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Motivational Interviewing for the Busy Practitioner · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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So, yeah, a brief counseling approach that helps generally with patient treatment
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adherence, especially around health behaviors like smoking and exercise and
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medication, stuff like that.
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Sounds like you can end up saving time. Yeah.
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Music.
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I'm Holly Wayment, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Click on the link in this podcast for free credit that may include CME,
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MOC, or ethics credit, depending on our topic or podcast.
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Today, we're talking about motivational interviewing, a well-established gold
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standard counseling approach that helps with treatment adherence with things
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like diet, exercise, substance use, and more.
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You may have heard about it. You might be trying it, but I'm so excited because
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here today on Pediatrics Now is an expert in the field.
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Joining me here, Dr. David Roberts, a tenured associate professor of psychiatry
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at UT Health with nearly 20 years of experience as a behavioral health researcher,
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clinician, administrator, and trainer.
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Dr. Roberts, thank you so much for being here today on Pediatrics Now.
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Hi, Holly. Thanks so much for having me. I'm really excited to talk about using
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motivational interviewing.
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So you're a member of the Motivational Interviewing Network of trainers.
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You've trained more than 3,000 healthcare professionals in MI,
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and most recently you've developed an online platform for professionals to practice
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MI skills in small groups, and you have flexibly scheduled online training sessions.
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That's right. You know, for years, I've been passionate about motivational interviewing,
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but also a little bit frustrated with the limitations in our ability to effectively teach it to people,
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especially the difficulty of helping people get distributed practice in these techniques.
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And so that's what this new training platform is about. And this is now how
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we're teaching motivational interviewing more and more often here at UT Health.
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And I'll put the link to your training sessions that are all for CME credit, correct?
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Yeah. So we'll put that or a hyperlink in the podcast.
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And is it okay if I call you David? Yeah, that'd be great. Thanks.
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Our audience here, pediatric practitioners. There was one doctor I talked to.
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He said, so really, I've heard of motivational interviewing, but what is it?
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Yeah, it's a great question. It's one of these sort of buzzwords that I think
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most people hear about in their training, especially people in the health sciences
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and healthcare professions.
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So what it is, is an approach to counseling. It's sometimes called a directive
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approach. It's sometimes called a brief approach.
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What it really is, is a set of techniques that you don't have to be a psychotherapist
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or a licensed counselor to use.
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Really, anybody can be taught to use this set of techniques.
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And it's really for helping another person who's facing the possibility of change
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in their life, and especially some sort of health behavior change, like smoking,
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possibly new medical procedures that you're having to do because you've got
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a new illness and the doctor's saying you've got to do this now,
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like pediatric diabetes, for example.
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When a patient is facing a decision or a new challenge and has to respond to it,
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motivational interviewing is a set of techniques for helping them take on this
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decision and hopefully make a choice that's going to be in the best interest
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of their health moving forward.
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For pediatric practitioners and general practitioners, the challenge is time,
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even though it sounds like this could end up helping so much and even saving time.
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But when you're seeing 40 patients a day, maybe 15 minutes or less in the.
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Do you incorporate MI? Yeah, I mean, it's a great question.
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I think it's a really common concern because when you think of counseling,
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you think of therapy, you think of kind of creating space and having slow,
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meandering conversations about your history and your emotions,
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and there's not time for that in a busy physician encounter.
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And I think sort of the paradox with it, but also the The real skill in it is
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finding a way to make it very personal, even in the short amount of time that you have.
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A couple little ways to think about this. I like to use the phrase,
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you can have motivational interviewing always be running in the background,
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kind of like virus detection software.
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Like it's always bubbling up through your language.
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It's kind of a style of being with another person as much as it is a set of procedures.
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So that's one way to always have it present in your room is to embody what we
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call the spirit of motivational interviewing.
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That includes especially supporting the autonomy or the sort of self-direction
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of the patient you're working with.
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And, of course, all patients have their autonomy constrained.
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And especially kids and adolescents are extremely aware of the way that their
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free choices are limited.
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But everybody's choices are limited. So it's talking with the patient in a way
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where you're highlighting the choices that they themselves really have.
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And then second, I would say you're finding a way to show the patient that you're
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really listening to them.
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One of the best ways to do that is just the question, what matters most to you in this?
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Or what's most important to you about this? And last, I'll just throw in this
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other little technique, a way to sort of get to your agenda while also using
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MI skills is to direct to the topic.
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So maybe you say, I want to talk about your diabetes. Can we talk about your diabetes?
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And then maybe the patient says, yeah, what do you want to tell me about my diabetes?
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And then you, the provider, say, I just want to hear how you feel about it or
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how you're feeling about it.
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So there's a balanced maneuver there where you're directing to the topic,
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but once you get there, you're handing the microphone over to the patient to
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let them take the first stab at the conversation.
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It almost sounds like you're handing the power back to them.
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Yeah, that's a really nice way to put it. And it's really all about that.
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MI, it's sometimes referred to as a dance. It's the dance of who sort of is
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exerting the push or the pressure, who's taking the power. And we're always
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giving the power back to the patient.
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But then if the patient's sort of struggling with it or not moving with it,
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we might take a little bit of it back and see if we can push.
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So say if I was the patient and then I said, well, I mean, I don't think about
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it a lot. I don't really want to think about it, but it's fine.
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Yeah, I might look for a way to sort of validate that and say,
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that makes a lot of sense.
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Tell me why you feel that way about it or tell me what's more important than this.
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So I might put it, validate what you said, put it back on you and ask for elaboration.
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All my friends get to eat junk food. They don't have to eat at a certain time.
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They don't have to have a special device on their body.
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It's just embarrassing. So I just try to not talk about it.
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Yeah, it makes a lot of sense. You're at a point in your life where you really
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care what your friends think.
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You look around at your friends and you say, why can't my life look like theirs?
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And it just feels not fair to you. That really makes sense.
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So what I did there, Holly, is I'm just validating.
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And I think sometimes a thing we'll do, either as parents or as providers,
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is we will validate where the patient is coming from. Like, yeah,
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that makes a lot of sense that it's frustrating to you.
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And then we'll quickly move into saying, but can't you see that it's important?
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Or, but I'm going to need you to do this. And that's okay.
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That's okay. But I would encourage listeners to experiment with letting the
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validation just hang in space. It makes a lot of sense that you look around
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at your friends and you say, why can't my life be like theirs?
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And you just let it hang out there.
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A question from a pediatric practitioner. She said, what about patient families
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who are vaccine hesitant?
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And where, of course, that doesn't make a lot of sense to us as medical,
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you know, in the medical world.
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How do you, it's such a challenge. Yeah.
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So I think in both of these scenarios, where we're headed is we start by validating
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the patient or the parent's perspective.
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But of course, where we want to move to is bringing in the other side.
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So if you can picture this sort of being a two-sided approach where there's
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a seesaw or a teeter-totter, and at the fulcrum is what we call the target behavior.
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So perhaps the target behavior is accepting a vaccination for your kid,
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or maybe the target behavior is getting on board with the procedure for you,
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the kid, your juvenile diabetes.
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In either case, we start by validating.
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Yeah, that makes, you know, I hear that from a lot of my patients,
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that concern about vaccinations.
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Tell me more about that. Tell me more about your concern. Okay.
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And then maybe the person says, well, you know, my neighbors say that if I give
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my kid the vaccination, they'll get autism spectrum disorder.
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So then we want to say, yeah, I, I've heard that too.
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And what makes, what other considerations are there? What other things are there
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that you've heard about vaccinations?
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You hear more. And then of course you want to bring in, and this is the skill
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and this is what you're gently doing.
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And then what are the arguments on the other side? Because I'm sure you've also
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heard people say, including physicians like me, you should get a vaccination.
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So what have you heard on that side? So there, what I've done,
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Holly, is I've invited them to start by telling me their hesitation with vaccinations.
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And then I've also, instead of telling them, yes, but there's medical science
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saying you should get vaccinations, I instead ask them.
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So this is one of the real principles of motivational interviewing is if we
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can elicit or evoke rather than telling, that's what we want to do,
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especially on the side of change.
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So I want to say, what have you heard? What do you already understand about
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why people advocate for vaccinations?
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And then maybe the person will say, well, I don't know.
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I don't know. I've heard that scientists say it's important,
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but the people I talk to say that the scientists are paid off by the government.
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So maybe that's what you hear in response. So then Holly, what you're trying
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to get to is what we call a double-sided reflection.
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So you say, let me see if I can summarize what you're saying.
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First and foremost, I can tell you want what's best for your kid. That's obvious.
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And hearing you talk, I hear that you're concerned about this question of vaccinations.
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On the one hand, you know that physicians and medical science really argue in favor of vaccinations.
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And you respect that. I mean, you're here today coming and talking to a physician
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about your kid's health care.
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And I know from your chart, you've brought your kid in before for injuries and
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checkups and that type of thing.
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So you trust the medical system by and large. But on the other hand,
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you've heard some concerning things about vaccinations and whether it could
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actually be harmful to your kid.
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So I can hear that you're pulled in two directions. Where do we go from here?
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So, Holly, what I've done there is try to convert this parent's resistance into ambivalence.
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And so it sounds like, so the number one, it's continue to ask questions,
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like think question before tell what to do. Yeah.
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Yeah. Absolutely. You want to reflect what you're hearing from them,
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show that their perspective is your focus, ask questions, which does,
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like you say, more of that, hearing more from them, hearing more back from them,
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making them hear that you understand their hesitation.
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And then the trick is finding that way to introduce the other side of the argument
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where you're drawing it out of them rather than telling it to them.
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And then some listeners will say, well, who has the time though to draw it out?
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That just sounds, I mean, this sounds so great what you're saying.
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Yeah. So then, so what if the mom or dad then says, well, I don't want some
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foreign substance put into my kid.
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Right, right. Then there's a number of ways to do this where you can kind of balance efficiency.
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So there's one thing that we call an amplified reflection, which is where,
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and this is a little bit on the more risky side.
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In general, motivational interviewing is a softer, non-directive, non-pushy approach.
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We really don't want the parent here to feel judged or pushed around,
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but we might say something like
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giving your kid medications is putting a foreign substance in your body.
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But for you, that feels different than putting a vaccination in your kid's body.
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So there I'm kind of highlighting a discrepancy. They say they don't want to
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put foreign substances in their kid's body, but I know they put medications
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in their kid's body. So I say I reflect to them. You see it as a different thing.
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To give your kids medications developed by pharmaceutical companies versus a
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vaccination developed by pharmaceutical companies.
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And then I might say, talk to me a little bit about that difference.
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So really, we're doing something here, Holly, that we call exploring ambivalence.
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And we can do it in ways that are a little more pushy, or we can do it in ways
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that if we have more time, kind of draw it out more slowly.
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And even the way, though, you said it, it didn't, To me, it sounded not at all
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pushy, but it sounds like it could be pretty incredible.
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And I'll emphasize another sort of part of this, which is we don't always expect
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that where we're going to get to is the patient changes their mind.
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This is not a panacea. So a way I like to talk about it is if you've got a patient
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or parent who's very resistant to the change you're talking about,
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then a really nice, reasonable goal for the meeting is to get to ambivalence.
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Like I was mentioning earlier to where you can start with the patient saying,
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no way, Jose, I'm not doing that.
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And at the end of the meeting, you're saying, so it sounds like you're definitely
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not going to do this today, but you've got some things that you're thinking
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about in terms of this decision moving forward.
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That's a really nice place to get. If the patient comes in and they're already
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ambivalent, then we really do have the goal of getting them to change.
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But with that person who's more on the resistance side, I think we want to support
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their autonomy and we want to demonstrate that.
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And that in the long game is going to help us. So we're oftentimes saying things
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like, of course, this is totally your choice.
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Of course, it's up to you whether you do this.
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Of course, I'm in the role of a trusted advisor and I'm not here to push you
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around. And very often we'll notice a paradoxical effect where when the patient
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can tell that we're not pushing them, they'll actually be more liable to come around to change.
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So even though the goal is for this child to get the vaccination or take the
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diabetes medication, exercise, and diet, you really have to be open to,
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still this child might not, the parent might not want that, but at least they're thinking about it.
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We're talking about it. The conversation is there. Yeah, that's right.
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They're exploring the ambivalence and they're exploring it openly with you as
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the provider in a way where they trust you to not try to push them.
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And even so, I know that a lot of practitioners hear this, where the parent about vaccines.
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So, but it's my child. I mean, other people, if they want to get their kids
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vaccinated, that's fine.
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And this is just about my family and my child. Yeah.
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And I'd say absolutely. Absolutely. This really has to be your choice.
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This has to be a personal choice. And really, I see myself as a resource for
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you as you face this decision.
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And I can tell it's an important decision for you. And I can tell that you're
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not taking this lightly.
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So, Holly, I think one of the things I'm trying to do right now is emphasize
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the sense of importance of the decision.
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I want to sort of find myself on the same page with the parent here saying,
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we both know this is a weighty decision.
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We both know that there can be big consequences on either side.
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And so I want to give you all the information you need to make this, to make a good decision.
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And then Holly, I might say sort of, you know, in the spirit of efficiency,
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one way we can get in and represent the other side instead of drawing it out
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is maybe I say, I'm just meeting this parent for the first time.
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I sit down. Oh, I see your child hasn't had vaccinations.
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Shall we go ahead and set that up for today? And then the parent says,
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I don't want to do vaccinations. I don't want to put any sort of foreign substance into my child.
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Then I might, if I don't have much time, if I have two or three minutes,
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I might say, of course, this is totally your choice.
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Of course, I can tell you want to do what's exactly right for your child.
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And I know you're aware that physicians and science recommend and the vaccination for your child.
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Help me understand a little bit your thinking on this.
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So what I've done there, Holly, is I've essentially attributed knowledge to the patient.
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I've said, I know you're aware that science recommends this.
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Talk to me a little bit about why you don't want to go with that perspective.
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So I haven't said, I'm telling you you should do this.
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I'm saying this third party science is telling you that you should do it.
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So in a sense, as the provider, I get to stand on the sidelines of the fray
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and not become a part of this adversarial confrontation.
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I get to say to the patient, you've got a bit of a challenge inside of your
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own head, and I'm here standing next to you,
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and I want to help you talk about that inner conflict you have or challenge
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you have between this perspective and the scientific perspective,
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but not between you and me.
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But that's what you're thinking, but don't say that. Okay. Yeah.
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And I've heard the approach like for listening, where you repeat back the last
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few words that someone said, and then you, then you ask them the question like,
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okay, so you like candy for talking about diabetes.
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Tell me about what types of, of candy, how important is, how often do you,
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or do you recommend something like that in a time crunch? Like just trying to focus.
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Yeah, I think, I think, well, yeah, you're referring to the use of reflections,
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like saying back what the person had said.
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And yeah, when you're doing motivational interviewing, I often say one of the
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best ways to know if you're doing motivational interviewing is,
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is to look at your conversation and, and ask, is most of what I'm saying a reflection?
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So, that's one of the real surprising things for people about motivational interviewing
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is that you're mostly doing reflections.
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Two-thirds of what you say should be a reflection.
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And typically, Holly, what we try for is we'll do a reflection and we won't
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even put a question at the end of it.
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So, I'll give you a little example of how we could use a reflection that would
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still push the conversation forward.
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And again, I'll do one that's a little bit provocative sounding just to make
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the point. So with this example with a kid, maybe who has juvenile diabetes
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and likes candy, I might say something like, having the sweets you like is more
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important to you than doing what's healthy.
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And that, I put it out there and just say it like that.
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And you can kind of feel, Holly, that it kind of sets something in motion in
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the air in between me and the kid.
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And it's going to set them, their mind thinking, gosh, that's kind of a provocative
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thing. Is this true? And what we find is that when you do reflections like that, people tend to respond.
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They tend to talk. And we want to do reflections more than questions because
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questions feel to patients like it's about our agenda.
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Whereas when we do reflections, it feels to the patient like it's more about them.
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So part of the process of doing motivational interviewing and building skill
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in motivational interviewing is saying, how can I use reflections to accomplish conversational tasks?
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I usually accomplish with questions.
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So, so for the, the child who has diabetes, when you set, you know,
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well, say he or she says like, well, no, of course I do want to be healthy,
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but I just, I also love candy and all of my friends eat candy.
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So I know I'm not supposed to, but I, I really want it and it's important to
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me, but I want to be healthy as well.
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Yeah. Yeah. Well, that's what we want to hear.
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Right. Because there we've got what I would call ambivalence, right?
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So I might lock it in and say, I hear you. On the one hand, you absolutely care
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about being healthy and you want to be healthy.
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And on the other hand, you want to do what your friends are doing and you want
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to have fun and you want to eat candy when kids are eating candy. It makes so much sense.
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So I would try to lock that in as a double-sided.
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And then where we might go with that is I might say, if there was a way that
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you could be healthy and feel like you're getting the sweets that your,
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that your friends get, you would want that most of all.
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And then maybe the child would say, well, yeah, I'd like that.
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And then maybe I could say, so you'd like to maybe explore some ways that you
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could stay healthy and also feel included and get those sweets.
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You want to help? Do you want to explore that with me? And maybe the kid would say, yes.
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And then you would talk about sweets that you can have when you're a diabetic.
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Go through some of those.
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That's right. I might say, depending on how old the kid is, I might say,
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what are some ideas you already have about that?
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What are some things you already understand about things that you can eat,
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that you like, that are sweet and yummy, but that don't get in the way of the diabetes?
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So always, if we can elicit from the patient, even when we're doing patient
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education, it's ironic sounding, but we still want to elicit.
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We want to say, what do you already understand about this? To the parent,
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tell me what you already understand about vaccinations, right? Right off the bat.
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What do you already, I hear you saying you don't want to do vaccinations.
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I'm sure you've got your reasons for that.
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Tell me what you already understand and tell me if there are pieces of this
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puzzle that I can help fill in for you. bits of information that you want to
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know about vaccinations that you don't already know.
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And for the child with diabetes, you might be able to talk about at a birthday
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party, eating the cake, but not the frosting or something like that within, you know, whatever the,
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it's, I know it's different for every kid, but some sort of example like that,
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if the, if the child do it. Yeah, that's right. That's right.
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And then to the extent that the kid is saying, well, I don't know at the birthday
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party, I don't think there are any good options. I think I do need to eat the
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cake or something like that, then we can get into talking about the sort of
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the ambivalence about it.
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So it sounds like in that situation at the birthday party, fitting in with what's
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happening, having all the fun your friends are having is more important than
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attending to your health in that moment.
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It kind of sounds like that's what you're saying. And maybe the kid would say yes.
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And then maybe I'd say, and how would that play out? Like, is that something
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that you think is okay, that maybe you take a break every once in a while from
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following what the doctor says?
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Or is that something that your parents and the doctor are going to have an issue with?
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So we just kind of explore the event as well as exploring alternative behaviors.
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And for the vaccine-hesitant family, I would want, you know,
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you probably would want to launch into, well, really, it's not just about your family.
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It's your neighbor, maybe their children or child cannot get vaccinated.
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So you could be literally putting their health at risk, or you could be spreading
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measles around, you know, like how, is that the wrong thing though?
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If you're saying, how would you think that something like that?
24:40
Yeah, exactly. Yeah. Yeah. This is perfect example, Holly, because there you
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want to bring in another thing, right?
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You want to kind of, you kind of want to assert that or challenge the patient,
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the parent with that, right?
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But you should think about other people. Think about the effects it's going
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to have on other people. So this gets us back to this important point about.
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I refer to it as judgment and autonomy. The two things that motivational interviewing
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draws our attention to and says, you better watch out.
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You don't want to lose your rapport with the patient by making them feel judged
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or by making them feel pushed around or controlled.
25:17
So in this instance, Holly, there's the risk that the patient will feel judged, right?
25:21
Like that the physician is saying, you're being selfish by not thinking about
25:26
the other families around you who you could be getting sick by not giving your
25:30
own kid the vaccination.
25:31
So instead of setting it up, sort of as I was saying earlier,
25:34
instead of setting it up as adversarial between you, the provider,
25:38
and the parent, hey, parent, you should do it different. You're being bad.
25:43
We want to instead say to the parent something like, and I know you've heard
25:48
this argument that you're putting other people at risk by not vaccinating.
25:54
And I wonder what your thoughts are about that when you hear people making that argument.
25:59
So you hear, Holly, I said, when you hear people making that argument,
26:03
that's a way that I'm situating it outside of myself. I'm saying,
26:06
I'm not saying this to you.
26:09
I'm not telling you you should think differently. I'm saying you've heard this
26:13
argument that you should think differently. And I wonder how you think about that.
26:18
And then what if the parent says, well, I think it's silly.
26:23
I, of course, wouldn't want to hurt my neighbors and I'm not.
26:26
It's just about my family. Yeah.
26:29
Then, you know, always I'm coming back to trying to lead with validation.
26:34
Like I can see why you're thinking that.
26:37
And then is there an opportunity for reframing?
26:40
Of course, you have to put your concerns about your family above all else.
26:45
And that makes a lot of sense. You care a lot about your family.
26:48
I think an opportunity, Holly, that we often have with the vaccine one in particular is, you know,
26:55
a statement like, if you learned today and you felt certain vaccinations are
27:03
healthier for my kid than not vaccinating,
27:06
I'm sure you would vaccinate your kid because what matters most to you is doing
27:11
what's healthy for your family.
27:13
So I might throw that out there and see what they say. That's another example
27:17
of one of those reflections that you just let it lie.
27:20
So clearly, maybe I'll try saying it to you, Holly, and we'll see what you say
27:24
as this imaginary parent.
27:26
Holly, what I'm hearing as we're talking is that vaccination or no vaccination,
27:31
I can tell that your family and the wellness of your family is really at the
27:36
top of your list. It's really important to you.
27:39
If, for example, You learned something today that made you convinced that,
27:43
wow, I can see that vaccinations are going to be healthier for my family.
27:48
I think you'd probably choose to get the vaccination.
27:51
You just haven't heard that information. You're just not clear about what the healthiest thing is.
27:57
So what might you say, Holly? Yeah. Well, I think I know what's best for my family.
28:01
You feel confident in what you've learned about vaccinations and their effects?
28:07
Well, I don't feel totally confident about it, but I feel like I've done research on my own.
28:13
I don't need doctors telling me what to do.
28:15
You're absolutely, I think you're right about this.
28:18
You have to make your own decision about this. If there's a way that I can provide
28:24
any more information about this to sort of fill out your understanding, I'd be happy to do that.
28:30
Is there any piece of that puzzle I could help you understand even better?
28:33
Sure. I would love the information.
28:36
Okay. And so let's say I provide you with this information and you sort of look
28:40
it over and it's information that says science shows your kid should get a vaccine.
28:46
And you look at it. What might you say then as this parent?
28:50
So I'm being told what to do by all these scientists, and they don't know my
28:56
family, and I know what's best for my kids.
28:59
Ah, I'm hearing that on the one hand, it's very important to you to do what's
29:05
right for your family, to do what's best for your kids.
29:07
But even more important than that is not being told what to do.
29:12
Yes, I want to find out on my own. You'd almost rather do what's wrong for your
29:18
family than do what's right for your family, but somebody else told you to do it.
29:22
Well, no, no, no, that's not what I'm saying.
29:25
And I'm just kind of joking around with that, but I want to,
29:28
I'm only half joking around with that because we're looking at this sort of
29:33
scientific information.
29:34
And honestly, Holly, the scientist inside of me is sort of saying,
29:38
well, golly, this looks like objective factual information, but I'm gathering
29:42
that's not what it looks like to you.
29:45
No, I do think that was really, it's, it's powerful because it's almost,
29:49
then there's not an argument. It's just more of a conversation.
29:52
And then I will know, I don't, that's not more important to me than the health of my family.
29:57
You know, that, that my health, the health of my children and my family,
30:03
that's the most important thing.
30:04
Yeah. Yeah. And I mean, my style with this, Holly, I'll be, I'll,
30:08
I'll be frank with you. I've had to learn this over the years.
30:11
I, I, I use a lot of these kind of paradoxical or amplified little reflections
30:17
that highlight the discrepancy in what the client is saying.
30:20
I think a lot of motivational interviewing practitioners are a bit softer with it than I am about that.
30:27
And what they're always sort of emphasizing is understanding the clients,
30:33
what's most important to the patient or the client, what the patient thinks they're able to do.
30:38
Because oftentimes with health
30:40
behavior changes, the patient doesn't feel confident they could do it.
30:45
For example, with smoking. It happens all the time. And this actually happened
30:48
to me when I was a smoker, where I said, I don't want to quit smoking. And I rationalized it.
30:54
But the truth was that I didn't think I had the ability to quit.
30:56
So a real through line and motivational interviewing is validating people's
31:03
uncertainty and vulnerability in the face of possible change so that they will
31:07
open up and say, the truth is, I wish I could, but I don't think I can.
31:11
You know, or there's a reason pulling me to not make this that I haven't brought
31:16
up and it's hard to talk about, but here it is.
31:19
We very often are using softness to open up those little corners for people
31:25
to come clean about why they're being resistant.
31:29
And, you know, back to your point, Holly, about how much time it takes.
31:32
Yeah, it is true that to a certain degree, to build a relationship with a patient,
31:36
it does take a little time. And as a physician, sometimes the way you do that
31:40
is by seeing them every three months and you build a relationship slowly over time that way.
31:46
There's no substitution for having a relationship if you're going to talk to
31:50
somebody about a very vulnerable topic related to their change.
31:55
One of the ways I sometimes teach motivational interviewing is I ask people,
31:59
think about a change that maybe you should make in your own life.
32:03
And let's talk about that. And so, you know, I can talk about,
32:06
well, I need to eat fewer breakfast tacos or I need to get better sleep or whatever.
32:10
And Holly, I'm sure you would have one or two of those that you could bring up.
32:12
But then I could say, now think about a change that you maybe should make in
32:16
your life that you would not feel comfortable talking with me about.
32:20
Right. And we all have those two, those things that we're too ashamed about to talk about.
32:25
And yet we make our patients talk about those things. I can tell you when I
32:29
had a therapist for a while, I didn't tell him some of my darkest secrets,
32:33
even though I should have. That's
32:34
the stuff I should have been working on because I was just too ashamed.
32:36
And that happens with our patients, I think, a lot.
32:39
And motivational interviewing could be the key to getting that almost hidden
32:44
information or information.
32:46
Yeah. Yeah. That those hidden, hidden forms of resistance. I think we can maybe
32:50
think of those. Hidden forms of resistance.
32:53
So, so did the motivational interviewing, did that help you to quit smoking, David?
32:58
Actually, no, it wasn't. I wasn't really aware of MI at the time,
33:02
but I did have to quit in my own way, you know, sort of in my own style, in my own way.
33:09
I did learn that. What got you interested in MI?
33:12
Well, thank you for asking that. It's, you know, I was really focused on psychotherapy
33:18
approaches for schizophrenia for the first half of my career.
33:22
But then here at UT, I'm in a clinic called the Transitional Care Clinic in
33:26
the Department of Psychiatry.
33:28
And I really got steeped over
33:31
the course of several years in working in a sort of a public-facing outpatient
33:37
community health setting and seeing how across the different types of encounter
33:43
types and the different provider types, a very common theme is,
33:48
can I engage this patient in care in a way that they're really meaningfully
33:54
and motivated to sort of be involved and really feel that they have skin in the game?
33:59
And that felt to me increasingly like the most important factor in the healthcare I was involved in.
34:05
And motivational interviewing is a single tool that we can use across gobs of
34:10
settings to address exactly that challenge.
34:13
And so I really dropped everything I was doing and totally pivoted towards learning
34:18
and sort of disseminating motivational interviewing.
34:22
Oh, that's great. The transitional clinic, what is that? Can you explain what the question is? Sure.
34:27
This was established in 2012 with the mission of engaging patients who have
34:34
recently presented to the psychiatric emergency department,
34:38
a range of area hospitals, and or have been hospitalized on the psychiatric inpatient unit.
34:45
And now these patients are ready to be discharged back into the community,
34:49
but they don't have an established provider team in mental health or behavioral
34:55
health. And it can take six months.
34:58
Even if you have Blue Cross Blue Shield, it can take six months to get a psychiatry
35:02
appointment for the first time.
35:04
So the transitional care clinic was established to have a sort of a wide open
35:08
front door for these people being discharged from inpatient psych or triage
35:12
from the emergency department.
35:14
And we take them in. We quickly establish them with care, give medication management,
35:19
counseling, case management services. And then over the course of three to six
35:23
months, we help them find long-term care in the community and we discharge them out the back door.
35:28
Do you see adults and kids or adults only?
35:33
Yes. Well, so just in the last three years, we now have established a clinic
35:38
that sees adolescents as well.
35:39
So we have a sister clinic, a partner to the TCC that's called the NOW Clinic.
35:45
NOW is New Opportunities for Wellness.
35:47
And that clinic is open to the public of Bexar County. It just has the mission
35:51
of helping people of Bexar County get access to mental health services.
35:56
And as of two years ago, we also have adolescent services there.
36:00
And our services are free to anybody who's uninsured.
36:05
And we do regular billing for people who have insurance.
36:08
I want to have the director on the show as well. It looks amazing.
36:12
And I saw for the adolescent clinic, there's even dogs that are part of the
36:16
therapy and they're on the website, the NOW website.
36:20
Yeah, that's right. Yeah. We have somebody, Meredith Stensland,
36:24
faculty member here who established this pet therapy program.
36:27
The dogs are always walking around between all of the clinics.
36:30
In fact, I've got a card for one of them that I'm looking at right here.
36:33
They all have their own little sort of like baseball cards where it says the
36:36
name of the dog and the breed and their little characteristics. It's very cute.
36:40
Wow. So, David, it sounds like you utilize motivational interviewing with every patient.
36:47
Yes, that is correct. At the point of engagement,
36:50
finding the motivation, every patient, more and more in healthcare,
36:54
including in primary care and in pediatrics, we're less and less focused on
37:00
infectious disease and accidents and more and more focused on health problems
37:05
that are linked with our health behavior choices.
37:08
So it's not really acceptable to sort of say, you know, I'm going to go ahead
37:12
and have you start exercising three days a week and come back in a year,
37:16
because we know that the patient isn't going to do that unless we provide more.
37:20
So we more, more, and more have to scaffold our prescriptions with some sort
37:26
of behavioral technology to get them to do the stuff. Do you do one-on-one coaching
37:31
with providers, like kind of how we're doing this today?
37:34
Yeah, we do. We do one-on-one and group-based coaching.
37:39
That's kind of what we were touching on at the beginning. To give providers
37:42
ongoing practice, we have a calendar through our training platform where we
37:47
have coaches throughout the week who have session times.
37:50
And you can just show up for the sessions if you happen to have a no-show or
37:54
an available hour. That's great.
37:57
So is there a common mistake with motivational interviewing that you want to mention?
38:04
Yeah, I would say that the most common mistake is what we call premature focus or premature planning,
38:12
where somebody will have a health problem and they'll be kind of stuck about
38:19
it. Like me with my breakfast tacos.
38:22
I eat breakfast tacos on the way to work too frequently, too many days a week I do that.
38:26
And the problem is if I come in and sit down with a provider and they start
38:31
saying, well, hey, let's fix this.
38:34
How about you drive a different way to work? How about you eat oatmeal in the
38:37
morning before leaving your house?
38:39
How about you leave your wallet at home so you can't get the tacos on the way?
38:43
And from an MI standpoint, that's premature.
38:47
That's launching into sort of a concrete problem-solving approach that is likely missing the point.
38:56
My problem is not that I can't come up with an idea for how to not eat tacos.
39:01
That's not the problem. The problem
39:04
is something inside me about my motivation and how I talk to myself.
39:08
So the mistake is going into cutting up with a concrete, literal solution as
39:14
if the person didn't understand what steps to take when actually it's a motivational issue.
39:19
So then what would happen next with the taco scenario? you?
39:23
Well, what would happen, I would be annoyed if the physician was like,
39:28
oh, let's make a plan for you to take a different route where you don't drive by Taqueria, Jalisco.
39:33
I'd be annoyed. I'd say, well, do you really think I didn't already think of that possibility?
39:37
So I think what I would advise instead would be exploring my ambivalence.
39:42
And the way to do that, if you have five minutes to have a conversation about
39:47
somebody's ambivalence, what I would recommend is the acronym DARN.
39:51
That stands for desire, ability, reasons, and need.
39:57
So those are what I think of as sort of the four natural categories of intrinsic motivation.
40:03
So I think David Roberts here is having a problem with eating tacos,
40:08
and he's intrinsically too motivated to eat those tacos and not motivated enough to resist.
40:14
Desire, ability, reason, and need. Desire refers to the feelings I have about it.
40:19
Any feelings at all that pull me toward the tacos are away. So I would want
40:23
my provider to say, tell me how you feel about the tacos.
40:27
Tell me how you feel when you eat them. Tell me how you feel when you don't eat them.
40:31
Tell me what the urges feel like. I would explore that.
40:34
Desire, ability, reason, and need. Ability is if you decided you wanted to quit
40:39
the breakfast tacos, how confident are you that you could do it?
40:42
Where 10 means I'm 100% confident, and one means I'm not at all confident.
40:47
So we would explore my confidence because very often people want to make a change,
40:51
but they don't try because they don't feel confident they can.
40:54
Desire, ability, reasons, and need. Reasons are the why. Why would you quit
40:58
the tacos? And need is how important is it to quit the tacos?
41:02
You want to get that question. And how important is it to you?
41:06
And is it every day you don't feel you should be eating the tacos?
41:10
Well, that's the thing, Holly, is it's not that important to me to never eat tacos.
41:15
And so that's one of the main reasons I keep eating them, is the importance
41:19
of quitting is not high enough.
41:21
I think ideally I'd have them one day a week, but five a week is way too often. you.
41:28
So then next, what would you say? Like, so what I'm hearing is that once a week is enough.
41:33
So how do you feel that you could do that?
41:36
Yeah. Oh, so, so, uh, yeah, Holly, that's really good example of that question.
41:41
How do you feel you could do that?
41:43
That I think is not a bad question, but it shows that thing I was just referring
41:48
to that little bit of a bias toward planning the concrete procedure,
41:53
how could you do it one day a week?
41:57
Whereas in MI, we're a little more interested in what would it feel like if
42:01
you were doing it one day a week?
42:03
How confident are you that you could do it one day a week?
42:07
Remind me, what are your reasons to do it one day a week?
42:10
And exactly how important is it to do it one day a week instead of five days a week?
42:15
We're more interested in those questions than in sort of how you could do it.
42:20
So in that case, I should have just focused on reflecting back?
42:24
Yeah. Yeah. You can reflect back or you can ask those darn questions.
42:29
So you can reflect back, this is important to you.
42:32
You can reflect back, you want to do this one day a week and you're looking
42:36
for, you're looking for the motivation to do it one day a week.
42:39
Or you can say, tell me more about why it's important to reduce it.
42:45
And then, so say there's five other patients and five other exam rooms waiting,
42:50
and I'm trying to get to the, like, wrap up the conversation about the tacos,
42:55
then how would you close but do it with care and try to accomplish what you're trying to accomplish?
43:01
Yeah. Well, so if this patient, David Roberts, was very sort of resistant around
43:07
the tacos, I would try to wrap up with reflecting ambivalence.
43:12
If, if instead this patient was ambivalent about tacos, I would try to wrap
43:18
up with a plan for action.
43:19
So let's just say I was ambivalent that I'm like, yeah, I need to get a handle
43:24
on this breakfast taco thing.
43:26
It's just, I never seem to really keep momentum, but I really wish I could, but I don't know.
43:32
So then if I'm wrapping up the session, I might say something like,
43:35
let me see if I can summarize where you're at with this, Mr.
43:38
Roberts. On the one hand, it's not a huge issue in your life And it's okay with
43:43
you that you're still eating some of these tacos And you love tacos and you
43:47
have the urge in the morning and it's not the end of the world On the other hand,
43:51
you came in here today and you brought it up with me and said, hey,
43:55
If I'm gonna make one health change these days, it is the tacos The tacos are
44:00
something that I'm kind of ready to really take a hard look at So Mr.
44:04
Roberts, I guess, where do we go from here? What's the next step?
44:08
That's probably how I'd end that.
44:10
That's great. So what about this scenario where there's a parent in the exam
44:16
room with their child and they're saying to the pediatrician,
44:20
like, I just can't get Andrea to help around the house.
44:25
She won't do anything to help. And it's so frustrating. I love my daughter so
44:31
much, but this is just, it's so hard.
44:33
Yeah. So this is interesting. This is, of course, we've exploded the complexity
44:38
of it because now we've got both Andrea, the daughter in the room,
44:41
and we have the parents in the room, right?
44:43
And we're sort of, the question is, are we going to change the parent's behavior?
44:48
Are we going to change the kid's behavior? Are we going to do a little bit of both?
44:51
I mean, what sort of jumps to my mind is that the parent hasn't set up the incentive
44:58
structures within the home to cause the child to help out around the house.
45:02
And so if I'm just meeting with that parent one-on-one, I might be interested in exploring.
45:09
You know, on the one hand, it sounds like you'd really like Andrea to help out around the house.
45:14
On the other hand, it sounds like you're not comfortable requiring her to do
45:19
that. I might start with that.
45:22
I do want to require her to do that, but it's just not working. She just won't do it.
45:26
I see. So what you're telling me is that you're putting the requirement in place
45:31
and she's not doing it and she's comfortable with the consequences of not doing it.
45:38
She just keeps doing it and keeps getting the consequences. I don't think she's comfortable with it.
45:43
But a lot of times I don't give her consequences.
45:47
I see. So you're kind of thinking I could give her greater consequences.
45:52
I could increase the negative consequences of her not helping out.
45:56
Or you're thinking I could come up with more reinforcers for her to do it,
46:02
more, you know, treats or kudos for her to help out.
46:05
Or maybe you're thinking of something else.
46:08
Well, she's just, she's under so much stress. And she says like none of her
46:12
friends have to help out at home. I see. So I don't push it.
46:17
I see. You want to be kind of, you want to be compassionate toward her.
46:22
You don't want to overstress her and overburden her. On the other hand,
46:25
there's a part of you that thinks it's reasonable to expect this.
46:30
Yes. Me too. So that's kind of a, that's a little bit of a pickle you're facing.
46:35
That's a bit of a tricky choice you're facing.
46:38
You could choose to make the consequences of her not helping out actually substantial
46:44
enough that they affect her behavior, but that might stress her out.
46:49
On the other hand, you could let things ride the way they are,
46:53
help her not be as stressed, but you'll still be frustrated with her not helping out.
46:58
Yes. I mean, sometimes it just feels easier just to let her watch TV.
47:01
Right. Well, you know, let me ask you this, Holly. Like, if you decided,
47:06
you know what, I want to make the choice of putting the consequences in place
47:11
that are severe enough to change her behavior, how able do you feel to actually
47:17
carry that out from 1 to 10?
47:19
Where 10 is, oh, I'm 100% sure I can put this structure in place in the household if I chose to.
47:25
And 1 is, I do not think I could implement this.
47:29
I feel quite confident I could do it But I don't know if I'm giving the right
47:33
consequences So maybe 10.
47:36
So you feel confident that you could put a structure in place,
47:39
but you're not confident that
47:41
you could kind of design the right incentive structure to make it work.
47:47
Yes. I don't think I know what are the right consequences in this case.
47:53
And if you had help to put together an incentive structure by somebody who maybe
47:59
had experience or knew what they were doing, would you want that?
48:05
Would you, would you like snap that up and definitely do it?
48:08
What are your thoughts on that?
48:09
Yes, I would love to. I mean, I had, I think there was one parent telling me
48:13
that they, the child shouldn't come to the dinner table and eat if they're not
48:17
going to help set the table.
48:18
It's a, it's a privilege. We all need to help out, but that seems kind of cruel.
48:23
So I don't want to be harsh.
48:26
Yeah, I really can tell you don't want to lose sight of the love and connection
48:31
you have for your daughter and attending to her stress level and all those things.
48:36
You want to be fair and you want to be kind, but you also want her to be growing
48:41
up responsibly and turning into an adult and helping out.
48:44
Yes, it's such an important lesson in life. And I know my parents instilled
48:50
that in me and it's helped me so much.
48:52
Yeah, it sounds like I'm hearing you say that you really do want to implement
48:57
an incentive structure of some sort, that it really would be worth it as long
49:02
as you can find the right level that's not too punitive.
49:06
Yes, I would love that. Oh, okay. And then we can sort of, Holly,
49:10
from there, I think we were going to just the question of me connecting you with that resource.
49:16
Okay. So finding something that you know, or if you know the answer,
49:20
go ahead and say it, or is it better to print it out and give it to the patient
49:24
in this case or the website or something?
49:26
I think that that really depends on my read of the patient and if they have
49:31
the wherewithal to do it themselves.
49:33
If they're sort of maybe struggling or if they're lower functioning or if they
49:36
have way too much on their plate, I might scaffold them and give them the sheet
49:40
and walk through it with them.
49:41
If they seem really capable of doing it and really motivated,
49:45
I might just point them to it.
49:46
Okay, great. I know you have a patient. I have a couple more questions from clinicians.
49:52
You can do a couple more. Okay. Okay, so this doctor asks, and she says,
49:57
thanks for thinking of me, what are the best ways to break the ice when starting an interview?
50:03
Well, I think a really good one, which I alluded to earlier,
50:07
that kind of serves the dual purpose of being agenda-focused and also letting
50:13
the patient do the talking is to say, I'd love to hear from you today your thoughts on X.
50:20
And if it can, if you don't have much time and you want to get right into it,
50:26
hey, I see that we've got, I'm looking at your chart.
50:30
I see there's the question of the diabetes.
50:33
There's a question of how things are going at school right now.
50:36
There's a question of your leg. I know you got that injury playing soccer last
50:40
year or anything else you want to talk about. Where do you think we should get started?
50:44
So that's a way that we will often do it is we'll list two or three things that
50:49
are on our agenda that we want to talk about.
50:51
And then we'll say, or anything else, what would you like to talk about?
50:56
And really open the door wide open.
50:58
That's one way to do it. That's great.
51:02
Another practitioner says, I think I really need a whole course on this.
51:06
If he has any good suggestions, anything would be great. And I know we've talked about so much here.
51:12
It's nearly impossible for us to do this with our time constraints though. Right. Right.
51:18
Let me just double down on what I sort of think are maybe a couple of the really
51:23
core things I would want to convey.
51:26
One is, if the person, thinking of this person, think of what is the target behavior?
51:32
What is the change I'm hoping to help this person make?
51:35
Take the medication, start exercising,
51:39
eat more vegetables, do the vaccination, whatever it is, and then say to yourself,
51:44
as I'm starting talking with this
51:46
patient, are they more on the resistant side or more on the open side?
51:51
Okay. And if they're on the resistant side, your goal is to validate.
51:56
Show them that you're really listening to the source of their resistance,
52:02
validate that, and then get to what we call the double-sided reflection.
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The double-sided reflection is, on the one hand, I know you don't want to do this.
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And on the other hand, I hear there are those things pulling you toward considering doing it. Okay?
52:16
So that's if the person's mainly on the stuck.
52:18
And if the person's mainly on the change side, you want to evoke it as always.
52:25
And then you want to reflect. It sounds like you're sort of leaning toward this.
52:28
And then you want to try to elicit a change plan from them. Where do we go?
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Where do you want to go with this what sort of step or action
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do you want to take that and then the other thing i would emphasize
52:38
is darn desire ability reason and need exploring the person's motivation how
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do you feel about this possible change if you wanted to change how able do you
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feel to do it what are your reasons pulling you to do it or not do it and how
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important is it desire ability reason and need.
52:58
And everything that you just said, the final question I was going to ask is
53:02
a lot of doctors get, the parent has looked at Dr.
53:07
Google or chat PC and they feel that they're right about it.
53:11
So that takes a lot of time. Do you have any advice there?
53:15
So for when a patient maybe has consulted like Google doctor and maybe has some
53:22
misinformation, is that kind of what you're saying?
53:25
Yes, they've done their Google searches or found, you know, other places they
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have misinformation and they think they're right about it.
53:33
Yeah. So that gets into this territory that we call psychoeducation or I guess just education.
53:39
In psychiatry, we call it psychoeducation. Education, patient education.
53:43
The principle, so we have a principle called illicit, provide illicit.
53:47
So when the patient, when you want to give some information,
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like to disabuse them of some incorrect information or whatever,
53:54
we start out by eliciting.
53:56
What do you already understand? I can tell that you've already done a lot of research.
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That means this is important to you. I'm glad that this topic is important to
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you. I think it's an important topic too.
54:07
So validating, right? Then what have you already learned? What do you already understand?
54:13
Draw it out from them. And then the question, how can I flesh out this puzzle for you?
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What pieces of the puzzle might I help you put together?
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What don't you know that I could provide you? So I'm really an information resource.
54:27
And then if I hear some blatantly incorrect information, I might say,
54:31
hey, some of the information you shared with me is inaccurate or some of it
54:36
doesn't fit with the scientific research. Would you like to hear that?
54:40
So then offer to give corrective information. Don't shove it, but offer it.
54:45
And then if they say, no, I'm good. Yeah.
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Then we say, of course, it's up to your choice. It's up to you to make decisions
54:52
on the basis either of the facts or whatever other information you want to go
54:57
on. Of course, you have to make your own decisions.
55:00
I'm here. Should you decide to include sort of a factual or scientific basis
55:04
in your decision-making, I'm here for that.
55:07
David, this is so insightful. It's such an honor to talk to you.
55:11
Is there anything you wanted to mention
55:14
right before we wrap or have we we covered i think
55:17
we've done we've done a really nice smorgasbord i really appreciate how
55:20
you float around with me with these different topics and yeah if
55:23
anybody has any interest in learning more about motivational interviewing
55:27
and especially practicing any of this i would just encourage them to reach out
55:30
to me either with the link or with my email david roberts here at utesca and
55:34
we will be doing an interview for our Pediatrics Now for Parents podcast that
55:40
that can be found wherever you listen or pediatricsnowforparents.com where you
55:45
could tell your patient,
55:47
a parent who comes to you, my kid won't help with the dishes.
55:50
You could listen to that episode. So we'll do that when you have more time, David.
55:55
Wonderful. That sounds great.
55:57
Okay. So Dr. David Roberts, an expert on motivational interviewing.
56:02
Thank you so much for being here today on Pediatrics Now.
56:05
Thanks, Holly. It was wonderful. I had a great time.