Go with the FLO


In addition to FRAMES, you may encounter FLO. This is another way to remember the basic steps and strategies behind motivational interviewing. Which one you use, if either, is a matter of personal and professional preference.

  • Feedback
  • Listen
  • Options explored
  • No W(arnings)!


Set the stage

It is best to have the parent out of the room then set the agenda with patient while being collaborative.

An example: “I’d like to talk with you about what brought you to the ER, is that OK? As I do with all the young people I see, I’ll ask you a number of questions about different parts of your life, including school, friends, and activities you’re involved in.”

Goal: Acquires permission, explains why you are there, normalizes interview.

Segue to Questioning

Begin with some open ended questions to enable your patient to begin to open up on their own, if they are willing, prior to you presenting the results of the screening.

  • “What are you most concerned about?”
  • “What do you think is important to discuss?”
  • “What are your concerns?”

Follow up on any answers and summarize what you have heard so that you can be sure that you and the patient have a shared understanding.

Share the results

Substance use may have come up in the previous open questions. If so, then you have a natural segue to screening results. If not, then you will need to provide one and then share the results.

For example: “Do you remember the questions I asked you about substance use?  That test was given to thousands of teens across the US. Scores can range from 0 to 6. You scored a 3 which is much higher than other youth your age. What do you think of that?”

From that point forward, you role is primarily to provide feedback based on how he or she responds. You are likely to encounter resistence, something like:

  • “I don’t have a drinking problem.”
  • “Everyone I know gets high as often as I do.”
  • “I can quit whenever I want.”

This is natural, and how you respond can be extremely important. You are not trying to prove to them they have a problem and any attempt to directly do so will usually simply lead to more resistance and defensiveness. Some response starters could include:

  • “I’m not here to convince you you’re an alcoholic…I’d simply like to discuss the situation…”
  • “I’d just like to give you some information…”
  • “I’d really like to hear your thoughts about . . .”

If there is an injury involved, or some physiological signs of misuse/abuse, then you can use those as a entryway into further discussion: “What role do you think alcohol played in your injury?” or “How do you think alcohol (or other substances) may be affecting your body? (life, etc)?”

In the end, you have to let go at this point of trying to change the patient’s behavior and focus primarily on getting him or her to be willing to talk to you about your concerns, and, for that, you will have to listen, show them that you are listening, and truly empathize with them, that is, understand them.

Listen (and understand!)

They won’t buy what you are selling if they think you aren’t paying attention to what they are saying.

Ambivalence is very normal as a dialogue ensues.

Start with positives of remaining the same

  • “What do you like/ the upside about (current behavior)?  What would you miss if you did not (current behavior)?”

Explore the negatives of remaining the same

  • “What’s not so good/the downside of (current behavior) for you?”

Listen for change talk

  • “Maybe drinking did play a role in what happened.”
  • “It’s not that fun anymore.”
  • “I know I can quit because I have quit before.”

Summarize pros and cons of changing behavior for them and ask for an active affirmative of agreement on the summary, and reinforce change talk when you hear it, and highlight reasons for change, then, when you sense that the discussion is on a positive note that you can capitalize on, ask for an rating:

  • “On a scale of 1 – 10, how important is it for you to change your drinking?”
    • “Why didn’t you give it a higher number?”
    • “Why didn’t you give it a lower number?”

Recap of Listen (and understand)

  • Summarize
  • Acknowledge ambivalence
  • Summarize Pro and Con
  • Summarize importance/confidence
  • Highlight reasons for change
  • Seek a rating of change

Options explored

Assuming the patient has indicated some desire to change, then we need to support them in making a change, even if that change may be to continue to think about changing. To do this, we start with open-ended questions again, just as in feedback. We do this to provide the patient with the opportunity to generate their own possible options and plans for changing their behavior, which is far more likely to lead to actual change than if we set forth options and a plan for them initially.

  • “What do you think you will do?”
  • “What changes are you thinking about making?”
  • “What do you see as your options?”

Although they may respond in myriad ways, the things patients say will likely boil down to only a handful of options, a “menu”:

  • Manage drinking (cut down)
  • Eliminate drinking (quit)
  • Never drink and drive (risk reduction)
  • Seek help (refer to treatment)
  • Utterly nothing (no change)

And your role becomes that of an advisor trying to help them develop and commit to plans and actions to make their menu choices happen.

  • “If you wanted to change. . .”
  • “If the time were right . . .”
  • “How would you do it?”

While doing that, there are a few important strategies to remember:

  • Ask permission
    • “Would it be OK if I shared my concerns with you?”
  • Remain patient-centered
    • Help identify options and elicit commitments from patients without telling what to do
  • Allow for disagreement
    • “This may or may not be helpful to you but I’ve found that its useful for many people in situations that seem similar to yours.”
  • Elicit their reaction
    • “I understand you to be saying that…. What do you think?”
    • “Something that might be helpful would be to… What do you think?”