Motivational Interviewing for the Busy Practitioner Part 2

Music. Back on the show today is Dr. David Roberts.

He's an Associate Professor of Psychiatry at UT Health San Antonio. Dr. Roberts, thank you so much for being back here on the show today. I'm thrilled to be with you again, Holly. We're getting a great response from our pediatrician listeners on motivational interviewing, and it helps so much. The insight you gave us in the last episode, because who has the time, really, even though we know how much it will help, but they're seeing 40 patients a day and it's just hard.

I love meeting with anybody I can, whenever I can, to practice motivational interviewing. And so I'm hopeful that the time we spend together will stimulate others to sort of create and join us maybe in some of our practice opportunities. And it's a very popular episode. And maybe we could reiterate here, if you have a family wondering if they should get vaccinated for measles.

How, cause that's, I know that's a huge challenge, but I know we're talking today about talking to younger kids around the age 13 and younger. And maybe that's a scenario that we could, we could talk about with each, each age group, if that works for you. Talking about the question of vaccination across age groups? Yes.

Yeah, sure. I mean, I think that regardless sort of of the topic area, I think what we're going to be wanting to, and really even regardless of the population, maybe the broad frame that we want to start out with is we want to get into the conversation. We want to invite that person and welcome that person into the conversation in a way that feels that they can be trusting with us.

Sometimes pediatricians or physicians, we're sort of entitled to have conversations about difficult topics with patients that they expect us to talk about those topics, and so we do, but that doesn't necessarily mean that the patient feels comfortable or feels safe. And so often we will get very restricted versions of the patient in our physician conversations.

So what we're really trying to do is enter into a conversation on the topic, very simple, join me in this conversation on this topic, and then use a lot of your sort of your non-verbals and your human connection skills to create a sense of comfort and safety in the topic. And it's remarkable how far just that will take you.

When really it seems, if you think about it, well, that's time I don't have, but really it's going to help save time because the patient will be more receptive to what you're talking about. That's right. That's right. And then when you're imagining this open-ended conversation, it makes perfect sense to say, I don't have time for open-ended chit-chat dialogue.

So really then what it comes down to is how can you squeeze the most value out of a relatively short and relatively unstructured conversation? And that's kind of the trick and the magic of it. And I think in motivational interviewing, it's a very language focused approach so that each utterance you make really packs a punch. And so the way we start that out from the beginning is emphasizing the use of reflections. Reflections like a mirror reflect back to the patient what you've heard from them.

And so this is sort of our bread and butter technique. It is what we say essentially validating. So it's a way of making the patient feel not only that you have understood what they've said, but there's a way in which it makes sense to you and that it's acceptable to you. So that's our bread and butter. is, so let's say we're talking about the question of the measles vaccination. We start out by saying, can we talk about the measles vaccination?

I'd like to talk about that with you. So we efficiently go straight to the topic. And then perhaps the patient says, oh, great, here we go again, or something like that. And then what we want to do is hand it over to them and try starting to create that trust within the topic. Tell me how you feel about that. Sounds like you have some some real feelings about that.

I'd like to, I'd really like to hear from you what you think about the, the measles vaccination and really authentically hand it over to the patient to hear what they say, reflect it back to them, show them that you accept and understand where they're at. And then that's when the dance begins of you saying where and how can I fit in some of the information or agenda items that I want to fit in having created a little bit of trust.

Which could be difficult. It may feel so different because pediatricians being so in charge of so much of essentially this patient's health, and they've got those moments in the exam room and so many things coming at them. But it is, from what I learned from you from last time, you're putting the power back. You're giving it back to that parent and to that patient. Here, it's back to you. What are your thoughts on this? Yeah, yeah. What are your thoughts? And this is really your choice, right?

You're facing an important choice here. And then, of course, Holly, as you and I have discussed, where you're hoping to get, because you're trying to be efficient and bring some structure, some coherence to this conversation, what we're trying to get into is a double-sided reflection. Where we try to efficiently move to being able to say to the patient, I can hear that you are pulled in two directions.

That there are these doctors and public health experts, and it sounds like some of your family putting pressure on you to give your child the measles vaccination. But I can hear you're pulled pretty strongly by your own thoughts and values towards some arguments on the other side. How can I help you with this? So we're trying to get to this point where we're highlighting you're facing a choice, you're facing an important choice, and you're pulled in two directions.

And by doing that, it creates what we call a sort of sense of dissonance or discrepancy, which is an uncomfortable feeling of being on the fence-ness, that we want the patient to say, yes, that's right, I am pulled in two directions, and it doesn't feel good, I want resolution. That's where we want it. That's our sort of first goal.

And you say, David, when it comes to motivational interviewing, have it kind of bubbling up in the background with our conversations where it's kind of always on your mind. Yeah, yeah, right. So you always have this framework in mind. You're always half smiling because you know the patient is there wanting to be more well, wanting their child to feel better, wanting more health in their lives, and wanting to move in that direction.

So you always have a half smile on your face, but you also always have bubbling up a sense of this person is pulled in two directions. This person wants wellness and health, but there are factors that are pulling them toward resisting aspects of that. So that's, it's always bubbling up and we're always saying, let me validate that, that stuckness. Let me reflect my understanding that they're in a tough spot and that they want to move toward wellness and they're looking for my help with that.

I've been, like I said in the last episode, I've been using, utilizing this with my three teenagers with empathy. And, and I tried it with my, my 13 year old daughter where she had done something she wasn't supposed to. So she wasn't getting to go to the event that she wanted to. And she was so upset and she was crying. And then I, I thought about how you said, like, you think of the approach, like you're the, the child's attorney kind of think of it that way.

And so I launched into, I know you're so upset. It's so understandable. And I really wanted you to go to that too. And as you know, you weren't supposed to do this thing you did, but, and since that happened, this is the consequence. And I bet you'll be able to go next time, but now, you know, and it's up to you not to do that thing that you weren't supposed to do. And it was hard for me to say that too. It's totally your choice if you still want to keep doing that.

And I was just like, oh, and I just let it dangle there. You let that reflection dangle in the air, that reflection where you're really saying you to your daughter, you have a lot of autonomy here. Yes. Is that what it does when you let it dangle? It's like, yeah, it's saying this is you, this is your life, this is yours. And you sort of put that out in front of her. You're facing this choice moving forward. You have the freedom to either do the bad thing again or not.

As a mother, it's hard to acknowledge that freedom. Oh, it was so hard. But then a half hour later, we're watching a movie together on the couch, you know, and having a great time. And I felt like I avoided a really difficult conflict that used to happen, kind of this loop, recurring loop of conflict. Wow. Wow. I love hearing about your experiences with this, Holly.

And so, I mean, I think what What it brings up is maybe some of the themes that we want to track, and pediatricians already do this in a number of ways, when we think about the development of kids from, you know, age two through age 18, right? And so one of the tasks of development, one of the processes, is this process of individuation.

And I think what we're talking about when there's the parent and there's the kid is both parties want the kid to be moving toward greater and greater independence. But have very different ideas about what that should be looking like. And so we always get into these scrapes where the youth is trying to assert their independence more, and the adult is trying to constrain it and sort of support it at the same time.

And so that's the challenge, I think. When we're using MI with adults, we're more freely supporting autonomy, saying this is all up to you. With kids, much more often we're saying there are limits. You're in a situation of limited autonomy. me. And one thing I think I said to you last time, Holly, and I'll bring it up again now is there's, there's a benefit that can come from externalizing the, the, the limitations.

So saying like you did, there's a rule, there's a standard here that exists independent of you, my daughter, and you, you violated it. And therefore there's a consequence. And then what you're doing, Holly is aligning with your daughter and saying, I can totally see your perspective here, you don't like that standard, that rule to begin with, and you broke that rule, even though you know it's a rule and you know there's consequences, you broke it and you are not happy at all.

And I, and I get it. I get that you're not happy. So here we have the parent aligning with the child's emotion of it and feeling of it and empathizing, even while at the same time, it was the parent who implemented the rule. So one of the good things about the young, youngs, the little kids, the pre-operational up to age maybe five, six. Or yeah, five, you'll get kids who see the rules as being an objective fact of the environment and are less likely to say, but mommy, you put the rule in place.

And so they're less likely to question those things. And it's easier for us then to use motivational interviewing in a way where we're putting the rule on the outside and empathizing with the kid. As the kid starts getting a little bit older, and certainly by the time they're 14, 15, they're going to say, mom, I don't like that you made that rule and I want you to change it. So it's a little bit of a different conversation, of course.

And then what do you say? Do you talk about how we all have limited choices in life? Right, right. And so then you're talking with somebody who actually has a more mature mind, and they're able to, maybe they're 15, they're able to understand things like ambivalence. They're able to consider ambivalence for themselves, and they appreciate being treated like an adult. And so you can say to them, you can confess to your 15-year-old, yes, I did make this rule.

And it's hard for me knowing that it upsets you. And yet, and so because of that, I was pulled in two directions, but I still made this rule. And here's why I made the rule. And I'm standing by the rule. So to compassionately say to your child, it is my responsibility that I made this rule. In the end, I'm the one saying no to you and I'm standing by it. And I love you. And I appreciate that you don't like this. Yes. And it is painful to, to see your tears. You know, it's hard. Yeah. Yeah. Yep.

And I get that, that, that, that you're upset at me and that you don't fully understand, or it doesn't make sense to you while I, why I made this rule. And I know that's hard for you too. Yeah. So maybe don't say it's painful to see you're too, like more of empathy. So they, she knows it's okay to cry and be sad about it. Of course. Yeah. Yeah. And, and of course, we can always look for those opportunities to say, I want to support you in being your own person.

Because you really do want to support. I think you do, Holly, don't you? Yes. So much more than anything, right? Yeah. Yeah. And then I also heard you say that you have that protective side of you that wants to say, but stay under my wing. Right. Definitely.

So I know a pediatrician who sent me a question, she said that so much of, and I know we need to go to break soon, but, and we'll be back after, after the break, but, So much of motivational interviewing for pediatricians is talking to the parent with the child, maybe very young child sitting there or a baby or a 10-year-old, you know, different ages, of course. But a lot of it's talking to the parent. Right. And talking to the parent with the child in the room.

So that becomes a complicated dynamic, you might say, where you wouldn't want to undermine the parent in front of the child, but you may be trying to influence the parent's behavior as well. Exactly. Right. That's a great point. Right. Well, why don't we get into a specific example of that? Maybe we could dig down into a specific example of that scenario right after the break. How about that?

That sounds great. So we will be back right after this with Dr. David Roberts with UT Health San Antonio, and he's an expert on motivational interviewing. But how do you really implement it? How can it help you in your practice?

And how can it help you talk to your patients? I'm back with Dr. David Roberts. He's an expert in motivational interviewing. So Dr. Roberts, What's the best way to talk to parents you have in the exam room? There's a parent or parents and the child, and you've got 20 patients waiting for the rest of the afternoon, a packed exam room. I mean, I think that one of the values and principles of motivational interviewing is authenticity and transparency.

And so, again, I think probably most pediatricians already have this in mind. But to kind of reinforce it, we would like to be as transparent as we can while communicating to a parent in front of the child. And so we would like to be able to not really change the way we talk to the parent, acknowledging if it's a very young child that, for example, the parent is facing a decision regarding measles vaccination for their child.

And we will reinforce, always useful to reinforce to parents, you know, I know that your child's welfare is paramount in your mind. I know that that's your North Star. I think that's a real slam dunk that we can, you know, 99 out of 100 times assume that's true for the parent and be able to authentically reflect that.

And that's really important when you're talking to a parent about a decision like where they may be moving away from the medical advice, because that means that there's going to be a risk that they're going to feel judged by you, right? Anytime a parent may be making a decision for their child that the parent thinks the physician doesn't want them to make, the parent may be feeling defensive, may be feeling at risk of being judged.

So that's a time where we want to really reinforce and validate it's their choice. And we understand it's not an easy choice. And we know that what they want most is the wellness of their child. And that's what they're trying to figure out. But other than those considerations, there aren't huge things that jump to the front of my mind in terms of talking to the parent in front of the kids. I wonder if there were kind of particular concerns that are in your mind about that.

That's a great question. I need to think about that. When you were talking, a question that comes up in my mind is, it may seem counterintuitive. We're giving the power back to the person we're talking to when really it's helping us to hopefully have the outcome we're looking for.

So by giving that power back to them, and it is in your hands, just the magic almost like of having these statements in your pocket like i know that's your north star that you you want your child's help that that's paramount to you that's number one i can i can see that or statements like you just said yeah yeah i appreciate your pointing out that apparent. Inconsistency or paradox like if i'm trying to make a person do something how does seeding my power help me get them to do the thing.

And I think that the way I think about the solution to that and why it makes sense is getting back to this idea that we've talked about that all organisms are naturally inclined to move toward growth and health. And that's why we always have a half smile on our face when we talk to our patient, because we know that that's where they're headed. And so all things being equal, if you give a person the freedom to make their own decisions, they will march straight towards growth and wellness.

Now, we know that that doesn't happen because people get blocked in a range of ways. That's true. And so a lot of the work of MI is drawing people's attention and exploring ambivalences that came out of the ways they've gotten blocked. But at the end of the day, we want to hand the wheel over to them and say, you know, I trust you that you're going to be doing what you think is best for you and healthiest for you. And on average, that ends up with the person making a healthy choice.

And you don't lose anything by saying that. You gain it, kind of like saying sorry. You don't lose anything by saying sorry to someone. Yeah. Yeah, that's a really good point because at the end of the day, it is their choice anyway. And they're going to choose what they choose even if you act like it's not their choice. Right. And I know when you are teaching pediatric practitioners, family practice doctors.

You have this way, like we're doing, going back and forth, talking directly to each other and bringing up scenarios. That's how you teach. Someone who uses this link that we'll put in this podcast can do exactly what we're doing, which is, I think, pretty phenomenal. Yeah, I mean, this is what I do. This is my favorite way to spend my time. And I'm so glad that you're willing to sort of engage with me on this.

And this is exactly what it feels like, exactly what it looks like to be working on these skills. I think one thing I wanted that's on my mind that I want to emphasize is when we're doing motivational interviewing, very often that means that us as the provider, what we have at the front of our minds is getting that change, right? We've got our eye on that target behavior. We're trying to use a technique that's going to somehow enable us to achieve that change with the patient.

And ironically, that can cause us to be pushy. And as you were just pointing out, the sort of big irony in this is the way we get the change is by not being pushy with the client. And so I think always as practitioners, we often need to remind ourselves to come back, come back to the starting place, which is focusing our attention on the experience of the patient.

And if we're talking about especially a child or especially an adolescent in the context of their emerging individuality and their growing sense of urgency that they be recognized as autonomous and that their emerging adulthood be sort of recognized and respected, we can do that so well in motivational interviewing by saying, I really want to hear your perspective on this.

And so this is one of the ways in which it almost feels like MI was tailor-made for working with adolescents who feel like they're not respected in their emerging adulthood. So really doubling down on understanding and demonstrating our understanding of the adolescent's perspective and showing that we see the nuance in it can really go so far. And it takes away that defensiveness. They don't have to defend that they know what they're doing, that kind of thing. That's right.

That's right. They don't have to defend it because we're being the lawyer for them. Right. We're saying it really makes so much sense. Your perspective that frees up their mental energy to do something else. They're not mobilizing all their energy to defend their dug in position. Instead, they're saying, well, golly, mom is being really open and flexible and she's not pushing me towards something. So I don't have to defend anything. Well, I guess I can think fresh about an

old problem then. That's wonderful. There's, there's a, I know I've talked to a lot of pediatric practitioners and the very understandable mindset is that when it comes to say the measles vaccine, if the parent isn't kind of open, seeming right away to be open-minded, if they're way the other way, you just don't have time. Don't, why even spend the time? You're not going to convince them.

So do you think that MI could be a way for someone who just seems so set on anti-vaccines to go ahead and at least try? I think so. I mean, I think that I mentioned this, Holly, in our very first conversation. A way I often like to think about MI is as a two-step process. Step one is going from resistance to ambivalence. Step two is from ambivalence to change. And so you're talking about a step one scenario.

And if we cut the goal down from, I'm not trying to get this parent or this patient to totally reverse their perspective, I'm not going to try to convince them to reverse their perspective on vaccinations. But if I can get to where we're having a mutually trusting and respectful conversation, and maybe a very brief one, in which we essentially are agreeing to disagree with smiles on our faces, that's a huge accomplishment. It's really big.

So one approach with this is to sort of take a smiling approach to, hey, I know you and I, we come from different perspectives on this question of vaccines, but let's just take a minute and see where we're at. So I know, you know, my job is a doctor. So of course, you know, I'm going to be pushing you to go for the vaccine. Do you have any questions about that, about why in that role I feel so passionate about pushing you for it?

Anything I can explain about that? So almost like doing this double role. Hey, I'm going to be the pushy physician because I really believe in this, but I can also be the person who talks to you about that conversation with the pushy physician. That's an approach that I really like to take with, again, just the goal of the patient being like, okay, this provider respects me. And we had a real honest conversation about the question of vaccines.

Then would you add on there, of course, it's your decision to get your child vaccinated, or when you don't know what to say, add that in? Yeah, yeah, yeah. Add that in when you don't know what to say and let the patient leave the session with that open loop where what they have kicking around in their head is, you know what? I like that physician. I like that doctor. I didn't feel judged. I didn't feel like they were making me feel like I was a bad parent or stupid or anything.

They were really respecting my position. And ironically, that has me a little bit more inclined to like them and like their position and want to kind of maybe consider going that way. That's a very realistic aim for that conversation. Because it could be difficult for a lot of parents to check at the door their authority, not that they need to, but they naturally have that defensiveness perhaps about their child. Right.

And if all of a sudden they're not being pushed to choose A over B, but it's their free choice, well, then maybe they will choose A. But if they're being pushed, then they're definitely not going to choose A. So say if, so you say, so I'm the pushy doctor I know because I care so much and believe in vaccines. So how are you feeling? And say that the parent says something like, I just don't believe in them. I think they're doing more harm than good. I've heard they can cause autism.

I think that, I mean, we're doing great and everything's fine and it's my decision. So I'm not hurting anyone. Yeah. And so we can explore that. You know, what I'm going for is I'm going to try to get my foot in the door to, to see, can I, cause right now they're doubling down on, I'm a hundred percent resistant. And what I want to be able to move forward is to be able to say, yeah, I can see how you're pulled that way.

And you're also pulled the other way. I want to explore ambivalence with them. So I think that I might say something like, well, Hey, thanks for talking with me about it. I know that what's most important is the health of your kid and that you really need and want to own that decision as the parent. And I just appreciate that you took the time to talk to me about it and that you're going to keep listening to this sort of medical perspective on this.

And, you know, just sort of share that, leave it there, and don't expect that you're going to be able to get to a change in decision today. I know you've mentioned the long game, and it's so hard to think of that when you've got those, I'm sure, the moments in the exam room or something that just happened with your child. Well, that's right. And I mean, you know, you can also try to find middle ground.

Like, so the technique of, one technique for rolling with resistance is what we call coming alongside. And that would be saying, I hear you loud and clear.

You've made your decision about vaccines, and you're not really interested in carrying on that conversation. That's totally fine. That's your choice. I wonder what you think about having a conversation about ways, if it does end up that your child gets measles, ways that you would want to respond to rapidly address that issue, or ways that we could mitigate the consequences that could come from your decision. Would you like to have that conversation?

Well, my child's perfectly healthy. Why would we even need to talk about that? Absolutely. We don't want your child to get measles. We don't expect your child to get measles. But, you know, this is in medicine more and more, we're shooting for preventative care. So we're saying things like, get a little exercise now, eat a few vegetables so that later you'll be healthier. It's the same thing with the vaccinations. I know what you're putting first and foremost is the wellness of your family.

Would you like to put some things in place to protect against the possibility of measles? Yes, as long as it doesn't involve a vaccine. Well, great. Then that makes sense. I kind of thought you were going to say that because I know you want to do what's best for your kid. And then I'm not me, Dave Roberts. I'm not a physician. So I don't know what a physician would say in terms of things that we could put in place. But what I like about where we've gotten with the conversation is we've got

the parent acknowledging there is a thing called measles. and there's a risk with getting measles. And we're on the same page that the parent wants to take some action to minimize that risk of if measles comes. And we're working in a space where that's acknowledged. So I'm feeling pretty good about this. We do have for our listeners a measles update. It's about the current state of the outbreak. And we do mention motivational interviewing to help encourage people to get vaccinated.

So would it be okay right there to, at some point in that conversation, to launch into saying something like, well, actually, perfectly healthy children with no underlying conditions do get pneumonia from the measles. It's the most common complication and children die from pneumonia, from the measles. Or would that be too much? Right. So you've got some information there, right? That's information that you want to impart to the patient, to the parent.

And whenever we're in that situation, I think you picked up on all you said, or is that too much? Recognizing, all right, there's risk. There's a risk if the parent is defensive. There's risk in my giving them information that goes against their perspective. So in motivational interviewing, we use something called elicit provide elicit, which is how to do information exchange. And the idea is we first ask the parent, ask the patient, what do you already know about this?

What information would you like about this? Or any sort of really a question to get them talking about their understanding and their thinking. Then within that context of that conversation, we might try to do the illicit, provide, illicit. We might do that provide. So let's see what this might sound like here. This is a parent who's pretty against vaccinations, and I want to get into the topic. So I might say, what do you make of what we're seeing with the reports on measles

rates in the state? How are you feeling about this situation? People had measles before there was a vaccine. So how did they get over it then? I mean, just naturally, we get sick sometimes. Yeah. And we saw this, we see this with things like COVID too, where there's a certain amount of people get sick and die from respiratory issues sometimes, and sometimes they don't. And this happens in populations. That's a perspective that makes a lot of sense.

What are you making of people's concern and the kind of urgency that some people have about increasing vaccinations for measles to tamp that down. I haven't really been paying attention, to be frank. Yeah. That doesn't seem very important to you. I mean, it is important, but my children are fine, and I know I've seen some things on social media talking about the dangers of vaccines, so it seems better to just steer clear. Yeah. It's kind of a scary topic either way you look, right?

It's sort of scary to think, what if my kid does end up being one of the ones who contracts measles? But on the other hand, it sounds like you're saying there's no good option if they do get measles. What do you understand about the options if your kid gets measles? Well, I also haven't really looked at that. I just assume that my child will get better. like she did from COVID. Yeah, right. Well, you know, one of the things that I'm here for is as an information resource.

And so I'd be happy to share information from the scientific research on any part of this that you want. Would you like to know more information on the measles statistics or treatment for measles? Sure. Okay. Then maybe I share some information on alternatives for treatment And this information shows there's no substitute for good vaccinations. And so I share that with you. And that would be called provide, illicit, provide, illicit. First, I'm asking you, what do you already understand?

Then I say, hey, we're talking about this. Would you like some more information? You said, sure. So I provide the information. Information says vaccines are the best way to go. And then I end with the final illicit. So what do you make of this information, Holly, about the importance of vaccines as the front line for preventing measles. Well, how do you know who to believe? All right. Yeah, that's important. What is the source of the information?

What is the source? And the information I've been giving you is from research articles in journals. What's your sense of that? I can explain more of that to you if you want information about it, or what do you understand about the validity of that source? Well, I think the scientists probably have something to gain by telling people to get vaccinated. They just they want to sell the vaccine. The scientists might want to make money with the pharmaceutical industry.

Probably. I think there's probably something behind it, some scheme. Yeah. Yeah. And certainly, we live in a capitalist society. There's a lot of people making money-driven decisions. And you don't want one of those decisions to determine your kid's health. Right. Yeah. Yeah. Makes sense. Well, do you think that that's something that has been addressed before? The risk of financial incentives clouding medical research?

Well, yes, probably. What do you make of this? I'd be happy to give more information about how science tries to prevent bias, tries to prevent those sorts of motives. But I don't know how important that is to you. How important is that issue in making your decision about vaccines? As long as I know that there's not an, you know, this behind the scenes motive and they're not trying to convince me of something that could hurt my child, then maybe I would consider it.

If you were confident that the people producing this research have the right intentions, you might listen to it. Yes. And as long as I knew it wasn't going to hurt my child. And how would you know that? What would convince you that it wasn't going to hurt your child? I would have to see it for myself. You would have to see people getting vaccinations and not suffering for it? Yes. And how would you know? I could share statistics with you.

We have access to the percentage of people who've been vaccinated who have had negative reactions. Would that kind of a research paper be useful? Sure. I can share that with you. Okay. So why don't we pause there? Holly, I think that was actually a really good example of, of what an MI conversation might look like. Would you, with what you gave to the patient include the part about pneumonia and kids dying from pneumonia, have it there.

Don't say it. Don't bring up some kids. It's rare, but it does happen or it was happening when there was lots of measles going around. There's a deadly brain disease that a kid can be fine and recover from the measles. And seven, eight, nine years down the road, it's been dormant and this deadly brain disease, suddenly is active and there's nothing doctors can do about it and kids die. I mean, is that all too much? I guess it's sounding too much as I'm saying it to you.

I think you just don't want to come across as being alarmist or trying to scare the person into making a decision. And you want to offer that information. Would you be interested in learning more about the worst case scenarios for what could happen? And one way that this can come up is you can say, I'm here to help you make this decision. What do you see as you look towards the future? What do you see as the best case scenario if you give your kid a vaccination?

What do you see as the worst case scenario if you don't do vaccination? And then maybe they say, I don't see worst case scenarios. He has a few bumps for a month or so. And then I might say, would you be interested in more information about worst case scenario? I happen to have some more info about that. Would you like me to help flesh out your understanding of worst case scenarios. So offer it, don't give it unilaterally, especially if it's potentially inflammatory.

Okay. And then if they say they don't want that information, you just, then it's time to wrap it. Thank you for listening and for talking to me about this. Yeah. Think of it as an opportunity to show them that you're trustworthy. Offer something, and if they decline, don't give it to them. Say, you got it.

This is your, that's your choice. and stand by your work, the more we can show them with our behavior, our respect for their autonomy, that's what really makes them believe it. Talk is cheap, right? And sometimes if you're not careful, MI talk can feel cheap, especially to patients who are not as verbal. You hear me, I'm a very verbal person. Some people really don't like me if they're not as sort of, if they're more physical and less sort of a jibber-jabber verbal person.

So sometimes just showing trustworthiness is really the way to do it. Well, I know you're a father and we've talked about how this could be so helpful for parents. So how about we go through a question that a parent had and kind of how you would talk to that child? Because it sounds like also it's pretty universal regardless of the age of the child. Go ahead, sir. Oh, yes. Sorry to interrupt. I'll just make one point about the

age of the child and then we can get into the scenario. I think it's one important consideration is sort of what we call pre-operational versus operational. So a cutoff at around the age of sort of 12, 13, 14, where kids develop the ability to think more abstractly. And that's the point at which they can start considering their own ambivalence much more richly. And, you know, considering ambivalence within motivational interviewing is a

big part of it. So before that age, we don't really use the ambivalence part of it as much. And starting at that age, we can really use it. So then how would we, because it's, as I mentioned, with my three teenagers, it's helping so much. So if you're talking about, say, a child 13 and younger, what are the things that you would say different? Would you not say, of course, it's your decision, you need to decide? Or I guess you would say that sometimes, but what do you want to say there?

So we're still, for me, the way to think about it is we're still working within a developmental frame, but we're earlier on in that developmental frame. So the emergence of individuality isn't about I'm my own grownup separate from you, mom. It's more about more rudimentary and primitive aspects of recognizing and validating the child's inner experience.

So much of the problems that emerge in family systems in early life for kids relate to not being seen, not feeling seen, and not feeling validated in their experience. And that can be both an emotional, a sense of emotional bereftness or an attachment problem, or they don't feel an emotional connection. But it can also conceptually be confusing if they're not getting the kinds of feedback from parents that help them start to see themselves as an individual freestanding agent.

So one real nice way to use that I think that we can use motivational interviewing with the littles, with the younger kids, looks a lot like what gets called play therapy, where we're essentially watching a child play, and then we're doing a lot of narrative reflecting of what's happening.

So, for example, if they're playing with Star Wars figures, maybe Chewbacca and Luke Skywalker, and we're watching the child play on the little sand table or something, we might say Chewbacca's very angry at Luke Skywalker. Chewbacca's chasing Luke. Luke is afraid of Chewbacca because he sees that Chewbacca's angry. And so we're kind of helping through our reflections to reinforce these relationships. And then we will translate that over into the child themselves.

So things like, and you are feeling angry at your sister yesterday, or maybe the kid is being quiet and sulky and we reflect, it's not easy to be here. Talking to a strange grownup is hard. So we're using our reflections to shore up and help instill a sense of their own separateness, a sense that we know they have thoughts, feelings, motives, and emotions that are separate from our own and that they have choices.

And so we're starting to also recognize that they have choices and that they're making choices and decisions. So I know that sounds very rudimentary, but for me, that's all within this MI frame. And is it important with that age group, too, to sometimes repeat back what they say and show that you're understanding and just let that dangle there without offering advice or saying, but you really should do that? I know you're sad about having to clean your room.

Absolutely. Well, absolutely. Absolutely. And I think this, I forget if I shared this with you or not, but one thing that I started doing with my son. So, yes. So, yes, reflect back what they say. I had been saying, like before, kind of do reflections even when they're not saying anything, right? So if they're quietly playing with Luke Skywalker and Chewbacca, I was describing a form of doing reflections to a silent child. Or if the child is sitting there being sulking, not saying anything,

you can reflect on that. You can reflect the process. And that's a wonderful thing to do with little kids and with teens who are not saying very much. But certainly when a kid is talking, you also are doing reflections. And it's a respectful, validating thing that helps a child feel puffed up and really seen in the room when we're doing reflective listening with the kid.

So one thing that I think is kind of, you know, a funny illustration of this is the way I like to joke, I became a parent a little bit older in life and I say, you know, nobody told me that the little kids, when they come home from school, that they're going to be stingy when you ask them how their day was. But my four-year-old, right? My four-year-old, now five, he comes home from kindergarten. And I'm like, how was your day? How was your day?

And he won't tell me. And he kind of clams up. And so, you know, I started playing with the motivational interviewing stuff and I started doing reflections instead. And so he would walk in the door, even before he said anything, I would hazard a reflection. Like I would say, you played on the field today instead of the sandbox. And what I found was that he would be much more responsive. He would say much more.

He might say back to me, no, no, I was in the sandbox for the first recess, but then for the second resets because Jonathan wanted to go out and, you know, he'd sort of start talking. And half the time it's because he's correcting me, right? So you'll get a version of this with teens also where the teen will be there, whatever. I'm using a stereotype, but being kind of sulky and not saying anything. And then maybe you just hazard a reflection like you're feeling kind of sleepy.

And then they'll be like, no, mom, I'm not sleepy. What's going on though is that Trevor was, and then they'll sort of start talking. But in contrast. I think a principle here is if instead of doing a reflection, we ask a question like, how was your day or why do you look sad? That feels like a demand on the child. And the child, in a sense, is like being oppositional. Like, I'm not going to give you that satisfaction. You don't get to tell me to report on my day and I have to report on my day

to you. So I'm going to sort of not give you the satisfaction of answering and assert my independence as a child. So that's a fun game to play. Do reflections with kids, even when they haven't said anything, and do reflections that you think are probably wrong about their inner experience and play with it. And that's a good way for you to practice your MI skills, too.

Well, nice. I remember, well, it was a few weeks ago, my teenage daughter, I asked her, I was trying to come up with things to ask her about her day. And then I asked, what did you have for lunch? And she said, food. That's a perfect example. Isn't that a good example? Yeah. But then where do you go from there? Right. But I mean, I think part of what you're saying is she was saying to you, duh, I had food. Right. Yes. And is that, yeah. It's like, don't burden me with obvious questions.

And kind of like, are you really interested in exactly what I ate? Or is the teen saying that kind of? Ah, like, mom, that's so lame that you're trying to like start a conversation with that kind of bland question or something like that. You don't really care about that. Yeah, maybe so. I mean, it's hard sometimes with teenagers with the response, you know, like that they'll respond back.

What's obvious they're doing and or not say anything and then the the urge is to say are you ignoring me right right what might be what might be a different sort of a reflection that you might say when what what might you use as reflection when she says food it sounds like maybe you had a sandwich it would like if i might be wrong is that what you're saying to do you don't know so you suggest some no i had tacos you could do that you could do that i think that would be fine i think

what what i have in mind and this we haven't really talked about this explicitly but i've alluded to it a little bit is process reflection so not reflecting on the content of what she said but reflect it reflect back what you've learned about her based on how she said it okay so what how would that what would that sound like maybe if she says food a reflection might be, that seemed like a silly question.

I see. So kind of like saying what we talked about before, I'm the pushy doctor, or I'm the doctor, so of course I'm going to push you to want to get, you know, I want you to get the vaccine. I believe in them. Kind of like that. Why don't you try being your daughter for a second and I'll be you and we'll do it. Okay. Here we go. Oh, hey, honey. Hey, what did you have for lunch? Food.

That felt to you like kind of a silly question for me to ask Well, yeah You don't need me grilling you after you get home and you're tired after a long day I'm so tired and hungry, yeah, Well, yeah, that's fine. Okay. Yeah. Yeah. Go ahead. Or what were you going to say next? I don't know what I was going to say. High school's not easy. Something like that. Okay. That's really good. So I have a specific question from a parent. Do you have time or do we need

to do that? Sure. Sure. Okay. So this parent, and it could come in up in a pediatrician's office.

So her, her child tends to, when she gets mad and I think she's around, they said 12 or 13, when she gets mad she'll like hit something or hit the table or do something like it's an anger response to say if something dropped on the floor then she'll hit something and then it causes its own problem like using kind of a it sounds more dramatic than it is but like doing something physically to show you're mad when you're mad and trying to get them to stop doing that and even so much

so as not being nice to themselves, like even doing like a choking sign on their, like, I'm so stupid and like around their neck or something, you know? So it's like getting so mad when normal stuff that frustrates people, everyone, say a glass drops on the floor and shatters and then having an anger response. Yeah. So the parent wants the kid to curb their behavior, their angry behavior. Yes. I hear you. Well, so, so yeah, let's, let's dig into this for a moment.

And I think part of it is what we actually just did right there, digging into it, because, you know, we have these situations and, you know, I know as a parent where my kid does something and I'm like, I just want him to not do that. That's annoying. I want that to stop. So my goal is to stop that behavior. And I would love it if I had a technique to stop that behavior. And I think in this situation, what motivational interviewing kind of wants to say is.

If you want that behavior to stop, remember, it's not your choice. There's another organism that's going to choose what's going to happen with that behavior. And so there's a whole set of things to keep in mind and sort of things to respect that that's the case. And one of them is, if I want that organism to change, I need to understand why they're doing it in the first place and what it means to them and why they might choose to change that behavior.

So with me, Holly sort of interviewing you about, you know, why did the parents think it was a problem? And what did they think was the underlying issue? And how are they hoping the child would be, would even be able to sort of change that? So this then gets us from a technique standpoint into the kind of MI, which is wanting to learn the story so you can validate it first. Step one, join in the stuckness and validate it.

Step one includes ah i really see why you have those angry reactions where you hit things i understand it now it makes so much sense to me that that is your reaction and why that comes out but then holly remember we also want to then get into and and i can tell or and i'm hearing there's a part of you that if you could would like it if you didn't react that way all the time right so that's where we want to get right and i and and the idea is

if i if as a parent i show the person centeredness through my techniques and my attitudes that the child is like wow dad really. In a non-pushy non-judgmental way is just caring to understand this about my experience that shifts that shifts the game it shifts that it's such a different thing from dad coming in and not understanding, but saying, stop doing that. And, and so we have trust faith that will by entering into the conversation with the client, Hey, can I talk to the kid?

Hey, let's talk about that hitting that you just got frustrated with the glass and hit the wall. Can we talk about that for a minute? And then the kid's like, Oh, fine. I know you want me to stop. Whatever. What do you want to say? And you say, I just want to hear your thoughts on it. I just want to hear how you feel about it. So remember, we've talked about this.

This, you know, the, the goal is get the story, get the conversation of the problem of the stuckness going so you can learn about it and validate it. And then you're going to see the seeds for change in it. I'm sure in this scenario, one of the C and it's idiosyncratic, it depends on the person deep listening to the individual youth in this scenario. But I imagine it'll include the opportunity for the parent to say.

Wow, there's a lot of pain in there. There's a lot of discomfort and pain, and I'm really sorry that it feels that way for you in those moments.

That can't be easy, right? That's in there. That's very likely in there for that kid. And maybe, I don't know, maybe they haven't felt that real empathy from their parent around that, and it could change the whole thing. So it's those moments that catalyze fresh opportunities for change where we can't quite have the opportunity, the path in our mind as we start the conversation, but we have a few go-to techniques that are going to present themselves based on what the kid comes up with.

And don't say something like, do you see that you're causing more harm a lot of times when you're so angry and react by hitting something or throwing something when you're angry about, because they already know they're doing that? Right. What our goal is, is to not tell them that, but to reflect their awareness of that. Right. I know that it's frustrating for you to see yourself do these things. I know you, if you could, I know you see that this affects mom.

I know that you see that. And I know, because I know you love mom, that it's not comfortable for you to see that. But obviously, it's not just something you can turn off. You know, I might try something like that. Yeah, so that's a technique that we've kind of touched on a few times is trying not to say the, but don't you see. What we often say in MI is we're trying to not tell, but instead to evoke the same point, whatever it is. Would it be wrong to say, how are you feeling in that moment?

Is it making you feel better to do that? Yeah, absolutely. We want to say, how are you feeling in that moment? But we generally avoid the closed question. So don't, don't add, is it making you feel better at the end, but just say, what is that like for you? How are you feeling? Okay. And it seems like it could be a conversation about self-compassion.

Well, so I think one thing that comes up here, and I'm not saying this as a universal, Holly, but sometimes what we'll do if we're talking to another person, especially a youngster, and maybe they're feeling depressed or they're beating themselves up, what we'll want to do is come in and say, don't do that. Don't beat yourself up. Come on. You're a good person. Come on. Look at your strengths. And I'm not saying that's bad.

That's fine. That's a good thing to do in general. We want people to feel better. We want them to know that we see them better than that. But there's a downside to that approach. And the downside to coming in and saying, don't feel that way, you should feel better, is it invalidates the way they're feeling in that moment. If I'm feeling really dark and low and depressed and you come in and say, hey, turn that frown upside down. Come on, look on the bright side.

I'm going to feel more distant from you. I'm going to feel not understood. It can be really hard for us as providers to come in and say, wow, you're in a really dark place. My heart goes out to you. You feel like you're stuck in this hole and you're looking for the light and you're not seeing it anywhere.

My heart really goes out to you. And just to leave it at that without sugarcoating and saying, but look on the bright side afterwards, but sometimes that's really what's necessary, especially with teens, seeing that mom or dad can actually just join in the suck and see that it's there and that they don't have the magic answer that they're going to try to force feed you.

Wow. That sounds like it could be really powerful. My father, he's an amazing father, but I do remember as a teenager, him saying to me one time, you look so much more beautiful when you smile. And that, that stood out to me. Like, oh, I did not, you know, it did not help anything. I'm sure, but. You didn't like that? Well, yeah. It didn't feel good? No. Ah, ah. I was hoping you'd say it didn't feel good. I was hoping you'd say that. And I remember it to this day.

That's great. But is that kind of, it's that not seeing where, you know, like, it's not, of course I'm upset right now. It's not, I need to smile through this. Why would I need to smile right now? You know, it's, it can almost feel like you're being judged for not being happy. Yes. And, and it's true. And again, especially as parents who are vulnerable, because we feel like if our child is upset, it reflects on us as a parent.

So then we feel shame, we feel guilt, we feel like we've done a bad job as a parent. And ironically, a little strain within us can get angry at our kid for making us look bad, right? Stop crying. Stop being depressed all the time. Stop messing up all the time. It makes me look bad. It makes me feel like a bad parent. And in a way, it makes me angry at you. So if we can find that compassion for the child and not make it about us and get angry, I think that's a piece of this too, isn't it?

That's really where we look at us. I mean, it makes a lot of sense. There's so much pressure in our society to be happy, which no one's happy all the time, of course. Yeah. Yeah. That's absolutely right. Well, this was another blockbuster, Holly. Yes. Thank you. Well, Dr. David Roberts, thank you so much for being here today on Pediatrics Now.

Thank you. I've had a real blast in these conversations, Holly, and you've really enabled me to sort of get into talking about MI in the way that I think is most useful. So thank you for that. Thank you. And hopefully you'll be back on the show again soon. So I'm sure we'll come up with another topic. I'm sure we will. Take care. Thank you, David. We hope you've enjoyed this episode of Pediatrics Now.

Click on the link for free credit if you're a practitioner. You can also email us with questions or episode ideas. That address is pediatricsnow at uthscsa.edu. We release a new episode every Friday. I'm Holly Wehment. I hope you can join us for our next episode.