Core Module 1: Building and Keeping Motivation

Unified Protocols for Transdiagnostic Treatment of

Emotional Disorders in Children and Adolescents:
Therapist Guide
Jill Ehrenreich-May , Sarah M. Kennedy , Jamie A. Sherman , Emily L. Bilek ,
Brian A. Buzzella , Shannon M. Bennett , and David H. Barlow

Publisher: Oxford University Press Print Publication Date: Dec 2017

Print ISBN-13: 9780199340989 Published online: Dec 2017
DOI: 10.1093/med-psych/
9780199340989.001.0001

Core Module 1: Building and Keeping Motivation

Chapter: (p. 3) Core Module 1: Building and Keeping Motivation

Author(s):
Jill Ehrenreich-May, Sarah M. Kennedy, Jamie A. Sherman, Emily L. Bilek, Brian A. Buzzella,
Shannon M. Bennett, and David H. Barlow

DOI: 10.1093/med-psych/9780199340989.003.0001

(Recommended Length: 1 or 2 Sessions)

Materials Needed for the Module

■ Module 1: Building and Keeping Motivation—Workbook Materials:

1. Defining the Main Problems (Worksheet 1.1)
2. Weighing My Options (Worksheet 1.2)

■ Defining the Main Problems—Parent (Appendix 1.2 at the end of this chapter)
■ Weekly Top Problems Tracking Form (Appendix 1.3 at the end of this chapter)
■ A parent module summary form is provided at the end of this chapter to help support
review of module materials with the parent(s) of your adolescent client. You may also use
materials from Chapter 9 (Module-P) to help support these discussions.

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Core Module 1: Building and Keeping Motivation

Overall Core Module 1 Goals

During Core Module 1, you will describe the purpose and structure of treatment, and
together with the adolescent and parent, determine the parent’s involvement in treatment.
Using Worksheet 1.1: Defining the Main Problems from the adolescent workbook and Appendix
1.2: Defining the Main Problems—Parent at the end of this chapter, both the adolescent and
parent should be asked to identify and rate the severity of three top problems they would like to
address over the course of treatment, and these (p. 4) top problems should be used to assess
and build motivation for change. Motivational enhancement strategies are introduced in this
module as the primary means of building both the adolescent’s and the parent’s motivation for
change, but these may be used more or less in session depending on the adolescent’s baseline
readiness for change and family investment in therapy. The ideas and concepts presented in this
module (also see Appendix 1.1: Additional Motivational Enhancement Topics) may also be
utilized throughout treatment and can be returned to throughout the course of therapy as
needed, but are especially useful when first developing rapport and whenever the adolescent is
struggling to remain engaged and move forward in the UP-A. In addition to providing an
introduction to the basic structure of treatment and discussing confidentiality and agency/
practice procedures, the goals of this module are as follows:

■ Goal 1: Orient the adolescent and family to treatment concepts and structure (including
level of parent involvement).
■ Goal 2: Obtain three top problems from the adolescent, as well as severity ratings for each
top problem. Identify “SMART” goals related to top problems.
■ Goal 3: Strengthen the adolescent’s motivation for change by identifying initial steps to
achieve SMART goals, by using motivational enhancement techniques, and by using the
decisional balance exercise. Secure adolescent commitment to treatment. (This goal is
optional and may be used if time permits or if motivation is low for change.)
■ Goal 4: Discuss parent’s motivation for treatment; obtain parent ratings of adolescent top
problems and explore any barriers to regular and continued engagement with treatment; and
strengthen the parent’s motivation for change using the motivational enhancement
techniques described in this module (motivational elements to be used as needed). Secure
parent commitment to treatment.

Therapist Note—Unified Protocol Theory

At the beginning of each UP-A module, there will be a Therapist Note that serves as a brief
reminder about how that module’s content links to the overall theory and case
conceptualization model of the Unified Protocols. In Module 1, you will be doing several
tasks for which it will be vital to keep the Unified Protocol theory and case conceptualization
model in mind, as described in the Introduction. First, you will be engaging your adolescent
client in a discussion about the function of strong emotions in her life as (p. 5) you build
initial rapport and motivation. In other words, what things has she been doing in response to
her strong emotions? What has worked for her? What has not? Second, as you establish top
problems and SMART goals in this module with both the adolescent and parent(s), it will be
vital to consider how these problems and goals fit within the framework of the Unified
Protocol. Would we expect such a problem to change with this specific intervention? If so,

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Core Module 1: Building and Keeping Motivation

how? Can you use language or modify problems or goals to better fit with the prevailing
theory or case conceptualization model of this approach? If so, you are encouraged to do so.

Adolescent Motivational Enhancement in the UP-A—A Primer1

Before we describe specific module content, a basic understanding of the

motivational enhancement techniques to be used in the UP-A may provide a useful framework
for understanding how to build and support motivation within this module and throughout
treatment. This module describes a number of motivational enhancement techniques that can be
used to help increase the adolescent’s and the parent’s motivation to change and commitment to
engage in the treatment process. Motivational enhancement is a therapeutic technique than can
decrease an adolescent’s ambivalence about and resistance to changing problematic or
interfering behaviors. It is important to emphasize that motivational enhancement techniques
are not skills to be taught to the client per se (although worksheets such as those in the UP-A
that promote goal setting and treatment commitment are often utilized); generally, it is a
conversational style that should be used not only in this initial module but throughout treatment
whenever ambivalence is encountered. The main enhancement strategy described here is
motivational interviewing, which gives the therapist a way of offering choices to the
adolescent and encouraging evaluation of the adolescent’s choices without force or judgment.
Motivational interviewing also helps resolve ambivalence by increasing discrepancy between the
adolescent’s current behaviors and the desired goals while simultaneously minimizing
resistance. There are also techniques discussed that (p. 6) more specifically target emotional
avoidance and home learning assignment compliance, which may be used primarily as
references for you to support adolescent involvement during subsequent modules.

Motivational enhancement is important in the UP-A because adolescents are often conflicted
about wanting to change or are hesitant about engaging in therapy. This is understandable from
a developmental perspective given that adolescents do not often think about their behavior,
including the types of avoidance behaviors and strong emotions we target in the UP-A, from a
long-term perspective. It is also common that an adolescent is not referring herself to therapy.
Many clients are persuaded by someone else (parents and teachers, for example) to engage in
treatment. Additionally, this treatment asks a lot of the client and family, and many adolescents
or their parent(s) might not be ready initially to work toward changing their behavior.

Emotional disorder symptoms typically go hand in hand with treatment ambivalence. In

particular, adolescents suffering from symptoms of depression may be lacking motivation for
many activities, including therapy. In addition, the emotional avoidance and ensuing avoidance
behaviors that typically accompany anxiety and depressive disorders can also lead to treatment
ambivalence, as these behaviors may feel needed or beneficial to the adolescent in the short
term. It is imperative that you keep the adolescent’s perspective in mind and learn what is
important enough to her to motivate continued engagement. It is important that the therapist
not use techniques that increase resistance, some of which are described at the end of this
module, as this will increase the adolescent’s opposition to the therapy process and decrease the
potential for therapeutic change.

A change in the adolescent’s motivation may take time. That doesn’t mean you need to stay on
this module for more than one or two sessions at this time, but rather you may simply need to be
more attentive to such issues in future sessions. Motivation may wax and wane throughout the
adolescent’s time in treatment. It is common for therapists to encounter some ambivalence
during emotion-focused behavioral experiments (especially for adolescents experiencing

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Core Module 1: Building and Keeping Motivation

significant depression), during the situational emotion exposure module, and with home learning
assignments throughout the modules (for all adolescents). Any treatment material may spark
some resistance or, in all likelihood, outside life stressors or family issues may promote
resistance at times in treatment.

(p. 7) Ambivalence can be obvious, such as a client being chronically late for sessions, arguing
with the therapist, or refusing to try a new technique in session, or more subtle, such as
avoiding discussions that cause distress by switching to another topic or interrupting the
therapist. If this occurs, you should use data-based monitoring tools and top problem ratings
within and between modules to help you most effectively refocus treatment on presenting
problems and better understand factors delaying progress. It is also important for you to
recognize if or when you are beginning to feel frustrated with the adolescent, which is a
common response to a client’s ambivalence about therapy. If you begin to feel helpless in efforts
to move the adolescent forward or feel as if you are doing all of the hard work, this can lead you
to label the adolescent as “unmotivated” or “resistant,” which can impact your relationship
profoundly. Therefore, not only are the techniques described below helpful for decreasing
adolescent ambivalence, they are also there to reduce your feelings of helplessness and
frustration.

Essential Components of Motivational Interviewing

1. Express empathy: This is seen as the cornerstone of motivational enhancement

and relates to any experiences conveyed by the client. It is marked by the underlying
attitude of acceptance in an effort to understand the client’s feelings and perspectives
without judging, criticizing, or blaming. Ambivalence is not viewed as psychopathology.
Instead, it is accepted as a normal part of human experience, and a normal part of the
therapeutic process.
2. Develop discrepancy: The adolescent’s awareness of the consequences of her behavior is
important. A discrepancy between present behavior and future goals will motivate change.
By pointing out the discrepancy in a nonjudgmental manner, you lead the adolescent to
present her own arguments for change. Discrepancy is explicitly developed in Module 1
using the decisional balance exercise in Goal 3 (below).
3. Avoid arguments: Arguments are easy to fall into but can be counterproductive to
change. When you defend your position, it breeds defensiveness in the client.
4. Roll with resistance: The therapist invites the client to see a new perspective, but this
perspective is not imposed. If the adolescent is ambivalent about the new perspective, do
not enforce it.
(p. 8) 5. Support self-efficacy: Belief in the possibility of change is an important motivator.
The client is responsible for choosing and carrying out personal change.

Empathy

High levels of empathy during treatment have been shown to be associated with positive
treatment outcomes across different types of psychotherapy. As a therapist, you are familiar with
empathy or compassion and how it can be expressed. Here are a few reminders about what
empathy looks like in session:

■ Listen in a supportive, reflective manner that demonstrates your understanding of your

adolescent client’s concerns and feelings.
■ Give sharp attention to each new client statement.

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Core Module 1: Building and Keeping Motivation

■ Continually use reflective listening—listening actively through a series of verbal (e.g., “I

understand”) and nonverbal (e.g., nodding) behaviors while also working to clarify what the
adolescent is saying and making sure there is mutual understanding.
■ Communicate respect for and acceptance of the client and her feelings.
■ Establish a safe environment for the client where you listen rather than tell.

Additional motivational enhancement techniques are provided in Appendix 1.1 at the end of this
module. These include the following:

■ A definition of resistance and techniques for decreasing resistance

■ Strategies that are useful when encountering resistance
■ Avoidance as a particular source of resistance in the UP-A
■ Methods for addressing struggles around home learning assignments/skills practice

Core Module 1 Content (Divided by Goals)

Goal 1

Orient the adolescent and family to treatment concepts and structure (including level of parent
involvement).

(p. 9) Introduction to UP-A Structure and Purpose

Welcome the adolescent and parent to this first session of the UP-A. As you initially orient the
adolescent and parent to the structure and purpose of the UP-A, several elements should be
emphasized. You may start by describing the UP-A broadly:

“The UP-A contains strategies that have been shown in research to help adolescents cope
more effectively with strong emotions and the situations in which they often have strong
emotions.”

You can then note that this treatment is not designed to get rid of strong emotions. Rather, this
treatment is designed to help the adolescent learn new ways to manage her emotions so that
these strong emotions do not mess up her life. You may briefly explore, while the parent is still in
the room, how strong emotions have impacted the adolescent’s life, or wait on further discussion
of this topic until after the parent leaves the room. As the adolescent is the expert on her own
emotional experience, emphasize that you will serve as a kind of coach, but the adolescent will
be the one to practice the strategies she learns. Indicate that together you and the adolescent
will be talking about many different emotions, but that the emotions she experiences most
frequently and intensely are the ones you will be talking about most often. You should indicate
that you will return to this topic and discuss strong emotions and related emotional behaviors
later in this session and more in subsequent sessions.

The Role of Out-of-Session Practice

Attending sessions and listening to the concepts will only set the stage for change. Practice of
the concepts in “real life” is what will result in noticeable, lasting changes. Every week, the
adolescent will be given home learning assignments from the UP-A workbook to aid in the
process of practicing the skills learned in session. These workbook materials should be filled out
at home and brought to the following session to remind the adolescent of the work she did over

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Core Module 1: Building and Keeping Motivation

the past week, as well as to remind her of any problems, setbacks, or obstacles that may have
occurred.

Course of Treatment

The length of the UP-A is not specifically dictated ahead of time, but on average, treatment lasts
approximately 16 weeks. Sessions are (p. 10) typically conducted weekly but may occur more
frequently if necessary to ensure the adolescent’s safety (as appropriate to your treatment
setting).

Use of Workbook Materials

During each session you will be covering a fair amount of material. The workbook has been
designed to supplement and support Therapist Guide materials in order to ensure that all
information is learned and practiced in and out of session.

Discuss Parental Involvement in Treatment and Rapport Building

At this point, you may excuse the parent from session. You may choose to give the parent a copy
of the Parent Summary Form for Core Module 1: Building and Keeping Motivation and Defining
the Main Problems—Parent (Appendix 1.2 in this chapter) to complete while the parent is
waiting for you to finish the remaining adolescent portion of this first session. These parent
materials can be found at the end of this chapter. The problems endorsed by the parent out of
session can then be discussed and confirmed as the parent-rated top three problems when the
parent returns to session. Alternatively, you can wait and have the parent and adolescent
complete their respective versions of the Defining the Main Problems worksheet together at the
end of this first session to promote collaboration and consistency across adolescent and parent
problems to be rated weekly.

Once alone, remind the adolescent that this treatment will be most successful if all members of
the team are aware of the skills being taught and of the concepts being learned. Inform the
adolescent that you will be checking in with the parent regularly and may have some sessions
with just the parent(s), but that you would like to do so in a way that is comfortable for the
adolescent. You should discuss with the adolescent what parental check-in format would make
her most comfortable. Parental check-ins will be required for this treatment; therefore, the
adolescent should not be given the option of denying parent check-ins.2 Some suggestions are
below:

■ 5- to 10-minute check-in with parent at the end of session with adolescent in the room
(p. 11) ■ 5- to 10-minute check-in with parent at the end of session with adolescent out of
the room
■ Up to three partial or full sessions with parent to help him or her support the adolescent
even more (i.e., Module-P sessions), plus 5- to 10-minute check-ins

Ask the adolescent what she is most comfortable with and try to use this as a guideline for
parent involvement. However, it may be good to indicate to the adolescent that you may need to
return to this discussion later (for example, if she requested no Module-P sessions, but you feel
it would be helpful to have one or more later).

Next, you may spend a bit of time getting to know the adolescent by asking non-intimidating
questions about her interests and life (e.g., family, friends, and school), particularly if the
adolescent appears reluctant or hesitant about therapy. Techniques of motivational enhancement
should be interwoven into the conversation in order to assess and enhance the adolescent’s

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Core Module 1: Building and Keeping Motivation

motivation for treatment. Remember—it’s okay if this module is more than one session, if that’s
appropriate to secure the adolescent’s motivation for therapy. It’s also okay to just “dive right
in” to top problems next.

Goal 2

Obtain three top problems from the adolescent, as well as severity ratings for each top problem.
Identify “SMART” goals related to top problems.

Therapist Note

Some adolescents may naturally identify goals before top problems. In these instances it
may be appropriate to switch the order of discussion.

Identifying Top Problems

In order to elicit top problems (Weisz et al., 2011), begin a brief discussion about why the
adolescent believes she is in treatment and what she sees as her main problems (at least three
for tracking on the Weekly Top Problems Tracking Form in Appendix 1.3) currently.

First, refer to Worksheet 1.1: Defining the Main Problems to guide this discussion. Allow the
adolescent to state whatever problems come to mind. If she generates problems that are clearly
outside the scope of this intervention, first be sure to fully understand the problems she is
describing, (p. 12) allowing her the opportunity to correct any misunderstandings (e.g., by
reflecting back what is heard). In addition, it may be useful to review any pretreatment
assessment materials with the adolescent to help prompt identification of her more impairing
concerns. This can be a useful time to remind the adolescent that this treatment is designed to
help her learn new skills to manage her strong emotions so that they do not keep her from doing
things she would like to be able to do. One way to generate top problems consistent with the UP-
A model in this section is to ask the adolescent:

“What are some situations in which you typically feel MOST overwhelmed or distressed?
What situations do you find you are avoiding? Do you find yourself doing other things, like
distracting yourself, to feel better in any situations? Are you avoiding, distracting yourself,
or doing other things to feel better because of intense emotions or bothersome
situations?”

Therapist Note

It is common for adolescents to note difficulties in social or romantic relationships as top

problems. These concerns can be addressed in the UP-A. For example, if the adolescent says,
“I want to have more friends,” assess what she thinks is keeping her from having more
friends. If it’s her tendency to avoid situations with new people because she feels
uncomfortable in these situations, offer hope that this can be addressed within the protocol.

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Core Module 1: Building and Keeping Motivation

If the adolescent says only that her parent is forcing her to come to treatment, ask her to
identify what her parent perceives to be the main problems. If the adolescent is unsure or
unwilling to provide examples, you may need to reference material discussed during the
adolescent’s intake assessment (if applicable) or you may need to encourage a discussion
between the parent and the adolescent about the parental rationale for seeking treatment at this
time.

Therapist Note

Negotiating top problems if the adolescent feels coerced into receiving treatment can be
tricky. Try your best to empathize with the adolescent’s perspective if this is the case.
Starting this discussion by focusing on SMART goals rather than top problems may help to
engage a more wary adolescent.

Here are some questions that might help get the conversation started:

“Whose idea was it that you come here?”

“Why do you think you are here?”
(p. 13) “What makes ____ think that you need to come here?”
“What will convince ____ that you don’t need to come here?”
“What does ____ think is the reason that you have (name of the behavior)?”
“What does ____ say you need to do differently?”
“Are you happy with the way things have been going in your life lately?”
“Is there anything you would like to see change in your life?”

Top problems are a central tool for ongoing progress monitoring in the UP-A. Thus, they should
be scored weekly on the Weekly Top Problems Tracking Form (see Appendix 1.3). Progress along
the three adolescent and parent top problems (whether identified as the same three problems or
two different sets of problems) can be presented back to clients and families weekly, as such
data may be useful for maintaining treatment motivation over time.

Identifying SMART Goals

The second half of Worksheet 1.1: Defining the Main Problems involves goal setting. The main
aim of this exercise is to increase the adolescent’s self-efficacy. It is important to discuss and
normalize the fact that adolescents can sometimes feel overwhelmed at the outset of treatment
—both about the potential to go from how distressed they are now to substantial relief from their
conditions and all the things that need to happen to get there! To a certain extent, an initial
focus on top problems versus goals may also feel overly negative in tone. To help address this
state of feeling overwhelmed and keep a hopeful outlook, we use a goal-setting exercise to
create a set of manageable goals from the client’s top problems. We introduce this exercise by
explaining to the adolescent that one factor that predicts success in treatment is setting
manageable, concrete goals early on (Weisz et al., 2011).

We are going to refer to these as SMART goals—goals that are Specific, Measurable, Attainable,
Relevant, and Time-Bound:

■ Specific goals are well defined and refer to the aspect of behavior change that is most
relevant for the adolescent (e.g., “improving my grades in school” versus “doing better at
school”).
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Core Module 1: Building and Keeping Motivation

■ Measurable goals allow for some observation of improvement over time (e.g., “making
three new friends” versus “making friends”).
■ Attainable goals are those that allow for the possibility of achievement during the course of
treatment.
■ Relevant goals are those most central to the adolescent’s top problems and the UP-A
treatment model.
(p. 14) ■ Time-bound goals are those that have some specified timeframe in which
measurable change will occur (e.g., “getting out of bed on time each day for the next
month”).

However, in the UP-A, goals can be a variety of short-term, long-term, or ongoing targets. For
example, some goals could be achieved in a few hours (such as “Go to the gym today”) whereas
others might be things the adolescent is always working toward (such as “Feeling more
comfortable talking to peers”). Although we encourage clients to discuss any goals they may
have (regardless of type), it’s important to make any larger, more abstract goals as concrete and
specific as possible using the SMART framework, when time permits or as may be relevant to
motivational enhancement. A good question to ask yourself as a therapist here is this: Can this
adolescent achieve her SMART goal in the time we have allotted for therapy using the UP-A? If
so, you have likely achieved a set of goals that you can use for ongoing motivational
enhancement throughout treatment to come.

Optional Goal 3

Strengthen the adolescent’s motivation for change by identifying initial steps to achieve
SMART goals, by using motivational enhancement techniques, and by using the decisional
balance exercise. Secure adolescent commitment to treatment. (This goal is optional and
may be used if time permits or if motivation is low for change.)

Identifying Steps to Achieve SMART Goals

Adolescents who need additional motivational enhancement may benefit from taking the three
SMART goals identified from Worksheet 1.1: Defining the Main Problems and identifying
actionable “baby steps” that may be helpful in achieving these goals. The purpose of this
exercise is to encourage the adolescent (a) to understand that change is possible and (b) to build
self-efficacy by identifying avenues for encouraging approach-oriented (versus avoidance-
oriented) solutions to her problems. When identifying these approach-oriented steps, it’s
important to recognize that the adolescent may not be ready to take larger steps toward these
goals at this time; however, she may find that smaller, approach-oriented steps are possible.

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Core Module 1: Building and Keeping Motivation

(p. 15) Strategies for Evoking Change Talk

Clients are generally much more willing to change when they come up with their own reasons
for doing so as opposed to being told to by someone else. This is certainly important to consider
when treating adolescents given the strong developmental needs for autonomy in this age
group. Once you have elicited a list of three top problems and SMART goals from the adolescent,
the following strategies are useful in encouraging the client to discuss the importance of change
(i.e., to engage in “change talk”):

1. Ask evocative and open-ended questions.

“What do you make of that?”
“Can you tell me more?”
“What do you think you might do?”

2. Explore the pros and cons of change, first asking about the benefits of keeping the status
quo, then asking about possible risks of having things stay the same.
“What do you like about how things are going now?”
“Is there anything about what’s going on that bothers you?”
“Tell me more about that.”

3. Ask for elaboration when change talk emerges.

“In what ways?”
“Could you tell me why that was a concern?”

4. Ask for specific examples to strengthen change talk when it emerges.

“When was the last time that happened?”
“Give me an example.”
“What else?”

5. Use the past to help the adolescent make decisions about the future by exploring times
when current behaviors weren’t a concern.
“You said things used to be better for you. What has changed?”
“What were things like before you started [insert behavior]?”

6. Look forward to the future to help the adolescent discover whether current behaviors are
helping her achieve what she wants out of life.
“If you were 100 percent successful in making the changes you want, what would be
different?”
“How would you like your life to be five years from now?”
“If you didn’t try to make changes, what might happen?”

(p. 16) Conduct Decisional Balance Exercise and Secure Commitment to Return to
Therapy

If the adolescent continues to struggle with motivation and commitment to therapy, work to
build a discrepancy between her current actions and her desired future outcomes as they relate
to treatment. Try to clarify the costs that the adolescent views as associated with making
therapy-related changes in her behavior at this time. Use Worksheet 1.2: Weighing My Options in
the workbook to reinforce this idea and, ideally, secure commitment to coming to therapy for at
least the next several sessions to see if benefits/pros can outweigh the cons identified. You can
also more simply ask:

“What are the worst things that might happen if you don’t make this change?”

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Core Module 1: Building and Keeping Motivation

“What are the best things that might happen if you do make this change?”

Goal 4

Discuss parent’s motivation for treatment; obtain parent ratings of adolescent top problems and
explore any barriers to regular and continued engagement with treatment; and strengthen the
parent’s motivation for change using the motivational enhancement techniques described in this
module (motivational elements to be used as needed). Secure parent commitment to treatment.

Obtain Parent Ratings of Their Adolescent’s Top Problems

At the end of the first session, make sure that you save enough time to bring the parent back
into the room. This can be with or without the adolescent also present depending on the
adolescent’s preference and your clinical judgment of whether it would make sense to have both
the parent and adolescent in the room together. Once the parent is present, review and assess
the appropriateness of the parent’s top problem list, take the parent ratings of top problem
intensity, and begin assessing the parent’s motivation to participate as necessary in the
adolescent’s treatment and potential barriers that might interfere with full engagement with the
treatment process. Again, it is ideal to have the adolescent and parent collaborate and agree on
three problems that will be rated by both each week. However, if agreement seems hard to
achieve at this time, you can (p. 17) proceed with three separate problems for each informant.
It is possible that the adolescent may be upset or angry with the parent for identifying a problem
the adolescent did not bring up. Normalize this concern and reiterate that all opinions are
valuable in this treatment.

Discussing and Building Parent Motivation

You are strongly encouraged, in this module or at later time points, to use motivational
enhancement techniques when interacting with the parent. Sometimes lack of motivation for
treatment on the part of a parent can strongly impact treatment progress. Parent motivation
should be assessed during initial sessions and monitored throughout treatment if issues arise
(e.g., problems with attendance, issues with parents helping enforce skills with younger
adolescents). The purpose of using motivational enhancement strategies with the parent during
this initial session is twofold:

1. To build the parent’s motivation to engage in treatment (i.e., by consistently bringing the
adolescent to session, participating in sessions when asked, assisting the adolescent with
home learning assignments, and providing an environment that supports the adolescent’s
ability to change)
2. To identify potential barriers that will prevent the adolescent and parent from fully
engaging in treatment, and to work to overcome these barriers. Barriers can include but
are certainly not limited to difficulty affording the cost of treatment, difficulty arranging
transportation to and from treatment, work or family commitments that get in the way of
treatment attendance, driving distance from home/work to the clinic, significant resistance
from the adolescent, fatigue, or simply trying to fit treatment into a hectic schedule.

It is important to discuss both parent motivation and potential barriers early in treatment.
Problems with engagement and attendance may be the result of low parent and/or adolescent
motivation to change, significant barriers standing in the way of treatment progress, or both.
Use motivational enhancement strategies to build parent motivation for change if you perceive
that parent motivation is low. On the other hand, where significant barriers to treatment exist,

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Core Module 1: Building and Keeping Motivation

you may find it useful to employ problem-solving techniques from Module 5 (Chapter 5 in this
Therapist Guide) to generate solutions to foreseeable barriers.

(p. 18) Addressing Issues Around Home Learning Assignment

Completion

Therapist Note

Although there is no explicit home learning assigned for Module 1, you might find this to be
a good opportunity to reinforce the importance of home learning assignments to this
treatment, discuss upcoming home learning assignments, and work on overcoming
anticipated barriers to their completion as specified below. You may also choose to return to
this section of Module 1 later in treatment to troubleshoot noncompliance with home
learning assignments if it arises.

The client’s completion of home learning assignments is an essential component of this protocol
for increased understanding of treatment concepts, utilization of learned techniques,
generalization of learned adaptive behaviors to multiple settings, and increased comfort with
uncomfortable emotions and/or sensations. Completing the home learning is essential for
maximum therapeutic gain.

Many clients will resist completing their home learning assignments for a variety of reasons. It is
important for you to underscore the importance of compliance with home learning assignments
and to reinforce completed home learning in every session until the benefits of home practice
are self-reinforcing this behavior.

Function of Noncompliance with Home Learning Assignments

When an adolescent is consistently coming in without having practiced skills during the week,
your first task is to find out why. The reason behind a client’s not completing the assigned tasks
will not only help to solve this issue but will likely provide clues for therapy overall. Below are
common reasons why people do not follow through with home learning assignments and
strategies to address them:

1. “I don’t think it will help.” This might be a clue that the client does not believe in the
therapeutic rationale. It will be important to link home learning to the client’s stated goals.
Don’t assign something to practice unless the adolescent has expressed an understanding
of and agreement to the assignment. Doing so might lead to more resistance and less
openness to change.
(p. 19) 2. “I wasn’t sure how to complete it.” This could simply mean the home learning
assignment is too vague. It will be important to explain when, where, with whom, for how
long, and with what materials the assignment should be completed. Often there is an
underlying perfectionism in clients causing them to assume that home learning
assignments need to be done “perfectly.” Address this black-and-white thinking in session
and assure the client that there is not a right or wrong way to complete an assignment.
3. “I forgot.” In this case, prompts might be necessary, particularly for clients who live in
chaotic environments or who have too much to do throughout the day. Help the client
create reminders around her home or at school, or call the client midweek if you have the
time.

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Core Module 1: Building and Keeping Motivation

4. “It was too difficult.” This might imply a deeper fear of failure when doing the
assignments or a fear of the emotional dysregulation that could come from the assignment,
or it might simply be that the task was too great. As a rule, it is best to start with behaviors
that the client is already doing some of the time. Anticipate possible difficulties and develop
backup plans. Have the client practice in session and ensure that she experiences success
in the session.
5. “It didn’t seem important.” You should reinforce the importance of home learning
assignments by using language that implies their importance. You should also consistently
review the past week’s home learning assignment at the beginning of each session. If the
client tries to bring up an important issue, express your intention to discuss it after home
learning assignment review. This should be less of an issue if the adolescent contributes to
choosing an assignment, so strive for this in each session.

(p. 20) Parent Summary Form for Core Module 1: Building and
Keeping Motivation

Core Module 1 is designed to help you and your teen identify problems and build motivation for
treatment. You and your teen will each identify goals for his or her treatment, reasons for
wanting to accomplish these goals, the steps you can each take to meet these goals, potential
barriers that may make it difficult to reach these goals, and signs that will let you know that
your teen is achieving these goals. You and your teen will also each identify three Top Problems
or issues you would like to be addressed in treatment, and these issues will be rated at every
session in order to make sure that the treatment is working to target and reduce problems that
both you and your teen would like to address.

In addition to identifying the things that may be going “wrong” for your teen right now because
of the strong emotions he or she is having, it is helpful to think about the goals your teen wants
to achieve in order to address these issues. In this treatment, we are asking you to identify a
type of goal that allows you and your teen to both build motivation for treatment tasks to come
by noting how your teen’s life could be improved through working on his or her top problems.
We refer to these goals using the acronym “SMART.” A SMART goal is:

■ Specific: Specific goals are ones that are clear, concrete, and well defined. An example of a
goal that is not specific is “doing better at school.” A better, more specific goal is “my teen
raising her Algebra grade from a ‘C’ to a ‘B.’ ”
■ Measurable: Measurable goals are goals that can be observed and tracked over time so
that you can see how much progress your teen is making. An example of a goal that is not
measurable is “making friends,” because it is difficult to know whether someone is making
progress toward this goal. Did your teen achieve the goal if he made one new friend, or must
he make more? A better, more measurable goal is “making three new friends.”
■ Attainable: A goal that is attainable means a goal that your teen can achieve, or that is
within his or her reach. Some goals are not attainable because they are very unlikely or
because only a very, very small number of people could possibly reach them (for example,
“become the Queen of England”). Other goals are not attainable because they would take a
very long time to achieve, much longer than the amount of time your teen will be in treatment
(for example, “get into a good college” if your teen is only 14). A better, more attainable goal
is “my teen raising her GPA from last semester to ___ this semester.”
■ Relevant: A goal that is relevant is one that is meaningful to your teen and one that has
something to do with the emotions that your teen will be focusing on in this treatment, such
as fear, sadness, or anger. A goal that is not likely to be relevant to your teen’s treatment is

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Core Module 1: Building and Keeping Motivation

“save enough babysitting money to buy a car” or “clean my room every day.” Although these
may very well be great goals, they may not have much to do with the emotions we will be
focusing on in treatment. A better goal is “raise my hand in every class, no matter how
nervous I feel.”
(p. 21) ■ Time-bound goals are goals that are very specific about when and how often you
would like something to occur. A goal that is not time-bound is “get out of bed in the
morning.” A better, more time-bound goal is “get out of bed when my alarm goes off each day
for the next month.”

Goals and top problems may differ between parents and teens. That’s okay! You and your teen’s
therapist will work together to finalize your top problems in session and will help you and your
teen to rate these weekly going forward.

Identifying Potential Barriers

It is also important to discuss with your teen’s therapist any potential barriers that may limit
your or your teen’s ability to work toward these goals. Examples of barriers include difficulty
affording the cost of treatment, difficulty arranging transportation to and from treatment, work
or family commitments that may get in the way of treatment attendance, driving distance from
home/work to the clinic, significant resistance from the teen, fatigue, or simply trying to fit
treatment into a hectic schedule. It is important to identify these barriers early in treatment, so
that you, your teen, and the therapist can work together to identify potential solutions.

What can I do to support my teen by building and keeping motivation for treatment?

✓ Attend every session with your teen.

✓ Identify the value and benefits of treatment.
✓ Listen to your teen’s concerns (if any) and review your teen’s goals, purpose, and
motivation for seeking therapy.
✓ Help your teen overcome any barriers to treatment.
✓ Have confidence in your teen’s ability to reach his or her therapy goals!

Maintaining Motivation

One way to maintain motivation for treatment is to look at the anticipated benefits and costs of
engaging in treatment and changing behaviors by using skills learned in therapy. If the benefits
of changing outweigh the costs, then teens are more likely to stay in treatment!

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Core Module 1: Building and Keeping Motivation

(p. 22) Appendix 1.1: Additional Motivational Enhancement Topics

What About Resistance?

Change is difficult for anyone. Every therapist reading this manual has set a goal before
(e.g., going to the gym more often, eating more nutritious meals) and not followed through with
it. Changing behaviors that stem from symptoms of anxiety and depression is just as difficult, if
not more so. It is imperative to understand that resistance does not necessarily reflect the
adolescent’s “true” character. It is a response, certainly, but it is not necessarily oppositional in
nature. Instead, it may signal a disconnect between where the therapist is and where the
adolescent is. This may include differing treatment goals, low readiness to change, and differing
views about the role of the therapist. As a therapist, you directly influence levels of resistance
and should remain aware of where the resistance is stemming from as it will be important to
address this if change is to occur. Often it is just as important to know what not to say as it is to
know what to say. Below are examples of language that can create “traps” for you and the client,
in which resistance is increased, motivation is challenged, and progress is stalled.

Question/Answer Trap
In this “trap,” the therapist and client fall into a pattern of question/answer, question/answer,
and so on. Although seemingly benign, and often necessary due to a need for further information
from the adolescent, this pattern tends to elicit only passive responses and closes off access to
deeper conversation. Therefore, clients are not encouraged to explore issues in depth. It also
cuts short the adolescent’s chances to explore motivation and offer reasons for changing. The
optimal pattern is to ask open-ended questions continually, with reflective listening as the
primary response to answers.

Therapist: You’re here because versus Therapist: So, what brings you
you’re anxious in school? here?
Client: Yeah. Client: I don’t know.
Therapist: Are you afraid of taking Therapist: You’re not sure why
tests? you’re here.
Client: Yeah. Client: Yeah.
Therapist: Are you afraid of the Therapist: How are things going
students? for you at home?
Client: Yeah. Client: Not so good.
Therapist: How many friends do you Therapist: Not so good, huh. Tell
have? me more about that.

(p. 23) Confrontation/Denial Trap

Most therapists have had the experience of meeting with an adolescent who is not yet ready to
change, and who provides a reasonable argument in response to every statement the therapist
makes about why change should happen. The therapist and client then engage in an
argumentative back-and-forth in which the client counters each argument for change with an
argument for remaining the same. The more the therapist defends his position, the more the
adolescent defends her position, until she is more convinced to keep the status quo than she was
before the session. If you leave your client with no other option than to argue with you, that is
what you will get.

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Core Module 1: Building and Keeping Motivation

Therapist: Well, your parents tell versus Therapist: So, your parents brought
me you’re depressed and won’t you here because they say you’re
leave your room. depressed. Is that true?
Client: I’m not depressed. Client: No.
Therapist: Well, you meet the Therapist: So you feel pretty okay?
criteria. Client: Well, sometimes. Sometimes I
Client: A lot of my friends are feel good, but lately that’s been less
bummed out like me. and less.
Therapist: Being sad is different Therapist: What’s that like?
than being depressed. Client: It’s awful. I used to see my
Client: I’m not depressed. I feel friends all the time.
fine. Therapist: That sounds really hard.

Expert Trap
Therapists can sometimes provide direction to the adolescent without first helping her
determine her own goals, direction and plans. The problem with this approach is that clients
may tend to passively accept the therapist’s suggestions and may only halfheartedly commit to
the difficult work involved in changing. A therapist using motivational interviewing is
nondirective, only offering suggestions for change when the client’s motivation is high, after
initial exploration of multiple pathways to change, or upon the adolescent’s request. (p. 24)

Client: I’m not sure the versus Client: I’m not sure if these
awareness exercises work for me. awareness exercises work for me.
Therapist: Well, research shows Therapist: No? In what way?
that this is helpful. You should Client: I can’t concentrate on my
give it a try. breath for that long! It’s stupid.
Client: But I did try it, and it Therapist: I wonder if there are other
didn’t help. ways of doing it that will feel more
Therapist: Try it a little longer. helpful to you?
It’ll work eventually if you really
give it a shot.

Labeling Trap
Labels are commonly used in psychology, and this pattern can filter into session. However, as
Miller and Rollnick state, “because such labels often carry a certain stigma in the public mind, it
is not surprising that people with reasonable self-esteem resist them” (2002, p. 68). Some
education about a client’s disorder might prove beneficial, but the emphasis should be on her
ability to change behavior, not on the label that has been given to her group of symptoms.

Client: So people have said versus Client: So people call me “depressed.” I

I’m depressed. I hate that hate that word.
word. Therapist: You don’t like being called
Therapist: You do meet the depressed?
criteria for depression.

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Core Module 1: Building and Keeping Motivation

Client: So you’re saying I am Client: No, it’s a stupid label. People say
depressed? they’re depressed if they’re sad for, like, a
Therapist: It’s just a word. I day.
wouldn’t let it get to you. Therapist: And things feel worse than
that for you?
Client: Yeah.

Premature Focus Trap

Although the premise of motivational interviewing does not mean that therapists simply follow
the client’s lead—as is done in Rogerian or person-centered therapy—you are cautioned against
focusing too quickly on a specific problem or aspect of a problem. This can be trickier if the
parents have identified what they feel is an issue. It is important to draw on the adolescent’s
perspective of the problem. (p. 25)

Therapist: Well, I talked to versus Therapist: Well, you know that I met with
your parents, and it sounds your parents earlier. I have an idea of
like school is a big issue for what’s on their mind, but now I want to
you. hear what’s on your mind.
Client: Yeah, the kids are so Client: I can’t stand the kids at school.
mean there. Therapist: Really? Tell me why.
Therapist: They also said Client: They’re so mean to me.
that you don’t turn in
homework. How long has that
been going on?

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Core Module 1: Building and Keeping Motivation

Blaming Trap
Clients may wish to blame others for their problems. Therapists may feel compelled to help the
adolescent take responsibility for difficulties that might have arisen. Neither of these urges is
useful. Blame is irrelevant to treatment gain. Miller and Rollnick (2002) suggest establishing a
“no-fault” policy when counseling a person.

Client: I can’t stand my parents. If versus Client: I can’t stand my parents. If

they hadn’t grounded me, then I they hadn’t grounded me then I
wouldn’t have snuck out of the wouldn’t have snuck out of the
house. house.
Therapist: Well, rules are rules. Therapist: I know it was
And this isn’t the first time you’ve frustrating. How did things go when
snuck out. you snuck out?
Client: But they don’t even get it! Client: It was fun at first, but
Therapist: You’re old enough to getting in trouble with the cops was
know better, though. scary.
Therapist: It sounds like that part
really troubled you.

Useful Strategies When Encountering Resistance

The therapist’s style can either increase or decrease a resistance to change, and it is
of utmost importance that you use strategies that will reduce the likelihood of defensiveness in
the adolescent. These strategies have often been referred to overall as rolling with resistance. It
is important to restate that resistance is not considered opposition by the client but a signal of
dissonance in the therapeutic relationship. The techniques described in Table 1.1 are simply to
help reduce this dissonance. (p. 26) (p. 27)

Table 1.1 Techniques to Help Reduce Dissonance

Technique Description Examples

Simple One way to reduce resistance is Client: But I can’t join that
Reflection simply to repeat or rephrase what club. I mean, I don’t know
the client has said. This anyone!
communicates that you have Therapist: Joining that club
heard the person, and that it is not seems nearly impossible
your intention to get into an because staying home feels
argument with the person. safer.
Client: Right, although maybe
I could see what it would take
to join.

Amplified This is similar to a simple Client: But I can’t join that

Reflection reflection, only the therapist club. I mean, I don’t know
amplifies or exaggerates to the anyone!
point where the client may
disavow or disagree with it. It is
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Core Module 1: Building and Keeping Motivation

important that you not overdo it, Therapist: Oh, I see. So you
because if the client feels mocked really couldn’t join that club
or patronized, she is likely to because everyone would make
respond with anger. fun of you.
Client: Well, it might not be as
bad as all that. But it would still
be hard.

Double-sided With a double-sided reflection, you Client: But I can’t join that
Reflection reflect both the current, resistant club. I mean, I don’t know
statement, and a previous, anyone!
contradictory statement that the Therapist: You can’t imagine
client has made. how you could join a new club,
and at the same time you’re
worried about not having many
friends.

Shifting Another way to reduce resistance Client: But I can’t join that
Focus is simply to shift topics. It is often club. I mean, I don’t know
not motivational to address anyone!
resistant or counter-motivational Therapist: You’re getting way
statements, and counseling goals ahead of things here. I’m not
are better achieved by simply not talking about your joining that
responding to the resistant club today, and I don’t think
statement. you should get stuck on that
concern right now. Let’s just
stay with what we’re doing
here—talking through the pros
and cons—and later on we can
worry about what, if anything,
you want to do about it.

Rolling with Resistance can also be met by Client: But I can’t join that
Resistance, or rolling with it instead of opposing club. I mean, I don’t know
Coming it. There is a paradoxical element anyone!
Alongside in this, which often will bring the Therapist: And it may very
client back to a balanced or well be that when we’re
opposite perspective. This through, you’ll decide that it’s
strategy can be particularly useful worth it to keep to yourself and
with clients who present in a stay in your room most of the
highly oppositional manner and day. That will be up to you. It
who seem to reject every idea or might be worth not trying.
suggestion.

Reframing Reframing is a strategy in which Client: My mom keeps telling

you invite clients to examine their me that I need to deal with my
perceptions in a new light or in a problems, go to therapy, clean
reorganized form. In this way, new my room. She’s such a nag! I’m

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Core Module 1: Building and Keeping Motivation

meaning is given to what has been tired of her telling me what to

said. do.
Therapist: Your mom must
care a lot about you to tell you
something she feels is
important for you, knowing that
you will likely get angry with
her.

Agreeing with This is a lesser way of rolling with Client: But I can’t join that
a Twist resistance. You initially agree with club. I mean, I don’t know
the client’s claim but with a slight anyone!
change in direction. This offers Therapist: You’ve got a good
you a way of influencing the point. And even if it means
direction of the conversation making some new friends, I
without creating a therapeutic wouldn’t want you to feel
disruption. uncomfortable.

Emphasizing People tend to assert themselves Client: But I can’t join that
Personal more if they think their club. I mean, I don’t know
Choice independence is on the attack. A anyone!
response that will squelch this Therapist: It was just a
reaction is to assure the person suggestion. What you do with it
that in the end, she has the is completely up to you. No one
ultimate say in what she does. can force you to walk in and
sign up.

Avoidance as a Source of Resistance

The cornerstone of this treatment is decreasing emotional behaviors, and yet this is an
area in which many adolescents are highly resistant as it involves purposely experiencing
feelings of fear and intense discomfort. In addition to the motivational enhancement techniques
discussed, here are some additional ways to approach resistance to the intentional experiencing
of emotions, whether in the form of exposure or emotion-focused behavioral experiments:

1. Elicit from the adolescent short-term and long-term consequences of continuing her
current emotional responses.
2. Most clients will ask, “Why should I try to feel bad on purpose?” When this happens, use
cognitive reappraisal and Socratic questioning techniques to explore their maladaptive
beliefs (e.g., “I won’t be able to stop crying”) about emotional avoidance and ensuing
emotional behaviors. It is important to understand the adolescent’s thoughts behind the
emotion. Is it fear that the emotion will never go away? Is the belief that being successful at
facing emotions will lead to feeling better and therefore more responsibility? Help clients
track the consequences of changing or keeping emotionally driven behaviors in and
between sessions. Ask clients to test their prediction that something awful might happen.
Be open to ways and times that emotional avoidance and behaviors can be adaptive for the
client. For example, if the adolescent shows emotions when she is bullied, this might lead to
more teasing and is therefore a maladaptive use of expressing emotion.

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Core Module 1: Building and Keeping Motivation

(p. 28) 3. For some clients, it might be necessary to teach coping skills (e.g., cognitive
reappraisal, problem solving) before asking them to confront emotions. This would require
some modification of the module order to maximize treatment benefits.
4. Help the client recognize and change maladaptive ways of avoiding emotion little by
little. Begin with small steps and work upward for clients having great difficulty. For
example, for a client who avoids the experience of sadness, you can first block subtle
moves, such as hiding tears or changing the subject when a distressing topic arises. Work
up from there.

Appendix 1.2: Defining the Main Problems—Parent

(p. 29)

(p. 30) Appendix 1.3: Weekly Top Problems Tracking Form

(p. 31) (p. 32)

Notes:
1 The motivational interviewing techniques described in this module are not original to the UP-A.
They are derived from Miller and Rollnick (2002) and Sobell and Sobell (2003). Techniques
discussing how to address therapy homework noncompliance and emotional avoidance at the
end of this module are also described in Leahy (2003).

2 The exception to this would be in the case of a strong negative parental influence on treatment
(e.g., interfering levels of parental psychopathology, history of abuse or extreme conflict).

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