Professor Deborah Christie Hello, and thank  you for joining me today on this webinar,   which is looking at health coaching strategies  to increase the motivation of adolescents. My   name’s Deborah Christie. I’m a Professor  of Paediatric and Adolescent Psychology,   and I’ve been working with young  people and their families for 30 years. Not everyone who has the capacity to  make decisions about their lifestyle   in order to care for their health is either  ready or willing to make these choices. This   lack of interest is frustrating for both  families and healthcare professionals,   and for young people themselves, who can’t  understand why caring for themselves might   be important, but why they can’t see it  as a priority and why they don’t have the   confidence to put it into practice  at different points in their life. In order for somebody to be confident that they  can change, they need to want to, and they need   to be equipped with skills and abilities and  resources that allow them to make those changes.   An initial reaction of healthcare professionals  is often just to educate people, to give them   information about what people need to know,  what people need to do. But for a significant   percentage, not just of adolescents, but for us,  as well, knowing why doesn’t mean that we do. So, if you take a coaching stance  with young people and you invite   them to think about what changes they might  want to make, when they would want to make   them and how they could make them, and  incorporate motivational interviewing,   solution focused or narrative ideas, we can  help young people start to resolve ambivalence   and explore how their life could be  different, if they choose to do so. All of these approaches require us, as  Psychologists and mental health professionals,   to be thoughtful and skilful and to  integrate our different treatment   approaches to make sure that we provide  something that works for the young people   that we’re working with. A coaching stance  works with ambivalence and resistance,   two key aspects that are always present  when we’re working with adolescents. Today, we’re going to talk about this health  coaching approach, this health coaching stance,   and illustrate how it can structure interactions  with adolescent clinics. We’re going to think   about how to layer on motivational interview  skills on top of this structure, as well as other   interventions that you might want to use, both in  remote and face-to-face consultations. And we’re   going to talk about how to empower adolescent  patients to understand and act on their data. So, the first question we want to ask is,  “How motivated are young people to do what   we want them to do?” Here’s a young woman,  15 years of age, she wants certain things,   to be independent, to be the same as other people,  but because she has a condition, maybe diabetes,   people keep reminding her about the things that  she already knows, that she needs to check her   bloods, that she needs to do injections. And her  experience is that dealing with this condition,   doing all of those things, is actually  stopping her doing things that she wants to do. My grandson was diagnosed with diabetes six months  ago, he’s just 13. And he came round for lunch,   and as we started weighing out the  bread and the nachos and all of the   things that had carbohydrates in them,  he said, “I just want to be able to have   a meal with my family without having to  do all of this.” Like this young woman,   he doesn’t want to think about  doing things differently. And so,   he’s already starting to ignore bits of his  diabetes in favour of his normal adolescent   life. But all of these young people know deep  down that they can’t ignore things forever. Just because we have facts, these facts don’t  always fit what our beliefs are. And even though   we have facts about what we have do in order to  stay healthy, the beliefs that we have might be   beliefs against change, beliefs in favour of  not changing. Those beliefs might be about an   intention not to change. A young person referred  because of drinking too much might not want to   stop drinking when they’re with their friends.  They might see the advantages of the status quo,   “If I stop drinking, my friends will all think  I’m a loser.” They have a belief about how   change can be disadvantageous, “Who am I going  to hang out with if I stop drinking?” and they   can be pessimistic about change. They could  have a belief that nothing is going to help,   particularly if they tried or they’ve  done some counselling, and for them,   it was just psychobabble, so why should  they even bother coming to see you? These beliefs drive negative comments, “You’ll  never understand what it’s like,” “I don’t   need to come here,” but they also drive other  things, other behaviours, about treatment. So,   you might get silence in the session, you might  get telegraphic speech, they might just check   their phone. They might not answer their phone  when you send them a reminder, or when you call   them to remind them about an appointment. Even  if they’ve agreed to come to the appointment,   they might not turn up. And the key thing is  that they won’t reply to emails, because what   we’ve learnt from some research we’ve been doing  recently is that young people don’t look at their   emails. They use all sorts of other mediums for  communication but forget sending them emails. How does this make you feel? Do you dread seeing  this young person? Does your heart sink when you   think about them, or when you talk about them  in supervision? Everything that you’ve tried   just doesn’t seem to work. Are you looking  forward to seeing them in 15 minutes? This   feeling of dread is one of the main drivers  of burnout in healthcare professionals. And   it’s one of the main drivers for not being  able to work effectively with young people,   because we have a belief that we have to right  and fix things, we have to make things right,   we have to fix it. We call it “the righting  reflex,” the knee jerk response to make   everything right. And what I’m going  to suggest is that you let go of this. Let’s think about when we’re working in a medical  culture. If we’re part of a treatment team,   as Psychologist, aspects of medical culture can  really impact negatively on wellbeing. Remember   that people experiencing higher stress levels  are less creative and less agile, mentally,   and that’s not just you, it’s the young person,  as well. So, when we’re faced with a stressful   consultation with somebody we’re concerned  about and worried about and want to do well by,   we become less creative and less agile, ‘cause  we’re pushing and pushing to try and sort things   out. When there’s that dominant paradigm of  care, not just in medicine, but also often in   mental health care, that involves solving things  and fixing things, it isn’t always effective or   appropriate. What we end up with is exhaustion,  feelings of hopelessness, caught in that cycle   of fixing that is incredibly depleting, and  as I’ve said, contributes to core burnout. So, if we were to take a breath, if we were  going to let go of that righting reflex,   if we were going to stop trying to fix things and  we were going to adopt a health coaching stance,   what would we be doing? So, we would be asking  questions that invite the young person to have   insight. We would be asking questions that help  expand their thinking. We would ask questions that   were non-rhetorical. We would use “what” and “how”  more than “why.” In fact, I would often argue that   we should just junk “why” completely, ‘cause “why”  is implicitly judgemental. “Why aren’t you doing   this?” However, we ask that question, whether we  ask it in a nice, curious way, the implication is   that we’re cross, and health coach questions are  non-directive, they’re not leading. And you can   only use this stance if you can accept the fact  that the young person is going to go their way. Now, we’re trying to get them to go the way that  we want them to go, but this is not an approach   for somebody that you are acutely concerned about.  If you need to do something to save somebody, it’s   not a health coaching situation. If somebody has a  BMI of 14, this is not a case, a space, for health   coaching. This is a space for you to do something  to make them safe. A kid that’s about to walk into   the road, we don’t have a conversation with them  about it, we catch hold of their hand and keep   them self. So, these questions are appropriate  when you are prepared to accept the fact that   the young person has got capacity and has got  the permission to make their own decisions. The next part of coaching, a health  coaching stance, is listening to understand,   not listening to respond. As we are actively  listening, we’re being deliberate and effortful,   we are just listening, not working out  what we are going to say next. We have   to be fully present in this moment, in the young  person’s moment, and give full attention to them,   not thinking, okay, what do I need to ask?  What do I need to say? What’s a good question   here? Listen to what they’re saying, to their  whole person, to all of them, to their words,   to the tone of their language, to the  expression in their body language. People are rarely really listened to. There’s a  lovely expression, “Somebody just needs a good   listening to,” but people rarely are listened  to. I had a session yesterday with somebody,   who started to cry at the very beginning  of the session, when I had asked them to   tell me what it was they were thinking about and  what they wanted to think about with me. They’d   been talking for about ten minutes, I hadn’t  said anything at all, I had just listened,   and they started to cry. And when they started  to cry, I asked them what were the tears about,   rather than assuming or jumping to understanding,  or thinking that it was because they were sad.   And what they told me was they were tears of  gratitude, because they rarely got really listened   to the way that I was listening. And this was  over a Zoom call, so how you sit, how you look,   how you catch their eye, your body language,  matters even more in a Zoom call. And remember,   when you’re listening to understand, what’s  going to get in the way of it? You’re busy,   you’re hungry, you’re worried about the next  session. Remember, you need to be fully present. So, I wanted to explain, first of all,  the structure, the coaching structure,   that a lot of Health Coaches, a lot of Coaches,  use for a session. And you can use this in a 15   minute session the same way that you can  use it in a 50 minute session. Start with,   “What are you thinking?” and listen. When  they get to the end of that wave of thinking,   then ask, “So, what might be an attainable goal?  What would you like to achieve today? When we   get to the end of our conversation, where do  you want to be?” Checking you’ve understood,   summarise, and make sure that you’ve reflected  back, using their words, what their goal is. Then, what are the realities? What are the  details for them about the situation? Some   people will just talk, some people will just  tell you what’s going on. But as they talk,   they will start to realise that they’re making  assumptions, and if you don’t interrupt them and   give them the space to make those realisations,  they will start to come up with their own   solutions and options. And towards the end, “What  are the obstacles and opportunities that you have   discovered as a result of the conversation today?”  And finally, the last question, “What will you do   now? What is the way forward for you? Of these  options and opportunities and obstacles, which   are you going to address first, tomorrow, before  I see you next?” So, TGROW gives us a structure. Let’s see how we can layer over a motivational  spirit. Motivational spirit is the basis,   it’s the bottom of the triangle, it’s the bottom  of the pyramid, of motivational interviewing. And   you can see here that there are things that  you do in motivational interviewing. I’m not   going to teach them to you today, but I’m going  to point out the importance of using spirit when   you’re asking them. If you ask how to change  questions or change talk without having these   principles behind you, it will not be  motivating, it will not be motivational. So, let’s think about what is motivational  spirit? So, an acronym for this is PACE,   working in Partnership. I mentioned that Michael  White said that “good therapy should feel like a   conversation.” Working in partnership  means that you have done your best to   equalise the power dynamic, you are not doing  something to this young person. You have a   contract to work with them and be alongside  them, rather than doing therapy to them. Acceptance is the second part of working  in the motivational spirit. And acceptance   means acknowledging the absolute worth  of the individual you’re working with,   respecting them, as a human being. Acknowledging  the strength and value in the present situation,   not working towards telling them what they should  be doing, or could be doing, but acknowledging   them that right now – acknowledging with them  right now that this present situation has value. Autonomy is key in acceptance. You have  to believe that the decisions that are   made are down to that person you’re  working with, it is their choice. They   have the right to self-governance, and you are  developing autonomy, and giving them autonomy,   helping them understand that the  solutions lie in their hands. Let’s also think about empathy. I often hear  people say things, “Oh, well, you’ve got to be   empathic and sympathetic, and that’s the important  thing.” Actually, it’s not about feeling sorry. It   – you might have concern for them, but sympathy is  not what’s needed here, camaraderie is not what’s   needed. If somebody is in distress, you need to  be able to have empathy, and empathy is about   acknowledging, understanding, feeling, connecting  with the emotions, but not feeling sorry for them. And that affirming stance, the last part  of acceptance, is that you come into this   relationship with the young person with an  absolute affirmation of hope and optimism   that behaviour change is possible and will take  place. There have been times where I have said   to young people, “Shall I hold onto hope for  you? Why don’t we put it in a drawer here,   so I’ve always got it?” or I ask them to  tell me what hope looks like for them. I   might share what hope looks like for me, an  image of hope, when I hear them talk. I’ve   even read “Hope is a Thing Like Feather,”  the feather, a lovely poem about hope,   and hope is a thing like a feather, to help  people understand that hope is tenuous and   difficult to get hold of it, but I believe in  it, and I believe that it will happen. And then,   I believe in that young person’s competence to  change, and that’s why I have hope and optimism. Compassion is the next thing that’s important,  where we have kindness versus judgement, where   we believe in humanity versus isolation, where we  are mindful, rather than overidentifying with our   own thoughts or feelings, or overidentifying with  the feelings and thoughts of the young person.   That we are able to be in the moment, and that we  are able to encourage them to do so, as well. And,   finally, Evoking intrinsic motivation. It’s  not enough to create external reasons to   change. The change much come from within, and  that’s our role, using a motivational spirit. So, here I can show you that these processes  which are linked by values, engaging and focusing,   evoking, planning, and then maintaining, can  be mapped onto this structured coaching model.   The first step is engaging. I’ve read many  letters from other Psychologists that say,   “The young person wouldn’t engage,” or have had a  referral from another team because they’ve said,   “The young person refused to engage,”  or somebody’s discharged because “they   wouldn’t engage.” It’s not the young  person’s job to engage with you,   it’s your job to engage the young person. And so, the beginning of any therapeutic   relationship is to find ways to engage.  It might be that you ask them to tell you,   and ask the parents to tell you, what things are  important them – important to them, right now. Is   it about school? Is it about out – being outside  of school? Is it about their friendships? Asking   them about what their values are, finding out  what values are family values, or values that   they’ve developed as they’ve become an adolescent.  Asking them to walk you through a typical day,   explaining that in order to think about how  you might support them, and help them find   some solutions, you’d really like to understand  what they’re having to live with right now. And so, inviting stories of personal  strengths, abilities and resources,   gives us an opportunity to meet the person  where they are, to meet the person and   not meet the problem. The problem will come  along, but we have to meet the person first,   and this is, “What are you thinking  about?” This is inviting them to begin   by asking them what are their thoughts,  what do they want to engage with today? Our next value, our next stage, is creating  a shared, collaborative focus. This needs to   include everybody in the room. And it might in  – also include people who aren’t in the room.   It might include, for example, the Nurse that  made the referral, what they might want the   young person to be thinking about. It might  be the Doctor that they’ve recently seen,   who they didn’t get along with. Why do they think  the Doctor would want them to come and meet with   psychology? It might be a grandma or a granddad,  somebody else who’s involved and cares for them. And identifying the differences, validating  that everybody will have maybe different goals   and different focuses, but then, ultimately,  coming back to, “So, what’s important to you?   What do you want to be thinking about today?  What do you want to achieve today? What is   reasonable and possible for us to achieve?” And  checking in that we’re on track for the goal,   “Does today’s conversation fit with your  values? Do we have the right pieces in order   to reach that goal?” And “How are we going  to work on it? Shall we just work with you,   on your own, or would you like  your parents to be with us?” I think sometimes families are always  quite shocked that young people say,   “I don’t want to meet with the Psychologist  on my own. I actually want my mum and dad in   the room with me so that they can help me, or I  can help them understand what’s going on for me   right now.” So often, in psychological  services, we think we have to pull the   young person in and fix them and work with  them because their inner world is what we   must be focus on. Actually, we need to ask  the young person, how do they want to work? Our next step, our next stage, is understanding  what the reality is, and we do this by evocation,   by evoking, and this takes time. This isn’t always  going to happen in one session. Using motivational   questions to build commitment to change and build  motivation to change, hearing and addressing and   validating ambivalence. “On the one hand, you  really, really want to not have to come and   see me, but, on the one hand, at the moment,  everyone’s so worried about you, it’s hard not   to be brought to psychology sessions. On the one  hand, you want to keep yourself well because you   value your independence and, on the one hand,  it’s very difficult to manage your medication   regimen.” And as we do these, as we put these  bricks in, as we start to think about short-term   needs and long-term goals and values, we start to  identify change talk, and we find ways to affirm   what their reality is and how they want to start  making changes, driven by intrinsic motivation. Somebody described motivational interviewing  as “Plucking change talk out of the jaws of   ambivalence.” I really like this idea, and I  guess I was thinking, what are the things that   we need to be constantly looking for when we’re  having a conversation with somebody? There’s   a nice acronym, it’s DARNCAT, and DARNCAT  stands for looking for Desire statements,   “I want to,” “I wish to.” Looking  for Ability statements, ability to   change, “I could do this,” “It’s possible it  could do it.” Looking for Reasons to change,   “I need to do this because,” “I’m going to do  it because,” “If I don’t, then something else   will happen,” and really mining for needs, “What  are the consequences? Why do you need to change?” And once we’ve established there is desire and  ability and reason and a need, we then move into   commitment, looking for commitment, “I must do  this, “I must do it,” “I will do it because.”   Action statements, “I will do the following  things,” and timing, “I will do it next week,”   “I will do it every day next week,” “I will do  it in the morning and the afternoons.” I used   to work with young people where if I got them  to the point where they were able to say to me,   “I will do one blood sugar a day,” we had  made a major, major progress and achievement,   because when they’d arrived, they’d been  doing none. So, it’s not about big change,   it’s about small change, but it’s commitment  to that small change that really matters. Using motivational interviewing, reflecting skills  and abilities, for those of you that are familiar   with these, it’s a form of summarising, it’s  a form of feeding back and showing that you’re   listening to understand, and not to respond.  And summarising every, maybe, ten/15 minutes.   There aren’t any rules about how frequently  or how often you’re supposed to summarise,   but I like to think of it in this way, as picking  the flowers and handing them back as a bouquet.   “I’ve heard that you want to change, and that you  know that you could, because this matters to you,   because you need to do something in order to live  your life the way that you want to.” “I’ve heard   you say that you are committed to change and  that you’re going to do the following things.” And that summarising must acknowledge  ambivalence. It’s not about being that,   sort of, toxic positivity, that everything’s  hunky dory, everything’s okay. It’s about   acknowledging that there will be times  when people don’t want to do things,   but – about being specific, affirming and  acknowledging those statements of change.   But also acknowledging that if something  doesn’t happen, if it doesn’t follow through,   then what are they going to do? If they don’t make  it on day one, is that a disaster, or how about,   if they don’t do it on day one then they  just do it on day two and three? And “I’m   optimistic you can do this,” having those  statements of hope and optimism in there. We want to invite young people to tell us what  are their options. Do you remember that slides   that showed the O for TGROW, it’s, “What are  the possible obstacles, what are the options,   what are the opportunities?” and then asking,  “What are you going to do next?” But it’s their   plan, it’s not your plan, it’s theirs. So, not  giving too much, you’re not trying to fix it,   not going from doing nothing to doing everything  all in one week. Doing more than a little, a bit   like Goldilocks, getting it just right. But, also,  be prepared to alter it, “If it doesn’t work out   this week, that’s okay. Do you know what? We’ll  change it.” Being clear that this is an experiment   and that it’s just an experiment, and sometimes  experiments work and sometimes they don’t. So,   when you see them next, “Let’s look at the bits  that worked.” Bring in that solution-focused idea   that you will only think about the bits that went  well, and then you’ll be able to do more of them,   rather than somebody feeling that they’re going  to come along and tell you that they’ve failed. What about giving information? How do we give  information, ‘cause sometimes we have to?   Sometimes we’re in a situation where we want to  share results, or we want to ask people to tell   us what they know, or we want to tell them  some information. The key way of doing this,   using a motivational interviewing, and also  a health coaching, is to ask for permission.   “Is it okay if I give you a couple of my  ideas? When I’ve been listening to you today,   I had some thoughts. Would you be interested in  hearing about those thoughts?” So, you might say,   “Is it okay if we talk about your test  results?” And this is one of the few times   that you use a closed question, because  you are asking for yes or no permission. And if somebody says, “No, I don’t want to  talk about my test results,” then you can ask   them another question, which is, “So, how would  you like me to get those test results to you so   you can look at them, or think about them, or  understand them?” They’ve said they don’t want   to talk about them, but you need to let them have  them, so ask them how do they want to get them? If   somebody says they’re not interested in finding  out more about smoking, then you could say,   “It would be really helpful for me if I could  understand what you already know about smoking   and asthma. Could you tell me a little bit about  what you’ve already been told, or what you’ve   looked at on the internet, for example?” And when  you’re giving information, give it in a chunk,   one piece of information, and then say, “How does  that land? What does that make you think about?” If you’ve got a reflection, then give the  reflection and say, “So, having shared my   ideas with you, I wonder what your thoughts  are about it?” So, take it away from you,   and give it back to them, so that they are now  back in control of the conversation. What we’re   trying to do here is empower young people  to understand and act on their data. So,   we want to highlight choice, we want to say to  them things like, “No-one can force you to do   this,” if that statement is true. We want to  ask them, “What choices do you have?” Because   they always have choices. We need to clarify our  position as a guide, “I’m here to help you think   through your options. I’m not here to talk  about things in a judgmental way. So, what I   wanted to talk about is the fact that you’ve been  referred because of drinking,” or, “you’ve been   referred because injecting is difficult.”  Rather than saying, “You’ve been referred   because you drink too much,” or, “You’ve been  referred because you don’t inject.” So, always   giving information, always making statements that  are non-judgmental, and guiding and supporting. We’ve talked a lot about eliciting their ideas,  “How do you want to take things forward?” That’s   something I always ask young people at the end of  a session. For those of you that do transactional   analysis, I’m putting them into an adult position,  in many ways, I’m working – trying to work with   them as an adult to adult. I’m not telling  them they have to come. I’m not putting them   into a parent/child position, “I need to see you  next week,” which would be that, but “How do you   want to take things forward?” And then supporting  autonomy. So, rather than using “we” statements,   and saying, “We are going to do this together,”  or, “We can have this plan.” “Your plan is,”   using “you.” “You can do this,” “You’ve said you  would like to do this, and you want your first   step to be,” so it’s not you, ‘cause it’s not  your goal, and it’s not your plan, it’s theirs. Resistance, you’ve worked so hard, you’ve done  all of these steps and you’ve still got to the   point where they’re saying, “I don’t want to do  it,” “I’m not interested,” “I don’t want to work   with you,” “I don’t care,” “Nothing helps.” Those  are beautiful examples of resistance statements,   and resistance, rather than being futile, is  inevitable. So, if we’re faced with resistance,   the very first thing to do is stop and  think, what am I doing to fan the fire   of resistance? It’s probably that you’ve  made some incredibly directive statement,   you’ve just told them something to do, you’ve  moved out and away from a motivational position. So, you need to stop, and then you do  a drop, and there are three bits to   dropping. The first is to show that you  have accurate empathy. “You’re feeling   pretty frustrated today,” affirming  the behaviour, “but despite this,   you still have agreed to come and talk with  me, you still decided to come here today,   you still got out of bed and caught the bus” or  “the Tube to come and visit with me.” And then,   an apology, “I am sorry that you feel angry about  coming here, I am sorry that you feel that things   aren’t helping.” Accurate empathy, affirmation  and apology, that’s the first drop, the one down. And then you roll. Those of you that do  martial arts will know about the – a judo roll,   it’s the same principle, that you use the energy  of the person coming towards you to roll, so,   acknowledging ambivalence. “So, on the one hand,  you are really, really depressed and unhappy,   and, on the one hand, you really want things  to be different,” but emphasising all the time   that – and this is key in rolling, emphasising  autonomy, “You know, ultimately you decide   how to use the time we’ve got together, you  decide the things that you want to work on,   and what do you think needs to change for  things to be better? Is it other people?” And often with teenagers, it’s, “I’ve – the – I  want my parents to stop nagging me,” “I want my   Teachers to stop picking on me,” “I want people  to stop bullying me.” It is often about external,   and then we can think about, “Well, do  we have any control over them? You know,   what do you – you know, what ways do you think,  you know, you could do something about those   people? If you don’t have any control over  them, who do you have control over?” So,   always coming back to emphasising that  they have the choice about themselves,   and that’s the bit that you’re giving them,  and that’s the bit that they have to hold onto. Now, once you’ve got good at stop, dropping and  rolling, you find yourself back on track, and you   go round in this, sort of like, circle at times,  and then you can start to use your other skills,   that you’re – used or evoking, and planning. But  you might get to a point where you do, kind of,   think, actually, do they really want to change?  And I remember asking a girl if she wanted to   change, and she said, “No, I don’t really want  to change.” So, I asked her did she want to want   to change, and she said, “Well, hmmm, I’m not  sure I want to want to.” So, I then said to her,   “Do you want to want to want to change?” And she  looked at me, and she nodded very thoughtfully,   and she said, “Yeah, that’s it, I  want to want to want to change.” So, what we did was, we did a decisional balance,  where we looked at the pros and the cons. Now,   those of you who do motivational interviewing will  know that you can use a simple pros of change,   cons of change, just on one hand and on the  other hand. But you can also do the pros of   no change and the cons of no change, and then you  can do the pros of change and the cons of change,   so you can make four columns. What you  want to really focus on, to start with,   is the counter-change talk. So, “Why  do you want – what are the pros of   not changing? Why do – why should we just  stay – why should things stay as they are?” And that’s a way of building rapport, because  you start to understand the barriers. You know,   young people don’t want to, you know, stop  hanging out with kids that get them into trouble,   because those kids are good fun, those kids  are the ones that they like being with,   those are the ones that understand them.  And you can start to say, “So, that’s,   kind of, at the moment where you’ve got your  friendship group.” And then you can move,   once you’re really taken your time to  understand the counter-change talk,   you then can move to direction for change. “Well,  look, let’s think about how life could be then,   let’s think about what the pros of changing  your peer group might be, and what the cons   of not changing are going to be. If you don’t  change, what are the negative consequences?” So,   you start to reframe, and you start to affirm the  ability of the young person to see difference. The final bit is, obviously, maintenance. The bits  that are in between is where the change occurs.   But change is a journey, and you travel throughout  your lifespan, and that idea of two steps forward,   one step back, is always true when we’re working  with young people who are struggling with change.   So, what we need to do is review it, “What’s gone  well? What’s not gone so well? How did you make   the two steps forward in the first place? One  step back, I understand, I can understand how   it’s frustrating to have gone one step backwards,  but, you know, other young people do that.” So,   responding with empathy and non-judgment.  And, most important, framing that relapse as,   “just a setback, it’s not the end of the world,  you haven’t got all the way back to where you   were beginning. It’s a small slip, it’s a small  hiccup.” I like this phrase, even if I wasn’t   keen on the person who said it, but, “You have  to fight a battle more than once to win it.” So, here are 12 Top Tips to Motivate and Support  Change. Let’s start with the counter-change,   first of all, don’t present as the expert, don’t  try and convince or persuade. I’ve said this,   don’t use “we” language for goals and plans.  It’s not “we,” it’s “them.” But don’t miss   opportunities for discussions of values, if  you feel or hear a word that’s about a value,   ask, “Is that a value? Does that matter to  you?” Bring that in, and do not provide the   consequences of decisions or actions. I read a  tweet the other day of somebody with diabetes   who’d been offered a tour of the amputation ward.  I can tell you, not only do they not want to go,   it’s not going to change their behaviour. What  about dumping information? Don’t, don’t dump, but   don’t avoid information or feedback opportunities.  Look out for the young person asking for that   and think about whether that information  can promote or change or support a plan. So, my last six statements about what you do need  to do to motivate and support change. Clarify your   role as a guide, offer “you” statements, and  emphasise personal choice and control. Promote   their personal responsibility and emphasise  the importance of their values, their goals and   their plans. Elicit from them what would be the  consequences of any decisions or actions that they   make or take, and when you’re giving information  and feedback, then use ask, tell and ask. And use   menus of options when discussing plans. There’s  never just one good option, there are always lots. I hope you find these tips useful,   and I hope you’ve enjoyed listening to  today’s webinar. Thank you for your time.