors, like substance abuse or self-harm. MI is more often used with adolescents than children, as they are more emotionally developed, and have more control over their environment.
The core principles of MI are open-ended questions, affirmations, reflections, and summarization (OARS). They’re based on the idea that clinician and patient are equal partners, and the patient should always feel like they’re in the driver’s seat. Clinicians will use open-ended questions to form a better understanding of the patient’s values and goals for treatment. During these conversations, they will offer affirmations to help teens build the confidence to change. Clinicians will also repeat, rephrase, and summarize things the teen has said, allowing them to reflect on their own values and feel heard in the process.
While the OARS are used throughout each session of MI, there is a clear set of phases that clinician and patient usually go through during treatment. In the engagement phase, therapists create a judgment-free space for teenagers to share their feelings and reservations against change. Having established trust, they move on to the focusing phase and work with teens to identify the specific behaviors they’re willing to change. This process usually takes place over many sessions, as it can involve a lot of trial and error. Clinicians will then enter the evoking phase, discussing the disadvantages of maintaining unhealthy behaviors and encouraging teens to see the benefits to change. Finally, they enter the planning phase, in which clinicians help their patients break down goals in a way that feels manageable and discuss potential barriers. This phase is optional but necessary if the patient needs more guidance.
Many therapists find MI to be beneficial because it can be tailored to the patient’s needs. For instance, if adolescents struggle with depression or anxiety, it can be hard for them to find self-motivation. They can take more intensive therapy like cognitive-behavioral therapy (CBT) along with MI.
Many of us can relate to wanting to make positive lifestyle changes and struggling to find the motivation to do so. For teenagers, it can be very difficult to make those changes, especially if their parents are pushing them to do it. The psychologists who created motivational interviewing (MI) believed that a collaborative, patient-centered approach to treatment would help people successfully commit to change. MI is a form of therapy that enables patients to gain the self-motivation they need to change unhealthy behaviors.
The type of person who would benefit the most from MI is someone who shows resistance to therapy or change in general. They lack self-confidence, and even if they really want to change their behavior, they might not know where to start. The habit that they need to change, whether it’s drug abuse, alcoholism, or self-harm, has most likely become a coping mechanism to deal with other stressors in their everyday life. This can make it difficult for them to justify giving that behavior up, regardless of the negative consequences of continuing.
“When you think about a teenager,” says Christine Morrissey, LMSW, MSEd, a clinical social worker, “they’re undergoing a period of developing their sense of self, figuring out who they are. By the time an adolescent gets to treatment, you want to make sure that they believe they’re in the driver’s seat, which is something that doesn’t happen very often for them.”
Many teens go into therapy feeling angry or resentful, unsure why they need treatment. Therapists use MI to help teenagers overcome that ambivalence, giving them the space to explore their own goals and values and see how change can benefit them in the long run. MI is more often used with adolescents than children, as they are more emotionally developed and have more control over their environment.
What are the core principles of MI?
Motivational interviewing provides guidance for drawing out one’s own reasons and capacity for change. Clinicians are encouraged to act as an equal partner and avoid providing unsolicited advice, confrontation, or direction. To effectively guide their patients, they go by four core principles, which are known as the OARS:
- Open-ended questions
- Affirmations of strength, efforts, and past successes
- Reflections
- Summarization
“The idea of open-ended questions is that you can really get a person not only conversing with you about their life and their values and their goals, but also conversing with themselves,” Morrissey adds.
Many topics can be covered during these sessions, such as how the adolescent’s behaviors align or conflict with their values, identifying the important people in their life, and why change would be important to them.
As an example, Morrissey describes one of her patients, whose parents and friends are concerned about their vaping habits. “In more recent sessions, we’ve been focusing on the vaping behavior, and I started by asking open-ended questions about how much they vape and really inquiring about what vaping does for them and what the drawbacks of it are, with a curious and nonjudgmental stance,” she explains. “With time to explore this, we were able to focus on what a goal might be that aligns with their long-term health goals, and also discuss ambivalence and barriers that get in the way.”
During these conversations, clinicians are careful to offer affirmations that will help build confidence in their patient. For example, if a teen describes an instance where they had to make a difficult decision, the clinician will point out the amount of strength it must have taken for them to do so. The goal is to empower the teen to use that strength in all aspects of their life.
Reflective listening is also an essential part of MI sessions, allowing clinicians to show their patients that they really care about what they have to say. Clinicians will often use this technique to repeat, rephrase, and summarize key takeaways from what has been said during each session. This is meant to get patients to really think about what they’ve just communicated and determine if that’s how they actually feel. Do their actions align with their current values and goals?
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What is the process of treatment?
While the OARS are used by clinicians throughout each session of MI, there is a clear set of phases that clinician and patient usually go through during treatment. Depending on the needs of the patient, MI sessions can flow back and forth between phases. It’s just important that each phase is included.
Engagement: In this phase, clinicians want to get to know their patients and establish trust. It is made clear that these sessions are for them and not their parents, and anything they say will be confidential. The idea is to create a comfortable space for teenagers to share their feelings and possible ambivalence towards change. The purpose of this phase isn’t to come up with solutions quite yet, but to allow clinicians to meet their patients where they are and adjust to resistance rather than confront it head on.
Focusing: Once a solid relationship has been established between patient and clinician, they can then come up with the focus of treatment. At this stage of MI, most patients are unclear about the direction they want to take regarding recovery or making the desired lifestyle change. Still, clinicians want to make sure that this is a collaboration. They will often begin each session by discussing agenda items, making suggestions if needed, but ultimately allowing their patients to decide how to focus the sessions. Not only does this provide teenagers with the autonomy they need, but it also serves as a check-in for clinicians. They can assess whether their own goals for the sessions align with their patient’s and adjust accordingly.
This process is often gradual and can take place over several sessions, as clinicians must work with their patients to identify “change targets,” or the specific behaviors that need to change. They can draw upon the teenager’s values, which would’ve been established during the engagement phase, to identify their goals.
Morrissey explains, “The focusing is probably going to start wide and over time get narrower because over time, someone might realize that they kind of overshot their goal. If you’ve ever thought about starting a new exercise regimen and you’re like, ‘I’m going to run 10 miles every single day,’ and then over time you’re like, ‘Oh, that actually isn’t sustainable.’ Focusing would be like, ‘I want to move my body for at least 10 minutes a day.’ That can take a lot of time and trial and error.”
Evoking: The focusing phase can be difficult for teens, and they might display a great deal of resistance to setting goals. At this point, clinicians will begin the process of evoking “change talk.” This refers to any kind of statement that supports making a change. For example, a patient might say that they need to stop abusing substances, but don’t think they can do it. The change talk in that statement would be, “I need to stop abusing substances.” The clinician will keep them from going down a more negative line of thinking by asking, “What are the reasons you think you need to stop abusing substances?” With this technique, clinicians draw out the wants and needs of their patient without providing unwelcome advice.
At this stage, therapists can also work to reduce ambivalence towards change by first discussing the clear disadvantages to the patient maintaining their current unhealthy behavior. Clinicians will then use open-ended questioning and affirmations to encourage their patients to envision the benefits to change and to believe that this change is possible. Throughout these conversations, they remain optimistic and supportive while patients process their emotions towards changing their behavior.
Planning: The final phase of MI is planning. This is an optional phase but necessary when patients need more guidance on the steps that they need to take to change their behavior. It is at this point that they discuss barriers to their goals and how they might get past those barriers. Clinicians help their patients come up with a “change plan,” breaking down goals in a way that feels manageable. They also discuss what they might do if they experience setbacks.
Morrissey further explains this process when describing a session with one of her patients: “We also talked about what would happen if they ‘slipped up’ and vaped and discussed ways of using self-compassion to practice acceptance, combat all-or-nothing thinking, and get right back to goal-oriented behavior. . . there’s a lot of transitioning between stages, especially when there is ambivalence about change or slip-ups that come up that don’t align with the person’s goals.”
What are the benefits of MI?
The benefit to using motivational interviewing for teens is that it’s highly flexible and individualized. Depending on the patient’s needs, it can be used as standalone treatment, or used in tandem with other more intensive forms of treatment like cognitive-behavioral therapy (CBT). This can especially be true for adolescents who havemood disorders. For instance, if they’re struggling with depression or trauma, it could be really difficult for them to find self-motivation without the help of more comprehensive therapy.
“I really think it’s such a benefit to the client that they are the person who is the expert of their life, who knows themselves the best, who if they’re the person coming up with the solutions, they’re likely to be more realistic to their life. I think from a clinician’s perspective, it’s really fun work to do because you’re really tapping into someone’s inherent abilities. I think for the client themselves, it’s really beneficial because they get that autonomy,” says Morrissey.
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