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Motivational Interviewing for the Busy Practitioner Part 2 · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

• 0:00
  Music.
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  Back on the show today is Dr. David Roberts.
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  He's an Associate Professor of Psychiatry at UT Health San Antonio.
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  Dr. Roberts, thank you so much for being back here on the show today.
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  I'm thrilled to be with you again, Holly.
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  We're getting a great response from our pediatrician listeners on motivational
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  interviewing, and it helps so much.
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  The insight you gave us in the last episode, because who has the time,
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  really, even though we know how much
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  it will help, but they're seeing 40 patients a day and it's just hard.
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  I love meeting with anybody I can, whenever I can, to practice motivational interviewing.
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  And so I'm hopeful that the time we spend together will stimulate others to
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  sort of create and join us maybe in some of our practice opportunities.
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  And it's a very popular episode. And maybe we could reiterate here,
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  if you have a family wondering if they should get vaccinated for measles.
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  How, cause that's, I know that's a huge challenge, but I know we're talking
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  today about talking to younger kids around the age 13 and younger.
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  And maybe that's a scenario that we could, we could talk about with each,
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  each age group, if that works for you.
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  Talking about the question of vaccination across age groups? Yes.
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  Yeah, sure. I mean, I think that regardless sort of of the topic area,
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  I think what we're going to be wanting to, and really even regardless of the
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  population, maybe the broad frame that we want to start out with is we want
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  to get into the conversation.
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  We want to invite that person and welcome that person into the conversation
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  in a way that feels that they can be trusting with us.
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  Sometimes pediatricians or physicians, we're sort of entitled to have conversations
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  about difficult topics with patients that they expect us to talk about those topics,
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  and so we do, but that doesn't necessarily mean that the patient feels comfortable or feels safe.
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  And so often we will get very restricted versions of the patient in our physician conversations.
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  So what we're really trying to do is enter into a conversation on the topic, very simple,
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  join me in this conversation on this topic, and then use a lot of your sort
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  of your non-verbals and your human
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  connection skills to create a sense of comfort and safety in the topic.
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  And it's remarkable how far just that will take you.
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  When really it seems, if you think about it, well, that's time I don't have,
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  but really it's going to help save time because the patient will be more receptive
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  to what you're talking about.
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  That's right. That's right. And then when you're imagining this open-ended conversation,
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  it makes perfect sense to say, I don't have time for open-ended chit-chat dialogue.
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  So really then what it comes down to is how can you squeeze the most value out
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  of a relatively short and relatively unstructured conversation?
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  And that's kind of the trick and the magic of it. And I think in motivational
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  interviewing, it's a very language focused approach so that each utterance you
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  make really packs a punch.
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  And so the way we start that out from the beginning is emphasizing the use of reflections.
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  Reflections like a mirror reflect back to the patient what you've heard from them.
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  And so this is sort of our bread and butter technique. It is what we say essentially validating.
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  So it's a way of making the patient feel not only that you have understood what
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  they've said, but there's a way in which it makes sense to you and that it's acceptable to you.
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  So that's our bread and butter. is, so let's say we're talking about the question
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  of the measles vaccination.
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  We start out by saying, can we talk about the measles vaccination?
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  I'd like to talk about that with you. So we efficiently go straight to the topic.
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  And then perhaps the patient says, oh, great, here we go again, or something like that.
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  And then what we want to do is hand it over to them and try starting to create
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  that trust within the topic.
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  Tell me how you feel about that. Sounds like you have some some real feelings about that.
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  I'd like to, I'd really like to hear from you what you think about the,
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  the measles vaccination and really authentically hand it over to the patient
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  to hear what they say, reflect it back to them, show them that you accept and
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  understand where they're at.
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  And then that's when the dance begins of you saying where and how can I fit
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  in some of the information or
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  agenda items that I want to fit in having created a little bit of trust.
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  Which could be difficult. It may feel so different because pediatricians being
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  so in charge of so much of essentially this patient's health,
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  and they've got those moments in the exam room and so many things coming at them.
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  But it is, from what I learned from you from last time, you're putting the power
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  back. You're giving it back to that parent and to that patient.
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  Here, it's back to you. What are your thoughts on this?
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  Yeah, yeah. What are your thoughts? And this is really your choice, right?
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  You're facing an important choice here. And then, of course,
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  Holly, as you and I have discussed,
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  where you're hoping to get, because you're trying to be efficient and bring
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  some structure, some coherence to this conversation, what we're trying to get
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  into is a double-sided reflection.
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  Where we try to efficiently move to being able to say to the patient,
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  I can hear that you are pulled in two directions.
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  That there are these doctors and public health experts, and it sounds like some
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  of your family putting pressure on you to give your child the measles vaccination.
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  But I can hear you're pulled pretty strongly by your own thoughts and values
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  towards some arguments on the other side.
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  How can I help you with this? So we're trying to get to this point where we're
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  highlighting you're facing a choice, you're facing an important choice,
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  and you're pulled in two directions.
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  And by doing that, it creates what we call a sort of sense of dissonance or
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  discrepancy, which is an uncomfortable feeling of being on the fence-ness,
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  that we want the patient to say, yes, that's right, I am pulled in two directions,
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  and it doesn't feel good, I want resolution.
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  That's where we want it. That's our sort of first goal.
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  And you say, David, when it comes to motivational interviewing,
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  have it kind of bubbling up in the background with our conversations where it's
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  kind of always on your mind.
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  Yeah, yeah, right. So you always have this framework in mind.
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  You're always half smiling because you know the patient is there wanting to
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  be more well, wanting their child to feel better, wanting more health in their
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  lives, and wanting to move in that direction.
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  So you always have a half smile on your face, but you also always have bubbling
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  up a sense of this person is pulled in two directions.
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  This person wants wellness and health, but there are factors that are pulling
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  them toward resisting aspects of that.
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  So that's, it's always bubbling up and we're always saying, let me validate that, that stuckness.
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  Let me reflect my understanding that they're in a tough spot and that they want
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  to move toward wellness and they're looking for my help with that.
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  I've been, like I said in the last episode, I've been using,
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  utilizing this with my three teenagers with empathy.
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  And, and I tried it with my, my
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  13 year old daughter where she had done something she wasn't supposed to.
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  So she wasn't getting to go to the event that she wanted to.
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  And she was so upset and she was crying.
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  And then I, I thought about how you said, like, you think of the approach,
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  like you're the, the child's attorney kind of think of it that way.
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  And so I launched into, I know you're so upset. It's so understandable.
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  And I really wanted you to go to that too. And as you know, you weren't supposed
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  to do this thing you did, but, and since that happened, this is the consequence.
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  And I bet you'll be able to go next time, but now, you know,
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  and it's up to you not to do that thing that you weren't supposed to do.
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  And it was hard for me to say that too.
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  It's totally your choice if you still want to keep doing that.
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  And I was just like, oh, and I just let it dangle there.
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  You let that reflection dangle in the air, that reflection where you're really
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  saying you to your daughter, you have a lot of autonomy here.
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  Yes. Is that what it does when you let it dangle? It's like,
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  yeah, it's saying this is you, this is your life, this is yours.
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  And you sort of put that out in front of her. You're facing this choice moving forward.
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  You have the freedom to either do the bad thing again or not.
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  As a mother, it's hard to acknowledge that freedom.
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  Oh, it was so hard. But then a half hour later, we're watching a movie together
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  on the couch, you know, and having a great time.
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  And I felt like I avoided a really difficult conflict that used to happen,
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  kind of this loop, recurring loop of conflict. Wow.
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  Wow. I love hearing about your experiences with this, Holly.
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  And so, I mean, I think what What it brings up is maybe some of the themes that
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  we want to track, and pediatricians already do this in a number of ways,
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  when we think about the development of kids from, you know, age two through age 18, right?
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  And so one of the tasks of development, one of the processes,
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  is this process of individuation.
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  And I think what we're talking about when there's the parent and there's the
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  kid is both parties want the kid to be moving toward greater and greater independence.
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  But have very different ideas about what that should be looking like.
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  And so we always get into these scrapes where the youth is trying to assert
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  their independence more, and the adult is trying to constrain it and sort of
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  support it at the same time.
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  And so that's the challenge, I think. When we're using MI with adults,
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  we're more freely supporting autonomy, saying this is all up to you.
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  With kids, much more often we're saying there are limits. You're in a situation
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  of limited autonomy. me.
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  And one thing I think I said to you last time, Holly, and I'll bring it up again
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  now is there's, there's a benefit that can come from externalizing the, the, the limitations.
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  So saying like you did, there's a rule, there's a standard here that exists
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  independent of you, my daughter, and you, you violated it.
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  And therefore there's a consequence. And then what you're doing,
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  Holly is aligning with your daughter and saying, I can totally see your perspective here,
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  you don't like that standard, that rule to begin with, and you broke that rule,
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  even though you know it's a rule and you know there's consequences,
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  you broke it and you are not happy at all.
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  And I, and I get it. I get that you're not happy. So here we have the parent
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  aligning with the child's emotion of it and feeling of it and empathizing,
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  even while at the same time, it was the parent who implemented the rule.
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  So one of the good things about the young, youngs, the little kids,
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  the pre-operational up to age maybe five, six.
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  Or yeah, five, you'll get kids who see the rules as being an objective fact
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  of the environment and are less likely to say, but mommy, you put the rule in place.
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  And so they're less likely to question those things.
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  And it's easier for us then to use motivational interviewing in a way where
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  we're putting the rule on the outside and empathizing with the kid.
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  As the kid starts getting a little bit older, and certainly by the time they're
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  14, 15, they're going to say, mom, I don't like that you made that rule and
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  I want you to change it. So it's a little bit of a different conversation, of course.
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  And then what do you say? Do you talk about how we all have limited choices in life?
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  Right, right. And so then you're talking with somebody who actually has a more
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  mature mind, and they're able to, maybe they're 15, they're able to understand
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  things like ambivalence.
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  They're able to consider ambivalence
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  for themselves, and they appreciate being treated like an adult.
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  And so you can say to them, you can confess to your 15-year-old,
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  yes, I did make this rule.
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  And it's hard for me knowing that it upsets you.
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  And yet, and so because of that, I was pulled in two directions,
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  but I still made this rule. And here's why I made the rule. And I'm standing by the rule.
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  So to compassionately say to your child, it is my responsibility that I made this rule.
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  In the end, I'm the one saying no to you and I'm standing by it.
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  And I love you. And I appreciate that you don't like this.
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  Yes. And it is painful to, to see your tears.
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  You know, it's hard. Yeah. Yeah. Yep.
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  And I get that, that, that, that you're upset at me and that you don't fully
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  understand, or it doesn't make sense to you while I, why I made this rule.
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  And I know that's hard for you too.
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  Yeah. So maybe don't say it's painful to see you're too, like more of empathy.
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  So they, she knows it's okay to cry and be sad about it.
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  Of course. Yeah. Yeah. And, and of course, we can always look for those opportunities
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  to say, I want to support you in being your own person.
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  Because you really do want to support. I think you do, Holly, don't you?
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  Yes. So much more than anything, right? Yeah.
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  Yeah. And then I also heard you say that you have that protective side of you
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  that wants to say, but stay under my wing. Right. Definitely.
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  So I know a pediatrician who sent me a question, she said that so much of,
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  and I know we need to go to break soon, but, and we'll be back after, after the break, but,
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  So much of motivational interviewing for pediatricians is talking to the parent
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  with the child, maybe very young child sitting there or a baby or a 10-year-old,
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  you know, different ages, of course. But a lot of it's talking to the parent.
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  Right. And talking to the parent with the child in the room.
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  So that becomes a complicated dynamic, you might say, where you wouldn't want
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  to undermine the parent in front of the child, but you may be trying to influence
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  the parent's behavior as well.
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  Exactly. Right. That's a great
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  point. Right. Well, why don't we get into a specific example of that?
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  Maybe we could dig down into a specific example of that scenario right after
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  the break. How about that?
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  That sounds great. So we will be back right after this with Dr.
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  David Roberts with UT Health San Antonio, and he's an expert on motivational interviewing.
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  But how do you really implement it? How can it help you in your practice?
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  And how can it help you talk to your patients?
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  I'm back with Dr. David Roberts. He's an expert in motivational interviewing. So Dr. Roberts,
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  What's the best way to talk to parents you have in the exam room?
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  There's a parent or parents and the child, and you've got 20 patients waiting
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  for the rest of the afternoon, a packed exam room.
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  I mean, I think that one of the values and principles of motivational interviewing
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  is authenticity and transparency.
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  And so, again, I think probably most pediatricians already have this in mind.
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  But to kind of reinforce it, we would like to be as transparent as we can while
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  communicating to a parent in front of the child.
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  And so we would like to be able to not really change the way we talk to the
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  parent, acknowledging if it's a very young child that, for example,
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  the parent is facing a decision regarding measles vaccination for their child.
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  And we will reinforce, always useful to reinforce to parents,
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  you know, I know that your child's welfare is paramount in your mind.
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  I know that that's your North Star.
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  I think that's a real slam dunk that we can, you know, 99 out of 100 times assume
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  that's true for the parent and be able to authentically reflect that.
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  And that's really important when you're talking to a parent about a decision
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  like where they may be moving away from the medical advice, because that means
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  that there's going to be a risk that they're going to feel judged by you, right?
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  Anytime a parent may be making a decision for their child that the parent thinks
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  the physician doesn't want them to make, the parent may be feeling defensive,
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  may be feeling at risk of being judged.
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  So that's a time where we want to really reinforce and validate it's their choice.
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  And we understand it's not an easy choice.
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  And we know that what they want most is the wellness of their child.
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  And that's what they're trying to figure out. But other than those considerations,
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  there aren't huge things that jump to the front of my mind in terms of talking
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  to the parent in front of the kids.
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  I wonder if there were kind of particular concerns that are in your mind about that.
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  That's a great question. I need to think about that.
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  When you were talking, a question that comes up in my mind is,
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  it may seem counterintuitive.
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  We're giving the power back to the person we're talking to when really it's
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  helping us to hopefully have the outcome we're looking for.
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  So by giving that power back to them, and it is in your hands,
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  just the magic almost like of having these statements in your pocket like i
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  know that's your north star that you you want your child's help that that's
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  paramount to you that's number one i can i can see that or statements like you
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  just said yeah yeah i appreciate your pointing out that apparent.
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  Inconsistency or paradox like if i'm trying to make a person do something how
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  does seeding my power help me get them to do the thing.
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  And I think that the way I think about the solution to that and why it makes
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  sense is getting back to this idea that we've talked about that all organisms
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  are naturally inclined to move toward growth and health.
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  And that's why we always have a half smile on our face when we talk to our patient,
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  because we know that that's where they're headed.
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  And so all things being equal, if you give a person the freedom to make their
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  own decisions, they will march straight towards growth and wellness.
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  Now, we know that that doesn't happen because people get blocked in a range of ways.
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  That's true. And so a lot of the work of MI is drawing people's attention and
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  exploring ambivalences that came out of the ways they've gotten blocked.
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  But at the end of the day, we want to hand the wheel over to them and say,
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  you know, I trust you that you're going to be doing what you think is best for
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  you and healthiest for you.
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  And on average, that ends up with the person making a healthy choice.
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  And you don't lose anything by saying that. You gain it, kind of like saying sorry.
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  You don't lose anything by saying sorry to someone.
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  Yeah. Yeah, that's a really good point because at the end of the day,
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  it is their choice anyway.
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  And they're going to choose what they choose even if you act like it's not their choice.
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  Right. And I know when you are teaching pediatric practitioners,
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  family practice doctors.
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  You have this way, like we're doing, going back and forth, talking directly
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  to each other and bringing up scenarios.
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  That's how you teach. Someone who uses this link that we'll put in this podcast
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  can do exactly what we're doing, which is, I think, pretty phenomenal.
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  Yeah, I mean, this is what I do. This is my favorite way to spend my time.
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  And I'm so glad that you're willing to sort of engage with me on this.
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  And this is exactly what it feels like, exactly what it looks like to be working on these skills.
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  I think one thing I wanted that's on my mind that I want to emphasize is when
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  we're doing motivational interviewing, very often that means that us as the
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  provider, what we have at the front of our minds is getting that change, right?
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  We've got our eye on that target behavior.
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  We're trying to use a technique that's going to somehow enable us to achieve
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  that change with the patient.
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  And ironically, that can cause us to be pushy. And as you were just pointing
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  out, the sort of big irony in
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  this is the way we get the change is by not being pushy with the client.
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  And so I think always as practitioners, we often need to remind ourselves to
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  come back, come back to the starting place, which is focusing our attention
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  on the experience of the patient.
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  And if we're talking about especially a child or especially an adolescent in
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  the context of their emerging individuality and their growing sense of urgency
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  that they be recognized as autonomous and that their emerging adulthood be sort
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  of recognized and respected,
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  we can do that so well in motivational interviewing by saying,
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  I really want to hear your perspective on this.
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  And so this is one of the ways in which it almost feels like MI was tailor-made
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  for working with adolescents who feel like they're not respected in their emerging adulthood.
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  So really doubling down on understanding and demonstrating our understanding
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  of the adolescent's perspective and showing that we see the nuance in it can really go so far.
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  And it takes away that defensiveness. They don't have to defend that they know
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  what they're doing, that kind of thing. That's right.
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  That's right. They don't have to defend it because we're being the lawyer for them. Right.
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  We're saying it really makes so much sense. Your perspective that frees up their
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  mental energy to do something else.
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  They're not mobilizing all their energy to defend their dug in position.
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  Instead, they're saying, well, golly, mom is being really open and flexible
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  and she's not pushing me towards something.
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  So I don't have to defend anything. Well, I guess I can think fresh about an
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  old problem then. That's wonderful.
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  There's, there's a, I know I've talked to a lot of pediatric practitioners and
• 21:59
  the very understandable mindset is that when it comes to say the measles vaccine,
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  if the parent isn't kind of open, seeming right away to be open-minded,
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  if they're way the other way, you just don't have time.
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  Don't, why even spend the time? You're not going to convince them.
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  So do you think that MI could be a way for someone who just seems so set on
• 22:25
  anti-vaccines to go ahead and at least try?
• 22:29
  I think so. I mean, I think that I mentioned this, Holly, in our very first conversation.
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  A way I often like to think about MI is as a two-step process.
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  Step one is going from resistance to ambivalence.
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  Step two is from ambivalence to change. And so you're talking about a step one scenario.
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  And if we cut the goal down from, I'm not trying to get this parent or this
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  patient to totally reverse their perspective, I'm not going to try to convince
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  them to reverse their perspective on vaccinations.
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  But if I can get to where we're having a mutually trusting and respectful conversation,
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  and maybe a very brief one,
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  in which we essentially are agreeing to disagree with smiles on our faces,
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  that's a huge accomplishment. It's really big.
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  So one approach with this is to sort of take a smiling approach to,
• 23:22
  hey, I know you and I, we come from different perspectives on this question
• 23:26
  of vaccines, but let's just take a minute and see where we're at.
• 23:30
  So I know, you know, my job is a doctor.
• 23:32
  So of course, you know, I'm going to be pushing you to go for the vaccine.
• 23:36
  Do you have any questions about that, about why in that role I feel so passionate
• 23:41
  about pushing you for it?
• 23:43
  Anything I can explain about that? So almost like doing this double role.
• 23:48
  Hey, I'm going to be the pushy physician because I really believe in this,
• 23:52
  but I can also be the person who talks to you about that conversation with the pushy physician.
• 23:58
  That's an approach that I really like to take with, again, just the goal of
• 24:03
  the patient being like, okay, this provider respects me.
• 24:06
  And we had a real honest conversation about the question of vaccines.
• 24:10
  Then would you add on there, of course, it's your decision to get your child
• 24:15
  vaccinated, or when you don't know what to say, add that in?
• 24:19
  Yeah, yeah, yeah. Add that in when you don't know what to say and let the patient
• 24:25
  leave the session with that open loop where what they have kicking around in
• 24:30
  their head is, you know what?
• 24:32
  I like that physician. I like that doctor.
• 24:35
  I didn't feel judged. I didn't feel like they were making me feel like I was
• 24:40
  a bad parent or stupid or anything.
• 24:42
  They were really respecting my position. And ironically, that has me a little
• 24:47
  bit more inclined to like them and like their position and want to kind of maybe
• 24:51
  consider going that way.
• 24:53
  That's a very realistic aim for that conversation.
• 24:57
  Because it could be difficult for a lot of parents to check at the door their
• 25:01
  authority, not that they need to, but they naturally have that defensiveness
• 25:06
  perhaps about their child. Right.
• 25:09
  And if all of a sudden they're not being pushed to choose A over B,
• 25:14
  but it's their free choice, well, then maybe they will choose A.
• 25:17
  But if they're being pushed, then they're definitely not going to choose A.
• 25:21
  So say if, so you say, so I'm the pushy doctor I know because I care so much
• 25:27
  and believe in vaccines. So how are you feeling?
• 25:29
  And say that the parent says something like, I just don't believe in them.
• 25:33
  I think they're doing more harm than good. I've heard they can cause autism.
• 25:38
  I think that, I mean, we're doing great and everything's fine and it's my decision.
• 25:43
  So I'm not hurting anyone.
• 25:46
  Yeah. And so we can explore that. You know, what I'm going for is I'm going
• 25:49
  to try to get my foot in the door to, to see, can I, cause right now they're
• 25:55
  doubling down on, I'm a hundred percent resistant.
• 25:57
  And what I want to be able to move forward is to be able to say,
• 26:01
  yeah, I can see how you're pulled that way.
• 26:03
  And you're also pulled the other way. I want to explore ambivalence with them.
• 26:07
  So I think that I might say something like, well, Hey, thanks for talking with me about it.
• 26:13
  I know that what's most important is the health of your kid and that you really
• 26:19
  need and want to own that decision as the parent.
• 26:22
  And I just appreciate that you took the time to talk to me about it and that
• 26:25
  you're going to keep listening to this sort of medical perspective on this.
• 26:29
  And, you know, just sort of share that, leave it there, and don't expect that
• 26:34
  you're going to be able to get to a change in decision today.
• 26:39
  I know you've mentioned the long game, and it's so hard to think of that when
• 26:43
  you've got those, I'm sure, the moments in the exam room or something that just
• 26:48
  happened with your child.
• 26:49
  Well, that's right. And I mean, you know, you can also try to find middle ground.
• 26:54
  Like, so the technique of, one technique for rolling with resistance is what
• 26:59
  we call coming alongside.
• 27:00
  And that would be saying, I hear you loud and clear.
• 27:03
  You've made your decision about vaccines, and you're not really interested in
• 27:07
  carrying on that conversation. That's totally fine. That's your choice.
• 27:11
  I wonder what you think about having a conversation about ways,
• 27:16
  if it does end up that your child gets measles,
• 27:19
  ways that you would want to respond to rapidly address that issue,
• 27:24
  or ways that we could mitigate the consequences that could come from your decision.
• 27:30
  Would you like to have that conversation?
• 27:32
  Well, my child's perfectly healthy. Why would we even need to talk about that?
• 27:37
  Absolutely. We don't want your child to get measles. We don't expect your child to get measles.
• 27:41
  But, you know, this is in medicine more and more, we're shooting for preventative care.
• 27:46
  So we're saying things like, get a little exercise now, eat a few vegetables
• 27:50
  so that later you'll be healthier.
• 27:52
  It's the same thing with the vaccinations.
• 27:55
  I know what you're putting first and foremost is the wellness of your family.
• 28:00
  Would you like to put some things in place to protect against the possibility of measles?
• 28:05
  Yes, as long as it doesn't involve a vaccine. Well, great. Then that makes sense.
• 28:10
  I kind of thought you were going to say that because I know you want to do what's best for your kid.
• 28:13
  And then I'm not me, Dave Roberts. I'm not a physician. So I don't know what
• 28:17
  a physician would say in terms of things that we could put in place.
• 28:21
  But what I like about where we've gotten with the conversation is we've got
• 28:24
  the parent acknowledging there is a thing called measles. and there's a risk with getting measles.
• 28:30
  And we're on the same page that the parent wants to take some action to minimize
• 28:34
  that risk of if measles comes.
• 28:37
  And we're working in a space where that's acknowledged. So I'm feeling pretty good about this.
• 28:42
  We do have for our listeners a measles update. It's about the current state of the outbreak.
• 28:48
  And we do mention motivational interviewing to help encourage people to get vaccinated.
• 28:54
  So would it be okay right there to, at some point in that conversation,
• 28:58
  to launch into saying something like, well, actually, perfectly healthy children
• 29:03
  with no underlying conditions do get pneumonia from the measles.
• 29:08
  It's the most common complication and children die from pneumonia,
• 29:14
  from the measles. Or would that be too much?
• 29:16
  Right. So you've got some information there, right? That's information that
• 29:21
  you want to impart to the patient, to the parent.
• 29:24
  And whenever we're in that situation, I think you picked up on all you said, or is that too much?
• 29:30
  Recognizing, all right, there's risk. There's a risk if the parent is defensive.
• 29:36
  There's risk in my giving them information that goes against their perspective.
• 29:40
  So in motivational interviewing, we use something called elicit provide elicit,
• 29:44
  which is how to do information exchange.
• 29:48
  And the idea is we first ask the parent, ask the patient, what do you already know about this?
• 29:54
  What information would you like about this? Or any sort of really a question
• 29:58
  to get them talking about their understanding and their thinking.
• 30:01
  Then within that context of that conversation, we might try to do the illicit,
• 30:06
  provide, illicit. We might do that provide.
• 30:09
  So let's see what this might sound like here.
• 30:11
  This is a parent who's pretty against vaccinations, and I want to get into the topic.
• 30:19
  So I might say, what do you make of what we're seeing with the reports on measles
• 30:24
  rates in the state? How are you feeling about this situation?
• 30:28
  People had measles before there was a vaccine. So how did they get over it then?
• 30:34
  I mean, just naturally, we get sick sometimes.
• 30:38
  Yeah. And we saw this, we see this with things like COVID too,
• 30:42
  where there's a certain amount of people get sick and die from respiratory issues
• 30:47
  sometimes, and sometimes they don't.
• 30:49
  And this happens in populations.
• 30:51
  That's a perspective that makes a lot of sense.
• 30:54
  What are you making of people's concern and the kind of urgency that some people
• 31:00
  have about increasing vaccinations for measles to tamp that down.
• 31:04
  I haven't really been paying attention, to be frank. Yeah.
• 31:09
  That doesn't seem very important to you. I mean, it is important,
• 31:14
  but my children are fine, and I know I've seen some things on social media talking
• 31:19
  about the dangers of vaccines, so it seems better to just steer clear.
• 31:24
  Yeah. It's kind of a scary topic either way you look, right?
• 31:28
  It's sort of scary to think, what if my kid does end up being one of the ones who contracts measles?
• 31:35
  But on the other hand, it sounds like you're saying there's no good option if they do get measles.
• 31:44
  What do you understand about the options if your kid gets measles?
• 31:49
  Well, I also haven't really looked at that. I just assume that my child will
• 31:53
  get better. like she did from COVID.
• 31:57
  Yeah, right. Well, you know, one of the things that I'm here for is as an information resource.
• 32:03
  And so I'd be happy to share information from the scientific research on any
• 32:09
  part of this that you want.
• 32:11
  Would you like to know more information on the measles statistics or treatment for measles? Sure.
• 32:18
  Okay. Then maybe I share some information on alternatives for treatment And
• 32:23
  this information shows there's no substitute for good vaccinations.
• 32:29
  And so I share that with you. And that would be called provide,
• 32:33
  illicit, provide, illicit. First, I'm asking you, what do you already understand?
• 32:36
  Then I say, hey, we're talking about this. Would you like some more information?
• 32:40
  You said, sure. So I provide the information.
• 32:43
  Information says vaccines are the best way to go.
• 32:46
  And then I end with the final illicit. So what do you make of this information,
• 32:50
  Holly, about the importance of vaccines as the front line for preventing measles.
• 32:56
  Well, how do you know who to believe?
• 32:59
  All right. Yeah, that's important. What is the source of the information?
• 33:04
  What is the source? And the information I've been giving you is from research articles in journals.
• 33:11
  What's your sense of that? I can explain more of that to you if you want information
• 33:16
  about it, or what do you understand about the validity of that source?
• 33:21
  Well, I think the scientists probably have something to gain by telling people
• 33:25
  to get vaccinated. They just they want to sell the vaccine.
• 33:29
  The scientists might want to make money with the pharmaceutical industry.
• 33:35
  Probably. I think there's probably something behind it, some scheme.
• 33:39
  Yeah. Yeah. And certainly, we live in a capitalist society. There's a lot of
• 33:44
  people making money-driven decisions.
• 33:47
  And you don't want one of those decisions to determine your kid's health. Right.
• 33:53
  Yeah. Yeah. Makes sense.
• 33:55
  Well, do you think that that's something that has been addressed before?
• 34:00
  The risk of financial incentives clouding medical research?
• 34:07
  Well, yes, probably. What do you make of this? I'd be happy to give more information
• 34:11
  about how science tries to prevent bias, tries to prevent those sorts of motives.
• 34:18
  But I don't know how important that is to you.
• 34:21
  How important is that issue in making your decision about vaccines?
• 34:26
  As long as I know that there's not an, you know, this behind the scenes motive
• 34:30
  and they're not trying to convince me of something that could hurt my child,
• 34:35
  then maybe I would consider it.
• 34:36
  If you were confident that the people producing this research have the right
• 34:45
  intentions, you might listen to it.
• 34:48
  Yes. And as long as I knew it wasn't going to hurt my child.
• 34:52
  And how would you know that? What would convince you that it wasn't going to
• 34:57
  hurt your child? I would have to see it for myself.
• 35:00
  You would have to see people getting vaccinations and not suffering for it? Yes.
• 35:06
  And how would you know? I could share statistics with you.
• 35:09
  We have access to the percentage of people who've been vaccinated who have had negative reactions.
• 35:16
  Would that kind of a research paper be useful? Sure.
• 35:22
  I can share that with you. Okay. So why don't we pause there?
• 35:25
  Holly, I think that was actually a really good example of, of what an MI conversation might look like.
• 35:32
  Would you, with what you gave to the patient include the part about pneumonia
• 35:38
  and kids dying from pneumonia, have it there.
• 35:40
  Don't say it. Don't bring up some kids. It's rare, but it does happen or it
• 35:46
  was happening when there was lots of measles going around.
• 35:49
  There's a deadly brain disease that a kid can be fine and recover from the measles.
• 35:56
  And seven, eight, nine years down the road, it's been dormant and this deadly brain disease,
• 36:02
  suddenly is active and there's nothing doctors can do about it and kids die.
• 36:07
  I mean, is that all too much? I guess it's sounding too much as I'm saying it to you.
• 36:11
  I think you just don't want to come across as being alarmist or trying to scare
• 36:17
  the person into making a decision.
• 36:19
  And you want to offer that information. Would you be interested in learning
• 36:24
  more about the worst case scenarios for what could happen?
• 36:28
  And one way that this can come up is you can say, I'm here to help you make
• 36:32
  this decision. What do you see as you look towards the future?
• 36:35
  What do you see as the best case scenario if you give your kid a vaccination?
• 36:40
  What do you see as the worst case scenario if you don't do vaccination?
• 36:43
  And then maybe they say, I don't see worst case scenarios. He has a few bumps for a month or so.
• 36:47
  And then I might say, would you be interested in more information about worst case scenario?
• 36:53
  I happen to have some more info about that. Would you like me to help flesh
• 36:57
  out your understanding of worst case scenarios.
• 37:00
  So offer it, don't give it unilaterally, especially if it's potentially inflammatory.
• 37:07
  Okay. And then if they say they don't want that information,
• 37:10
  you just, then it's time to wrap it. Thank you for listening and for talking to me about this.
• 37:15
  Yeah. Think of it as an opportunity to show them that you're trustworthy.
• 37:20
  Offer something, and if they decline, don't give it to them. Say, you got it.
• 37:24
  This is your, that's your choice. and stand by your work, the more we can show
• 37:28
  them with our behavior, our respect for their autonomy, that's what really makes
• 37:33
  them believe it. Talk is cheap, right?
• 37:35
  And sometimes if you're not careful, MI talk can feel cheap,
• 37:39
  especially to patients who are not as verbal.
• 37:43
  You hear me, I'm a very verbal person. Some people really don't like me if they're
• 37:48
  not as sort of, if they're more physical and less sort of a jibber-jabber verbal person.
• 37:53
  So sometimes just showing trustworthiness is really the way to do it.
• 37:57
  Well, I know you're a father and we've talked about how this could be so helpful for parents.
• 38:05
  So how about we go through a question that a parent had and kind of how you
• 38:11
  would talk to that child?
• 38:13
  Because it sounds like also it's pretty universal regardless of the age of the child.
• 38:19
  Go ahead, sir. Oh, yes. Sorry to interrupt. I'll just make one point about the
• 38:23
  age of the child and then we can get into the scenario. I think it's one important
• 38:27
  consideration is sort of what we call pre-operational versus operational.
• 38:32
  So a cutoff at around the age of sort of 12, 13, 14, where kids develop the
• 38:40
  ability to think more abstractly.
• 38:42
  And that's the point at which they can start considering their own ambivalence much more richly.
• 38:49
  And, you know, considering ambivalence within motivational interviewing is a
• 38:53
  big part of it. So before that age, we don't really use the ambivalence part of it as much.
• 38:58
  And starting at that age, we can really use it.
• 39:01
  So then how would we, because it's, as I mentioned, with my three teenagers, it's helping so much.
• 39:09
  So if you're talking about, say, a child 13 and younger, what are the things
• 39:14
  that you would say different?
• 39:15
  Would you not say, of course, it's your decision, you need to decide?
• 39:19
  Or I guess you would say that sometimes, but what do you want to say there?
• 39:24
  So we're still, for me, the way to think about it is we're still working within
• 39:27
  a developmental frame, but we're earlier on in that developmental frame.
• 39:31
  So the emergence of individuality isn't about I'm my own grownup separate from you, mom.
• 39:37
  It's more about more rudimentary and primitive aspects of recognizing and validating
• 39:45
  the child's inner experience.
• 39:47
  So much of the problems that emerge in family systems in early life for kids
• 39:52
  relate to not being seen, not feeling seen, and not feeling validated in their experience.
• 40:01
  And that can be both an emotional, a sense of emotional bereftness or an attachment
• 40:06
  problem, or they don't feel an emotional connection.
• 40:08
  But it can also conceptually be confusing if they're not getting the kinds of
• 40:13
  feedback from parents that help them start to see themselves as an individual freestanding agent.
• 40:19
  So one real nice way to use that I think that we can use motivational interviewing
• 40:24
  with the littles, with the younger kids,
• 40:27
  looks a lot like what gets called play therapy, where we're essentially watching
• 40:32
  a child play, and then we're doing a lot of narrative reflecting of what's happening.
• 40:37
  So, for example, if they're playing with Star Wars figures, maybe Chewbacca
• 40:41
  and Luke Skywalker, and we're watching the child play on the little sand table
• 40:45
  or something, we might say Chewbacca's very angry at Luke Skywalker.
• 40:50
  Chewbacca's chasing Luke. Luke is afraid of Chewbacca because he sees that Chewbacca's
• 40:56
  angry. And so we're kind of helping through our reflections to reinforce these relationships.
• 41:01
  And then we will translate that over into the child themselves.
• 41:04
  So things like, and you are feeling angry at your sister yesterday,
• 41:09
  or maybe the kid is being quiet and sulky and we reflect, it's not easy to be here.
• 41:15
  Talking to a strange grownup is hard. So we're using our reflections to shore
• 41:22
  up and help instill a sense of their own separateness, a sense that we know
• 41:28
  they have thoughts, feelings,
• 41:29
  motives, and emotions that are separate from our own and that they have choices.
• 41:34
  And so we're starting to also recognize that they have choices and that they're
• 41:39
  making choices and decisions.
• 41:40
  So I know that sounds very rudimentary, but for me, that's all within this MI frame.
• 41:46
  And is it important with that age group, too, to sometimes repeat back what
• 41:50
  they say and show that you're understanding and just let that dangle there without
• 41:55
  offering advice or saying, but you really should do that?
• 41:59
  I know you're sad about having to clean your room.
• 42:03
  Absolutely. Well, absolutely. Absolutely. And I think this, I forget if I shared
• 42:07
  this with you or not, but one thing that I started doing with my son.
• 42:10
  So, yes. So, yes, reflect back what they say. I had been saying,
• 42:14
  like before, kind of do reflections even when they're not saying anything, right?
• 42:19
  So if they're quietly playing with Luke Skywalker and Chewbacca,
• 42:22
  I was describing a form of doing reflections to a silent child.
• 42:27
  Or if the child is sitting there being sulking, not saying anything,
• 42:30
  you can reflect on that. You can reflect the process.
• 42:32
  And that's a wonderful thing to do with little kids and with teens who are not saying very much.
• 42:37
  But certainly when a kid is talking, you also are doing reflections.
• 42:41
  And it's a respectful, validating thing that helps a child feel puffed up and
• 42:47
  really seen in the room when we're doing reflective listening with the kid.
• 42:50
  So one thing that I think is kind of, you know, a funny illustration of this is the way I like to joke,
• 42:56
  I became a parent a little bit older in life and I say, you know,
• 42:59
  nobody told me that the little kids, when they come home from school,
• 43:03
  that they're going to be stingy when you ask them how their day was.
• 43:06
  But my four-year-old, right?
• 43:07
  My four-year-old, now five, he comes home from kindergarten.
• 43:10
  And I'm like, how was your day? How was your day?
• 43:12
  And he won't tell me. And he kind of clams up. And so, you know,
• 43:15
  I started playing with the motivational interviewing stuff and I started doing reflections instead.
• 43:20
  And so he would walk in the door, even before he said anything,
• 43:24
  I would hazard a reflection.
• 43:26
  Like I would say, you played on the field today instead of the sandbox.
• 43:30
  And what I found was that he would be much more responsive. He would say much more.
• 43:35
  He might say back to me, no, no, I was in the sandbox for the first recess,
• 43:38
  but then for the second resets because Jonathan wanted to go out and,
• 43:41
  you know, he'd sort of start talking.
• 43:43
  And half the time it's because he's correcting me, right? So you'll get a version
• 43:46
  of this with teens also where the teen will be there, whatever.
• 43:49
  I'm using a stereotype, but being kind of sulky and not saying anything.
• 43:52
  And then maybe you just hazard a reflection like you're feeling kind of sleepy.
• 43:57
  And then they'll be like, no, mom, I'm not sleepy. What's going on though is
• 44:00
  that Trevor was, and then they'll sort of start talking. But in contrast.
• 44:05
  I think a principle here is if instead of doing a reflection,
• 44:08
  we ask a question like, how was your day or why do you look sad?
• 44:12
  That feels like a demand on the child.
• 44:16
  And the child, in a sense, is like being oppositional. Like,
• 44:20
  I'm not going to give you that satisfaction.
• 44:21
  You don't get to tell me to report on my day and I have to report on my day
• 44:25
  to you. So I'm going to sort of not give you the satisfaction of answering and
• 44:30
  assert my independence as a child. So that's a fun game to play.
• 44:34
  Do reflections with kids, even when they haven't said anything,
• 44:37
  and do reflections that you think are probably wrong about their inner experience and play with it.
• 44:42
  And that's a good way for you to practice your MI skills, too.
• 44:45
  Well, nice. I remember, well, it was a few weeks ago, my teenage daughter,
• 44:51
  I asked her, I was trying to come up with things to ask her about her day.
• 44:54
  And then I asked, what did you have for lunch? And she said, food.
• 44:57
  That's a perfect example. Isn't that a good example? Yeah. But then where do you go from there?
• 45:04
  Right. But I mean, I think part of what you're saying is she was saying to you,
• 45:08
  duh, I had food. Right. Yes.
• 45:12
  And is that, yeah. It's like, don't burden me with obvious questions.
• 45:17
  And kind of like, are you really interested in exactly what I ate?
• 45:21
  Or is the teen saying that kind of?
• 45:24
  Ah, like, mom, that's so lame that you're trying to like start a conversation
• 45:30
  with that kind of bland question or something like that. You don't really care about that.
• 45:35
  Yeah, maybe so. I mean, it's hard sometimes with teenagers with the response,
• 45:40
  you know, like that they'll respond back.
• 45:43
  What's obvious they're doing and or not
• 45:46
  say anything and then the the
• 45:50
  urge is to say are you ignoring me right right
• 45:53
  what might be what might be a different sort of
• 45:56
  a reflection that you might say when
• 45:59
  what what might you use as reflection when she says food
• 46:02
  it sounds like maybe you had a
• 46:05
  sandwich it would like if i might be
• 46:08
  wrong is that what you're saying to do you don't know
• 46:11
  so you suggest some no i had tacos you could
• 46:14
  do that you could do that i think that would be fine i think
• 46:17
  what what i have in mind and this we haven't really talked about
• 46:20
  this explicitly but i've alluded to it a little bit is process reflection
• 46:24
  so not reflecting on the content of what she said but reflect it reflect back
• 46:30
  what you've learned about her based on how she said it okay so what how would
• 46:36
  that what would that sound like maybe if she says food a reflection might be,
• 46:41
  that seemed like a silly question.
• 46:43
  I see. So kind of like saying what we talked about before, I'm the pushy doctor,
• 46:48
  or I'm the doctor, so of course I'm going to push you to want to get,
• 46:53
  you know, I want you to get the vaccine. I believe in them.
• 46:56
  Kind of like that. Why don't you try being your daughter for a second and I'll
• 46:59
  be you and we'll do it. Okay. Here we go. Oh, hey, honey.
• 47:04
  Hey, what did you have for lunch? Food.
• 47:08
  That felt to you like kind of a silly question for me to ask Well,
• 47:12
  yeah You don't need me grilling you after you get home and you're tired after
• 47:16
  a long day I'm so tired and hungry, yeah,
• 47:21
  Well, yeah, that's fine. Okay. Yeah. Yeah. Go ahead. Or what were you going
• 47:24
  to say next? I don't know what I was going to say. High school's not easy.
• 47:28
  Something like that. Okay. That's really good.
• 47:31
  So I have a specific question from a parent. Do you have time or do we need
• 47:35
  to do that? Sure. Sure. Okay.
• 47:37
  So this parent, and it could come in up in a pediatrician's office.
• 47:40
  So her, her child tends to, when she gets mad and I think she's around,
• 47:48
  they said 12 or 13, when she gets mad she'll like
• 47:52
  hit something or hit the table or do
• 47:55
  something like it's an anger response to say if
• 47:59
  something dropped on the floor then she'll hit
• 48:02
  something and then it causes its own problem like using kind of a it sounds
• 48:07
  more dramatic than it is but like doing something physically to show you're
• 48:10
  mad when you're mad and trying to get them to stop doing that and even so much
• 48:16
  so as not being nice to themselves,
• 48:19
  like even doing like a choking sign on their, like, I'm so stupid and like around
• 48:24
  their neck or something, you know?
• 48:26
  So it's like getting so mad when normal stuff that frustrates people,
• 48:32
  everyone, say a glass drops on the floor and shatters and then having an anger response.
• 48:39
  Yeah. So the parent wants the kid to curb their behavior, their angry behavior.
• 48:47
  Yes. I hear you. Well, so, so yeah, let's, let's dig into this for a moment.
• 48:51
  And I think part of it is what we actually just did right there,
• 48:55
  digging into it, because, you know, we have these situations and,
• 48:59
  you know, I know as a parent where my kid does something and I'm like,
• 49:02
  I just want him to not do that. That's annoying. I want that to stop.
• 49:06
  So my goal is to stop that behavior. And I would love it if I had a technique
• 49:11
  to stop that behavior. And I think
• 49:12
  in this situation, what motivational interviewing kind of wants to say is.
• 49:17
  If you want that behavior to stop, remember, it's not your choice.
• 49:22
  There's another organism that's going to choose what's going to happen with that behavior.
• 49:26
  And so there's a whole set of
• 49:28
  things to keep in mind and sort of things to respect that that's the case.
• 49:33
  And one of them is, if I want that organism to change, I need to understand
• 49:38
  why they're doing it in the first place and what it means to them and why they
• 49:44
  might choose to change that behavior.
• 49:46
  So with me, Holly sort of interviewing you about, you know, why did the parents think it was a problem?
• 49:51
  And what did they think was the underlying issue?
• 49:53
  And how are they hoping the child would be, would even be able to sort of change that?
• 49:58
  So this then gets us from a technique standpoint into the kind of MI,
• 50:02
  which is wanting to learn the story so you can validate it first.
• 50:08
  Step one, join in the stuckness and validate it.
• 50:12
  Step one includes ah i
• 50:16
  really see why you have those
• 50:18
  angry reactions where you hit things i
• 50:21
  understand it now it makes so much sense to me
• 50:24
  that that is your reaction and why that comes out
• 50:27
  but then holly remember we also want to then get into and and
• 50:32
  i can tell or and i'm hearing there's a
• 50:34
  part of you that if you could would like it if you didn't react that way all
• 50:39
  the time right so that's where we want to get right and i and and the idea is
• 50:43
  if i if as a parent i show the person centeredness through my techniques and
• 50:49
  my attitudes that the child is like wow dad really.
• 50:54
  In a non-pushy non-judgmental way is just caring to understand this about my
• 51:01
  experience that shifts that shifts the game it shifts that it's such a different
• 51:06
  thing from dad coming in and not understanding, but saying, stop doing that.
• 51:11
  And, and so we have trust faith that will by entering into the conversation
• 51:17
  with the client, Hey, can I talk to the kid?
• 51:20
  Hey, let's talk about that hitting that you just got frustrated with the glass and hit the wall.
• 51:25
  Can we talk about that for a minute? And then the kid's like,
• 51:28
  Oh, fine. I know you want me to stop. Whatever. What do you want to say?
• 51:31
  And you say, I just want to hear your thoughts on it. I just want to hear how
• 51:34
  you feel about it. So remember, we've talked about this.
• 51:38
  This, you know, the, the goal is get the story, get the conversation of the
• 51:42
  problem of the stuckness going so you can learn about it and validate it.
• 51:46
  And then you're going to see the seeds for change in it.
• 51:50
  I'm sure in this scenario, one of the C and it's idiosyncratic,
• 51:53
  it depends on the person deep listening to the individual youth in this scenario.
• 51:57
  But I imagine it'll include the opportunity for the parent to say.
• 52:02
  Wow, there's a lot of pain in there. There's a lot of discomfort and pain,
• 52:07
  and I'm really sorry that it feels that way for you in those moments.
• 52:11
  That can't be easy, right? That's in there. That's very likely in there for that kid.
• 52:15
  And maybe, I don't know, maybe they haven't felt that real empathy from their
• 52:22
  parent around that, and it could change the whole thing.
• 52:25
  So it's those moments that catalyze fresh opportunities for change where we
• 52:31
  can't quite have the opportunity,
• 52:32
  the path in our mind as we start the conversation, but we have a few go-to techniques
• 52:39
  that are going to present themselves based on what the kid comes up with.
• 52:42
  And don't say something like, do you see that you're causing more harm a lot
• 52:47
  of times when you're so angry and react by hitting something or throwing something
• 52:52
  when you're angry about, because they already know they're doing that? Right.
• 52:56
  What our goal is, is to not tell them that, but to reflect their awareness of that.
• 53:02
  Right. I know that it's frustrating for you to see yourself do these things.
• 53:08
  I know you, if you could, I know you see that this affects mom.
• 53:13
  I know that you see that. And I know, because I know you love mom,
• 53:17
  that it's not comfortable for you to see that.
• 53:19
  But obviously, it's not just something you can turn off.
• 53:22
  You know, I might try something like that. Yeah, so that's a technique that
• 53:25
  we've kind of touched on a few times is trying not to say the, but don't you see.
• 53:31
  What we often say in MI is we're trying to not tell, but instead to evoke the
• 53:37
  same point, whatever it is.
• 53:39
  Would it be wrong to say, how are you feeling in that moment?
• 53:42
  Is it making you feel better to do that?
• 53:44
  Yeah, absolutely. We want to say, how are you feeling in that moment?
• 53:47
  But we generally avoid the closed question. So don't, don't add,
• 53:52
  is it making you feel better at the end, but just say, what is that like for
• 53:55
  you? How are you feeling?
• 53:56
  Okay. And it seems like it could be a conversation about self-compassion.
• 54:01
  Well, so I think one thing that comes up here, and I'm not saying this as a
• 54:05
  universal, Holly, but sometimes what we'll do if we're talking to another person,
• 54:09
  especially a youngster, and maybe they're feeling depressed or they're beating themselves up,
• 54:14
  what we'll want to do is come in and say, don't do that.
• 54:17
  Don't beat yourself up. Come on. You're a good person. Come on.
• 54:21
  Look at your strengths. And I'm not saying that's bad.
• 54:25
  That's fine. That's a good thing to do in general. We want people to feel better.
• 54:29
  We want them to know that we see them better than that.
• 54:32
  But there's a downside to that approach. And the downside to coming in and saying,
• 54:37
  don't feel that way, you should feel better, is it invalidates the way they're feeling in that moment.
• 54:43
  If I'm feeling really dark and low and depressed and you come in and say,
• 54:48
  hey, turn that frown upside down. Come on, look on the bright side.
• 54:52
  I'm going to feel more distant from you. I'm going to feel not understood.
• 54:57
  It can be really hard for us as providers to come in and say,
• 55:00
  wow, you're in a really dark place. My heart goes out to you.
• 55:05
  You feel like you're stuck in this hole and you're looking for the light and
• 55:08
  you're not seeing it anywhere.
• 55:11
  My heart really goes out to you. And just to leave it at that without sugarcoating
• 55:16
  and saying, but look on the bright side afterwards, but sometimes that's really
• 55:20
  what's necessary, especially with teens,
• 55:22
  seeing that mom or dad can actually just join in the suck and see that it's
• 55:27
  there and that they don't have the magic answer that they're going to try to force feed you.
• 55:33
  Wow. That sounds like it could be really powerful. My father,
• 55:36
  he's an amazing father, but I do remember as a teenager, him saying to me one
• 55:41
  time, you look so much more beautiful when you smile.
• 55:44
  And that, that stood out to me. Like, oh, I did not, you know,
• 55:48
  it did not help anything. I'm sure, but. You didn't like that?
• 55:52
  Well, yeah. It didn't feel good? No.
• 55:55
  Ah, ah. I was hoping you'd say it didn't feel good. I was hoping you'd say that.
• 56:00
  And I remember it to this day.
• 56:04
  That's great. But is that kind of, it's that not seeing where,
• 56:07
  you know, like, it's not, of course I'm upset right now. It's not,
• 56:10
  I need to smile through this.
• 56:12
  Why would I need to smile right now?
• 56:14
  You know, it's, it can almost feel like you're being judged for not being happy.
• 56:22
  Yes. And, and it's true. And again, especially as parents who are vulnerable,
• 56:27
  because we feel like if our child is upset, it reflects on us as a parent.
• 56:32
  So then we feel shame, we feel guilt, we feel like we've done a bad job as a parent.
• 56:38
  And ironically, a little strain within us can get angry at our kid for making
• 56:43
  us look bad, right? Stop crying.
• 56:47
  Stop being depressed all the time. Stop messing up all the time.
• 56:51
  It makes me look bad. It makes me feel like a bad parent. And in a way, it makes me angry at you.
• 56:56
  So if we can find that compassion for the child and not make it about us and
• 57:00
  get angry, I think that's a piece of this too, isn't it?
• 57:03
  That's really where we look at us. I mean, it makes a lot of sense.
• 57:06
  There's so much pressure in our society to be happy, which no one's happy all
• 57:11
  the time, of course. Yeah.
• 57:12
  Yeah. That's absolutely right.
• 57:15
  Well, this was another blockbuster, Holly. Yes. Thank you.
• 57:19
  Well, Dr. David Roberts, thank you so much for being here today on Pediatrics Now.
• 57:25
  Thank you. I've had a real blast in these conversations, Holly,
• 57:29
  and you've really enabled me to sort of get into talking about MI in the way
• 57:34
  that I think is most useful. So thank you for that.
• 57:37
  Thank you. And hopefully you'll be back on the show again soon.
• 57:41
  So I'm sure we'll come up with another topic.
• 57:44
  I'm sure we will. Take care. Thank you, David.
• 57:50
  We hope you've enjoyed this episode of Pediatrics Now.
• 57:54
  Click on the link for free credit if you're a practitioner. You can also email
• 57:58
  us with questions or episode ideas.
• 58:00
  That address is pediatricsnow at uthscsa.edu.
• 58:07
  We release a new episode every Friday.
• 58:09
  I'm Holly Wehment. I hope you can join us for our next episode.