Motivational Interviewing for the Busy Practitioner

So, yeah, a brief counseling approach that helps generally with patient treatment adherence, especially around health behaviors like smoking and exercise and medication, stuff like that.

Sounds like you can end up saving time. Yeah. Music.

I'm Holly Wayment, and this is Pediatrics Now, cases, updates, and discussions for the busy pediatric practitioner. Click on the link in this podcast for free credit that may include CME, MOC, or ethics credit, depending on our topic or podcast. Today, we're talking about motivational interviewing, a well-established gold standard counseling approach that helps with treatment adherence with things like diet, exercise, substance use, and more.

You may have heard about it. You might be trying it, but I'm so excited because here today on Pediatrics Now is an expert in the field. Joining me here, Dr. David Roberts, a tenured associate professor of psychiatry at UT Health with nearly 20 years of experience as a behavioral health researcher, clinician, administrator, and trainer. Dr. Roberts, thank you so much for being here today on Pediatrics Now.

Hi, Holly. Thanks so much for having me. I'm really excited to talk about using motivational interviewing. So you're a member of the Motivational Interviewing Network of trainers. You've trained more than 3,000 healthcare professionals in MI, and most recently you've developed an online platform for professionals to practice MI skills in small groups, and you have flexibly scheduled online training sessions.

That's right. You know, for years, I've been passionate about motivational interviewing, but also a little bit frustrated with the limitations in our ability to effectively teach it to people, especially the difficulty of helping people get distributed practice in these techniques. And so that's what this new training platform is about. And this is now how we're teaching motivational interviewing more and more often here at UT Health.

And I'll put the link to your training sessions that are all for CME credit, correct? Yeah. So we'll put that or a hyperlink in the podcast. And is it okay if I call you David? Yeah, that'd be great. Thanks. Our audience here, pediatric practitioners. There was one doctor I talked to. He said, so really, I've heard of motivational interviewing, but what is it?

Yeah, it's a great question. It's one of these sort of buzzwords that I think most people hear about in their training, especially people in the health sciences and healthcare professions. So what it is, is an approach to counseling. It's sometimes called a directive approach. It's sometimes called a brief approach. What it really is, is a set of techniques that you don't have to be a psychotherapist or a licensed counselor to use. Really, anybody can be taught to use this set of techniques.

And it's really for helping another person who's facing the possibility of change in their life, and especially some sort of health behavior change, like smoking, possibly new medical procedures that you're having to do because you've got a new illness and the doctor's saying you've got to do this now, like pediatric diabetes, for example.

When a patient is facing a decision or a new challenge and has to respond to it, motivational interviewing is a set of techniques for helping them take on this decision and hopefully make a choice that's going to be in the best interest of their health moving forward. For pediatric practitioners and general practitioners, the challenge is time, even though it sounds like this could end up helping so much and even saving time.

But when you're seeing 40 patients a day, maybe 15 minutes or less in the. Do you incorporate MI? Yeah, I mean, it's a great question. I think it's a really common concern because when you think of counseling, you think of therapy, you think of kind of creating space and having slow, meandering conversations about your history and your emotions, and there's not time for that in a busy physician encounter.

And I think sort of the paradox with it, but also the The real skill in it is finding a way to make it very personal, even in the short amount of time that you have. A couple little ways to think about this. I like to use the phrase, you can have motivational interviewing always be running in the background, kind of like virus detection software. Like it's always bubbling up through your language. It's kind of a style of being with another person as much as it is a set of procedures.

So that's one way to always have it present in your room is to embody what we call the spirit of motivational interviewing. That includes especially supporting the autonomy or the sort of self-direction of the patient you're working with. And, of course, all patients have their autonomy constrained. And especially kids and adolescents are extremely aware of the way that their free choices are limited.

But everybody's choices are limited. So it's talking with the patient in a way where you're highlighting the choices that they themselves really have. And then second, I would say you're finding a way to show the patient that you're really listening to them. One of the best ways to do that is just the question, what matters most to you in this?

Or what's most important to you about this? And last, I'll just throw in this other little technique, a way to sort of get to your agenda while also using MI skills is to direct to the topic. So maybe you say, I want to talk about your diabetes. Can we talk about your diabetes? And then maybe the patient says, yeah, what do you want to tell me about my diabetes? And then you, the provider, say, I just want to hear how you feel about it or how you're feeling about it.

So there's a balanced maneuver there where you're directing to the topic, but once you get there, you're handing the microphone over to the patient to let them take the first stab at the conversation. It almost sounds like you're handing the power back to them. Yeah, that's a really nice way to put it. And it's really all about that. MI, it's sometimes referred to as a dance. It's the dance of who sort of is

exerting the push or the pressure, who's taking the power. And we're always giving the power back to the patient. But then if the patient's sort of struggling with it or not moving with it, we might take a little bit of it back and see if we can push. So say if I was the patient and then I said, well, I mean, I don't think about it a lot. I don't really want to think about it, but it's fine. Yeah, I might look for a way to sort of validate that and say, that makes a lot of sense.

Tell me why you feel that way about it or tell me what's more important than this. So I might put it, validate what you said, put it back on you and ask for elaboration. All my friends get to eat junk food. They don't have to eat at a certain time. They don't have to have a special device on their body. It's just embarrassing. So I just try to not talk about it. Yeah, it makes a lot of sense. You're at a point in your life where you really care what your friends think.

You look around at your friends and you say, why can't my life look like theirs? And it just feels not fair to you. That really makes sense. So what I did there, Holly, is I'm just validating. And I think sometimes a thing we'll do, either as parents or as providers, is we will validate where the patient is coming from. Like, yeah, that makes a lot of sense that it's frustrating to you. And then we'll quickly move into saying, but can't you see that it's important?

Or, but I'm going to need you to do this. And that's okay. That's okay. But I would encourage listeners to experiment with letting the validation just hang in space. It makes a lot of sense that you look around at your friends and you say, why can't my life be like theirs? And you just let it hang out there.

A question from a pediatric practitioner. She said, what about patient families who are vaccine hesitant? And where, of course, that doesn't make a lot of sense to us as medical, you know, in the medical world. How do you, it's such a challenge. Yeah. So I think in both of these scenarios, where we're headed is we start by validating the patient or the parent's perspective. But of course, where we want to move to is bringing in the other side.

So if you can picture this sort of being a two-sided approach where there's a seesaw or a teeter-totter, and at the fulcrum is what we call the target behavior. So perhaps the target behavior is accepting a vaccination for your kid, or maybe the target behavior is getting on board with the procedure for you, the kid, your juvenile diabetes. In either case, we start by validating. Yeah, that makes, you know, I hear that from a lot of my patients, that concern about vaccinations.

Tell me more about that. Tell me more about your concern. Okay. And then maybe the person says, well, you know, my neighbors say that if I give my kid the vaccination, they'll get autism spectrum disorder. So then we want to say, yeah, I, I've heard that too. And what makes, what other considerations are there? What other things are there that you've heard about vaccinations? You hear more. And then of course you want to bring in, and this is the skill and this is what you're gently doing.

And then what are the arguments on the other side? Because I'm sure you've also heard people say, including physicians like me, you should get a vaccination. So what have you heard on that side? So there, what I've done, Holly, is I've invited them to start by telling me their hesitation with vaccinations. And then I've also, instead of telling them, yes, but there's medical science saying you should get vaccinations, I instead ask them.

So this is one of the real principles of motivational interviewing is if we can elicit or evoke rather than telling, that's what we want to do, especially on the side of change. So I want to say, what have you heard? What do you already understand about why people advocate for vaccinations? And then maybe the person will say, well, I don't know. I don't know. I've heard that scientists say it's important, but the people I talk to say that the scientists are paid off by the government.

So maybe that's what you hear in response. So then Holly, what you're trying to get to is what we call a double-sided reflection. So you say, let me see if I can summarize what you're saying. First and foremost, I can tell you want what's best for your kid. That's obvious. And hearing you talk, I hear that you're concerned about this question of vaccinations. On the one hand, you know that physicians and medical science really argue in favor of vaccinations.

And you respect that. I mean, you're here today coming and talking to a physician about your kid's health care. And I know from your chart, you've brought your kid in before for injuries and checkups and that type of thing. So you trust the medical system by and large. But on the other hand, you've heard some concerning things about vaccinations and whether it could actually be harmful to your kid. So I can hear that you're pulled in two directions. Where do we go from here?

So, Holly, what I've done there is try to convert this parent's resistance into ambivalence. And so it sounds like, so the number one, it's continue to ask questions, like think question before tell what to do. Yeah. Yeah. Absolutely. You want to reflect what you're hearing from them, show that their perspective is your focus, ask questions, which does, like you say, more of that, hearing more from them, hearing more back from them, making them hear that you understand their hesitation.

And then the trick is finding that way to introduce the other side of the argument where you're drawing it out of them rather than telling it to them. And then some listeners will say, well, who has the time though to draw it out? That just sounds, I mean, this sounds so great what you're saying. Yeah. So then, so what if the mom or dad then says, well, I don't want some foreign substance put into my kid.

Right, right. Then there's a number of ways to do this where you can kind of balance efficiency. So there's one thing that we call an amplified reflection, which is where, and this is a little bit on the more risky side. In general, motivational interviewing is a softer, non-directive, non-pushy approach. We really don't want the parent here to feel judged or pushed around, but we might say something like giving your kid medications is putting a foreign substance in your body.

But for you, that feels different than putting a vaccination in your kid's body. So there I'm kind of highlighting a discrepancy. They say they don't want to put foreign substances in their kid's body, but I know they put medications in their kid's body. So I say I reflect to them. You see it as a different thing. To give your kids medications developed by pharmaceutical companies versus a vaccination developed by pharmaceutical companies.

And then I might say, talk to me a little bit about that difference. So really, we're doing something here, Holly, that we call exploring ambivalence. And we can do it in ways that are a little more pushy, or we can do it in ways that if we have more time, kind of draw it out more slowly. And even the way, though, you said it, it didn't, To me, it sounded not at all pushy, but it sounds like it could be pretty incredible.

And I'll emphasize another sort of part of this, which is we don't always expect that where we're going to get to is the patient changes their mind. This is not a panacea. So a way I like to talk about it is if you've got a patient or parent who's very resistant to the change you're talking about, then a really nice, reasonable goal for the meeting is to get to ambivalence. Like I was mentioning earlier to where you can start with the patient saying, no way, Jose, I'm not doing that.

And at the end of the meeting, you're saying, so it sounds like you're definitely not going to do this today, but you've got some things that you're thinking about in terms of this decision moving forward. That's a really nice place to get. If the patient comes in and they're already ambivalent, then we really do have the goal of getting them to change. But with that person who's more on the resistance side, I think we want to support their autonomy and we want to demonstrate that.

And that in the long game is going to help us. So we're oftentimes saying things like, of course, this is totally your choice. Of course, it's up to you whether you do this. Of course, I'm in the role of a trusted advisor and I'm not here to push you around. And very often we'll notice a paradoxical effect where when the patient can tell that we're not pushing them, they'll actually be more liable to come around to change.

So even though the goal is for this child to get the vaccination or take the diabetes medication, exercise, and diet, you really have to be open to, still this child might not, the parent might not want that, but at least they're thinking about it. We're talking about it. The conversation is there. Yeah, that's right. They're exploring the ambivalence and they're exploring it openly with you as the provider in a way where they trust you to not try to push them.

And even so, I know that a lot of practitioners hear this, where the parent about vaccines. So, but it's my child. I mean, other people, if they want to get their kids vaccinated, that's fine. And this is just about my family and my child. Yeah. And I'd say absolutely. Absolutely. This really has to be your choice. This has to be a personal choice. And really, I see myself as a resource for you as you face this decision.

And I can tell it's an important decision for you. And I can tell that you're not taking this lightly. So, Holly, I think one of the things I'm trying to do right now is emphasize the sense of importance of the decision. I want to sort of find myself on the same page with the parent here saying, we both know this is a weighty decision. We both know that there can be big consequences on either side. And so I want to give you all the information you need to make this, to make a good decision.

And then Holly, I might say sort of, you know, in the spirit of efficiency, one way we can get in and represent the other side instead of drawing it out is maybe I say, I'm just meeting this parent for the first time. I sit down. Oh, I see your child hasn't had vaccinations. Shall we go ahead and set that up for today? And then the parent says, I don't want to do vaccinations. I don't want to put any sort of foreign substance into my child.

Then I might, if I don't have much time, if I have two or three minutes, I might say, of course, this is totally your choice. Of course, I can tell you want to do what's exactly right for your child. And I know you're aware that physicians and science recommend and the vaccination for your child. Help me understand a little bit your thinking on this. So what I've done there, Holly, is I've essentially attributed knowledge to the patient.

I've said, I know you're aware that science recommends this. Talk to me a little bit about why you don't want to go with that perspective. So I haven't said, I'm telling you you should do this. I'm saying this third party science is telling you that you should do it. So in a sense, as the provider, I get to stand on the sidelines of the fray and not become a part of this adversarial confrontation.

I get to say to the patient, you've got a bit of a challenge inside of your own head, and I'm here standing next to you, and I want to help you talk about that inner conflict you have or challenge you have between this perspective and the scientific perspective, but not between you and me. But that's what you're thinking, but don't say that. Okay. Yeah.

And I've heard the approach like for listening, where you repeat back the last few words that someone said, and then you, then you ask them the question like, okay, so you like candy for talking about diabetes. Tell me about what types of, of candy, how important is, how often do you, or do you recommend something like that in a time crunch? Like just trying to focus. Yeah, I think, I think, well, yeah, you're referring to the use of reflections, like saying back what the person had said.

And yeah, when you're doing motivational interviewing, I often say one of the best ways to know if you're doing motivational interviewing is, is to look at your conversation and, and ask, is most of what I'm saying a reflection? So, that's one of the real surprising things for people about motivational interviewing is that you're mostly doing reflections. Two-thirds of what you say should be a reflection.

And typically, Holly, what we try for is we'll do a reflection and we won't even put a question at the end of it. So, I'll give you a little example of how we could use a reflection that would still push the conversation forward. And again, I'll do one that's a little bit provocative sounding just to make

the point. So with this example with a kid, maybe who has juvenile diabetes and likes candy, I might say something like, having the sweets you like is more important to you than doing what's healthy. And that, I put it out there and just say it like that. And you can kind of feel, Holly, that it kind of sets something in motion in the air in between me and the kid. And it's going to set them, their mind thinking, gosh, that's kind of a provocative

thing. Is this true? And what we find is that when you do reflections like that, people tend to respond. They tend to talk. And we want to do reflections more than questions because questions feel to patients like it's about our agenda. Whereas when we do reflections, it feels to the patient like it's more about them. So part of the process of doing motivational interviewing and building skill in motivational interviewing is saying, how can I use reflections to accomplish conversational tasks?

I usually accomplish with questions. So, so for the, the child who has diabetes, when you set, you know, well, say he or she says like, well, no, of course I do want to be healthy, but I just, I also love candy and all of my friends eat candy. So I know I'm not supposed to, but I, I really want it and it's important to me, but I want to be healthy as well. Yeah. Yeah. Well, that's what we want to hear. Right. Because there we've got what I would call ambivalence, right?

So I might lock it in and say, I hear you. On the one hand, you absolutely care about being healthy and you want to be healthy. And on the other hand, you want to do what your friends are doing and you want to have fun and you want to eat candy when kids are eating candy. It makes so much sense. So I would try to lock that in as a double-sided.

And then where we might go with that is I might say, if there was a way that you could be healthy and feel like you're getting the sweets that your, that your friends get, you would want that most of all. And then maybe the child would say, well, yeah, I'd like that. And then maybe I could say, so you'd like to maybe explore some ways that you could stay healthy and also feel included and get those sweets. You want to help? Do you want to explore that with me? And maybe the kid would say, yes.

And then you would talk about sweets that you can have when you're a diabetic. Go through some of those. That's right. I might say, depending on how old the kid is, I might say, what are some ideas you already have about that? What are some things you already understand about things that you can eat, that you like, that are sweet and yummy, but that don't get in the way of the diabetes?

So always, if we can elicit from the patient, even when we're doing patient education, it's ironic sounding, but we still want to elicit. We want to say, what do you already understand about this? To the parent, tell me what you already understand about vaccinations, right? Right off the bat. What do you already, I hear you saying you don't want to do vaccinations. I'm sure you've got your reasons for that.

Tell me what you already understand and tell me if there are pieces of this puzzle that I can help fill in for you. bits of information that you want to know about vaccinations that you don't already know. And for the child with diabetes, you might be able to talk about at a birthday party, eating the cake, but not the frosting or something like that within, you know, whatever the, it's, I know it's different for every kid, but some sort of example like that,

if the, if the child do it. Yeah, that's right. That's right. And then to the extent that the kid is saying, well, I don't know at the birthday party, I don't think there are any good options. I think I do need to eat the cake or something like that, then we can get into talking about the sort of the ambivalence about it.

So it sounds like in that situation at the birthday party, fitting in with what's happening, having all the fun your friends are having is more important than attending to your health in that moment. It kind of sounds like that's what you're saying. And maybe the kid would say yes. And then maybe I'd say, and how would that play out? Like, is that something that you think is okay, that maybe you take a break every once in a while from following what the doctor says?

Or is that something that your parents and the doctor are going to have an issue with? So we just kind of explore the event as well as exploring alternative behaviors. And for the vaccine-hesitant family, I would want, you know, you probably would want to launch into, well, really, it's not just about your family. It's your neighbor, maybe their children or child cannot get vaccinated.

So you could be literally putting their health at risk, or you could be spreading measles around, you know, like how, is that the wrong thing though? If you're saying, how would you think that something like that? Yeah, exactly. Yeah. Yeah. This is perfect example, Holly, because there you want to bring in another thing, right? You want to kind of, you kind of want to assert that or challenge the patient, the parent with that, right?

But you should think about other people. Think about the effects it's going to have on other people. So this gets us back to this important point about. I refer to it as judgment and autonomy. The two things that motivational interviewing draws our attention to and says, you better watch out. You don't want to lose your rapport with the patient by making them feel judged or by making them feel pushed around or controlled.

So in this instance, Holly, there's the risk that the patient will feel judged, right? Like that the physician is saying, you're being selfish by not thinking about the other families around you who you could be getting sick by not giving your own kid the vaccination. So instead of setting it up, sort of as I was saying earlier, instead of setting it up as adversarial between you, the provider, and the parent, hey, parent, you should do it different. You're being bad.

We want to instead say to the parent something like, and I know you've heard this argument that you're putting other people at risk by not vaccinating. And I wonder what your thoughts are about that when you hear people making that argument. So you hear, Holly, I said, when you hear people making that argument, that's a way that I'm situating it outside of myself. I'm saying, I'm not saying this to you. I'm not telling you you should think differently. I'm saying you've heard this

argument that you should think differently. And I wonder how you think about that. And then what if the parent says, well, I think it's silly. I, of course, wouldn't want to hurt my neighbors and I'm not. It's just about my family. Yeah. Then, you know, always I'm coming back to trying to lead with validation. Like I can see why you're thinking that. And then is there an opportunity for reframing? Of course, you have to put your concerns about your family above all else.

And that makes a lot of sense. You care a lot about your family. I think an opportunity, Holly, that we often have with the vaccine one in particular is, you know, a statement like, if you learned today and you felt certain vaccinations are healthier for my kid than not vaccinating, I'm sure you would vaccinate your kid because what matters most to you is doing what's healthy for your family.

So I might throw that out there and see what they say. That's another example of one of those reflections that you just let it lie. So clearly, maybe I'll try saying it to you, Holly, and we'll see what you say as this imaginary parent. Holly, what I'm hearing as we're talking is that vaccination or no vaccination, I can tell that your family and the wellness of your family is really at the top of your list. It's really important to you.

If, for example, You learned something today that made you convinced that, wow, I can see that vaccinations are going to be healthier for my family. I think you'd probably choose to get the vaccination. You just haven't heard that information. You're just not clear about what the healthiest thing is. So what might you say, Holly? Yeah. Well, I think I know what's best for my family. You feel confident in what you've learned about vaccinations and their effects?

Well, I don't feel totally confident about it, but I feel like I've done research on my own. I don't need doctors telling me what to do. You're absolutely, I think you're right about this. You have to make your own decision about this. If there's a way that I can provide any more information about this to sort of fill out your understanding, I'd be happy to do that. Is there any piece of that puzzle I could help you understand even better? Sure. I would love the information.

Okay. And so let's say I provide you with this information and you sort of look it over and it's information that says science shows your kid should get a vaccine. And you look at it. What might you say then as this parent? So I'm being told what to do by all these scientists, and they don't know my family, and I know what's best for my kids. Ah, I'm hearing that on the one hand, it's very important to you to do what's right for your family, to do what's best for your kids.

But even more important than that is not being told what to do. Yes, I want to find out on my own. You'd almost rather do what's wrong for your family than do what's right for your family, but somebody else told you to do it. Well, no, no, no, that's not what I'm saying.

And I'm just kind of joking around with that, but I want to, I'm only half joking around with that because we're looking at this sort of scientific information. And honestly, Holly, the scientist inside of me is sort of saying, well, golly, this looks like objective factual information, but I'm gathering that's not what it looks like to you. No, I do think that was really, it's, it's powerful because it's almost, then there's not an argument. It's just more of a conversation.

And then I will know, I don't, that's not more important to me than the health of my family. You know, that, that my health, the health of my children and my family, that's the most important thing. Yeah. Yeah. And I mean, my style with this, Holly, I'll be, I'll, I'll be frank with you. I've had to learn this over the years. I, I, I use a lot of these kind of paradoxical or amplified little reflections that highlight the discrepancy in what the client is saying.

I think a lot of motivational interviewing practitioners are a bit softer with it than I am about that. And what they're always sort of emphasizing is understanding the clients, what's most important to the patient or the client, what the patient thinks they're able to do. Because oftentimes with health behavior changes, the patient doesn't feel confident they could do it. For example, with smoking. It happens all the time. And this actually happened

to me when I was a smoker, where I said, I don't want to quit smoking. And I rationalized it. But the truth was that I didn't think I had the ability to quit. So a real through line and motivational interviewing is validating people's uncertainty and vulnerability in the face of possible change so that they will open up and say, the truth is, I wish I could, but I don't think I can.

You know, or there's a reason pulling me to not make this that I haven't brought up and it's hard to talk about, but here it is. We very often are using softness to open up those little corners for people to come clean about why they're being resistant. And, you know, back to your point, Holly, about how much time it takes. Yeah, it is true that to a certain degree, to build a relationship with a patient,

it does take a little time. And as a physician, sometimes the way you do that is by seeing them every three months and you build a relationship slowly over time that way. There's no substitution for having a relationship if you're going to talk to somebody about a very vulnerable topic related to their change. One of the ways I sometimes teach motivational interviewing is I ask people, think about a change that maybe you should make in your own life.

And let's talk about that. And so, you know, I can talk about, well, I need to eat fewer breakfast tacos or I need to get better sleep or whatever. And Holly, I'm sure you would have one or two of those that you could bring up. But then I could say, now think about a change that you maybe should make in your life that you would not feel comfortable talking with me about. Right. And we all have those two, those things that we're too ashamed about to talk about.

And yet we make our patients talk about those things. I can tell you when I had a therapist for a while, I didn't tell him some of my darkest secrets, even though I should have. That's the stuff I should have been working on because I was just too ashamed. And that happens with our patients, I think, a lot. And motivational interviewing could be the key to getting that almost hidden information or information. Yeah. Yeah. That those hidden, hidden forms of resistance. I think we can maybe

think of those. Hidden forms of resistance. So, so did the motivational interviewing, did that help you to quit smoking, David? Actually, no, it wasn't. I wasn't really aware of MI at the time, but I did have to quit in my own way, you know, sort of in my own style, in my own way. I did learn that. What got you interested in MI? Well, thank you for asking that. It's, you know, I was really focused on psychotherapy approaches for schizophrenia for the first half of my career.

But then here at UT, I'm in a clinic called the Transitional Care Clinic in the Department of Psychiatry.

And I really got steeped over the course of several years in working in a sort of a public-facing outpatient community health setting and seeing how across the different types of encounter types and the different provider types, a very common theme is, can I engage this patient in care in a way that they're really meaningfully and motivated to sort of be involved and really feel that they have skin in the game?

And that felt to me increasingly like the most important factor in the healthcare I was involved in. And motivational interviewing is a single tool that we can use across gobs of settings to address exactly that challenge. And so I really dropped everything I was doing and totally pivoted towards learning and sort of disseminating motivational interviewing. Oh, that's great. The transitional clinic, what is that? Can you explain what the question is? Sure.

This was established in 2012 with the mission of engaging patients who have recently presented to the psychiatric emergency department, a range of area hospitals, and or have been hospitalized on the psychiatric inpatient unit. And now these patients are ready to be discharged back into the community, but they don't have an established provider team in mental health or behavioral health. And it can take six months.

Even if you have Blue Cross Blue Shield, it can take six months to get a psychiatry appointment for the first time. So the transitional care clinic was established to have a sort of a wide open front door for these people being discharged from inpatient psych or triage from the emergency department. And we take them in. We quickly establish them with care, give medication management,

counseling, case management services. And then over the course of three to six months, we help them find long-term care in the community and we discharge them out the back door. Do you see adults and kids or adults only? Yes. Well, so just in the last three years, we now have established a clinic that sees adolescents as well. So we have a sister clinic, a partner to the TCC that's called the NOW Clinic. NOW is New Opportunities for Wellness.

And that clinic is open to the public of Bexar County. It just has the mission of helping people of Bexar County get access to mental health services. And as of two years ago, we also have adolescent services there. And our services are free to anybody who's uninsured. And we do regular billing for people who have insurance. I want to have the director on the show as well. It looks amazing.

And I saw for the adolescent clinic, there's even dogs that are part of the therapy and they're on the website, the NOW website. Yeah, that's right. Yeah. We have somebody, Meredith Stensland, faculty member here who established this pet therapy program. The dogs are always walking around between all of the clinics. In fact, I've got a card for one of them that I'm looking at right here. They all have their own little sort of like baseball cards where it says the

name of the dog and the breed and their little characteristics. It's very cute. Wow. So, David, it sounds like you utilize motivational interviewing with every patient. Yes, that is correct. At the point of engagement, finding the motivation, every patient, more and more in healthcare, including in primary care and in pediatrics, we're less and less focused on infectious disease and accidents and more and more focused on health problems that are linked with our health behavior choices.

So it's not really acceptable to sort of say, you know, I'm going to go ahead and have you start exercising three days a week and come back in a year, because we know that the patient isn't going to do that unless we provide more.

So we more, more, and more have to scaffold our prescriptions with some sort of behavioral technology to get them to do the stuff. Do you do one-on-one coaching with providers, like kind of how we're doing this today? Yeah, we do. We do one-on-one and group-based coaching. That's kind of what we were touching on at the beginning. To give providers ongoing practice, we have a calendar through our training platform where we have coaches throughout the week who have session times.

And you can just show up for the sessions if you happen to have a no-show or an available hour. That's great. So is there a common mistake with motivational interviewing that you want to mention?

Yeah, I would say that the most common mistake is what we call premature focus or premature planning, where somebody will have a health problem and they'll be kind of stuck about it. Like me with my breakfast tacos. I eat breakfast tacos on the way to work too frequently, too many days a week I do that. And the problem is if I come in and sit down with a provider and they start saying, well, hey, let's fix this.

How about you drive a different way to work? How about you eat oatmeal in the morning before leaving your house? How about you leave your wallet at home so you can't get the tacos on the way? And from an MI standpoint, that's premature. That's launching into sort of a concrete problem-solving approach that is likely missing the point. My problem is not that I can't come up with an idea for how to not eat tacos.

That's not the problem. The problem is something inside me about my motivation and how I talk to myself. So the mistake is going into cutting up with a concrete, literal solution as if the person didn't understand what steps to take when actually it's a motivational issue. So then what would happen next with the taco scenario? you?

Well, what would happen, I would be annoyed if the physician was like, oh, let's make a plan for you to take a different route where you don't drive by Taqueria, Jalisco. I'd be annoyed. I'd say, well, do you really think I didn't already think of that possibility? So I think what I would advise instead would be exploring my ambivalence. And the way to do that, if you have five minutes to have a conversation about somebody's ambivalence, what I would recommend is the acronym DARN.

That stands for desire, ability, reasons, and need. So those are what I think of as sort of the four natural categories of intrinsic motivation. So I think David Roberts here is having a problem with eating tacos, and he's intrinsically too motivated to eat those tacos and not motivated enough to resist. Desire, ability, reason, and need. Desire refers to the feelings I have about it.

Any feelings at all that pull me toward the tacos are away. So I would want my provider to say, tell me how you feel about the tacos. Tell me how you feel when you eat them. Tell me how you feel when you don't eat them. Tell me what the urges feel like. I would explore that. Desire, ability, reason, and need. Ability is if you decided you wanted to quit the breakfast tacos, how confident are you that you could do it? Where 10 means I'm 100% confident, and one means I'm not at all confident.

So we would explore my confidence because very often people want to make a change, but they don't try because they don't feel confident they can. Desire, ability, reasons, and need. Reasons are the why. Why would you quit the tacos? And need is how important is it to quit the tacos? You want to get that question. And how important is it to you? And is it every day you don't feel you should be eating the tacos? Well, that's the thing, Holly, is it's not that important to me to never eat tacos.

And so that's one of the main reasons I keep eating them, is the importance of quitting is not high enough. I think ideally I'd have them one day a week, but five a week is way too often. you. So then next, what would you say? Like, so what I'm hearing is that once a week is enough. So how do you feel that you could do that? Yeah. Oh, so, so, uh, yeah, Holly, that's really good example of that question. How do you feel you could do that?

That I think is not a bad question, but it shows that thing I was just referring to that little bit of a bias toward planning the concrete procedure, how could you do it one day a week? Whereas in MI, we're a little more interested in what would it feel like if you were doing it one day a week? How confident are you that you could do it one day a week? Remind me, what are your reasons to do it one day a week? And exactly how important is it to do it one day a week instead of five days a week?

We're more interested in those questions than in sort of how you could do it. So in that case, I should have just focused on reflecting back? Yeah. Yeah. You can reflect back or you can ask those darn questions. So you can reflect back, this is important to you. You can reflect back, you want to do this one day a week and you're looking for, you're looking for the motivation to do it one day a week. Or you can say, tell me more about why it's important to reduce it.

And then, so say there's five other patients and five other exam rooms waiting, and I'm trying to get to the, like, wrap up the conversation about the tacos, then how would you close but do it with care and try to accomplish what you're trying to accomplish? Yeah. Well, so if this patient, David Roberts, was very sort of resistant around the tacos, I would try to wrap up with reflecting ambivalence.

If, if instead this patient was ambivalent about tacos, I would try to wrap up with a plan for action. So let's just say I was ambivalent that I'm like, yeah, I need to get a handle on this breakfast taco thing. It's just, I never seem to really keep momentum, but I really wish I could, but I don't know. So then if I'm wrapping up the session, I might say something like, let me see if I can summarize where you're at with this, Mr.

Roberts. On the one hand, it's not a huge issue in your life And it's okay with you that you're still eating some of these tacos And you love tacos and you have the urge in the morning and it's not the end of the world On the other hand, you came in here today and you brought it up with me and said, hey, If I'm gonna make one health change these days, it is the tacos The tacos are something that I'm kind of ready to really take a hard look at So Mr.

Roberts, I guess, where do we go from here? What's the next step? That's probably how I'd end that.

That's great. So what about this scenario where there's a parent in the exam room with their child and they're saying to the pediatrician, like, I just can't get Andrea to help around the house. She won't do anything to help. And it's so frustrating. I love my daughter so much, but this is just, it's so hard.

Yeah. So this is interesting. This is, of course, we've exploded the complexity of it because now we've got both Andrea, the daughter in the room, and we have the parents in the room, right? And we're sort of, the question is, are we going to change the parent's behavior? Are we going to change the kid's behavior? Are we going to do a little bit of both?

I mean, what sort of jumps to my mind is that the parent hasn't set up the incentive structures within the home to cause the child to help out around the house. And so if I'm just meeting with that parent one-on-one, I might be interested in exploring. You know, on the one hand, it sounds like you'd really like Andrea to help out around the house. On the other hand, it sounds like you're not comfortable requiring her to do that. I might start with that.

I do want to require her to do that, but it's just not working. She just won't do it. I see. So what you're telling me is that you're putting the requirement in place and she's not doing it and she's comfortable with the consequences of not doing it. She just keeps doing it and keeps getting the consequences. I don't think she's comfortable with it. But a lot of times I don't give her consequences. I see. So you're kind of thinking I could give her greater consequences.

I could increase the negative consequences of her not helping out. Or you're thinking I could come up with more reinforcers for her to do it, more, you know, treats or kudos for her to help out. Or maybe you're thinking of something else. Well, she's just, she's under so much stress. And she says like none of her friends have to help out at home. I see. So I don't push it. I see. You want to be kind of, you want to be compassionate toward her.

You don't want to overstress her and overburden her. On the other hand, there's a part of you that thinks it's reasonable to expect this. Yes. Me too. So that's kind of a, that's a little bit of a pickle you're facing. That's a bit of a tricky choice you're facing. You could choose to make the consequences of her not helping out actually substantial enough that they affect her behavior, but that might stress her out.

On the other hand, you could let things ride the way they are, help her not be as stressed, but you'll still be frustrated with her not helping out. Yes. I mean, sometimes it just feels easier just to let her watch TV. Right. Well, you know, let me ask you this, Holly. Like, if you decided, you know what, I want to make the choice of putting the consequences in place that are severe enough to change her behavior, how able do you feel to actually carry that out from 1 to 10?

Where 10 is, oh, I'm 100% sure I can put this structure in place in the household if I chose to. And 1 is, I do not think I could implement this. I feel quite confident I could do it But I don't know if I'm giving the right consequences So maybe 10. So you feel confident that you could put a structure in place, but you're not confident that you could kind of design the right incentive structure to make it work. Yes. I don't think I know what are the right consequences in this case.

And if you had help to put together an incentive structure by somebody who maybe had experience or knew what they were doing, would you want that? Would you, would you like snap that up and definitely do it? What are your thoughts on that? Yes, I would love to. I mean, I had, I think there was one parent telling me that they, the child shouldn't come to the dinner table and eat if they're not going to help set the table.

It's a, it's a privilege. We all need to help out, but that seems kind of cruel. So I don't want to be harsh. Yeah, I really can tell you don't want to lose sight of the love and connection you have for your daughter and attending to her stress level and all those things. You want to be fair and you want to be kind, but you also want her to be growing up responsibly and turning into an adult and helping out.

Yes, it's such an important lesson in life. And I know my parents instilled that in me and it's helped me so much. Yeah, it sounds like I'm hearing you say that you really do want to implement an incentive structure of some sort, that it really would be worth it as long as you can find the right level that's not too punitive. Yes, I would love that. Oh, okay. And then we can sort of, Holly, from there, I think we were going to just the question of me connecting you with that resource.

Okay. So finding something that you know, or if you know the answer, go ahead and say it, or is it better to print it out and give it to the patient in this case or the website or something? I think that that really depends on my read of the patient and if they have the wherewithal to do it themselves. If they're sort of maybe struggling or if they're lower functioning or if they have way too much on their plate, I might scaffold them and give them the sheet and walk through it with them.

If they seem really capable of doing it and really motivated, I might just point them to it. Okay, great. I know you have a patient. I have a couple more questions from clinicians.

You can do a couple more. Okay. Okay, so this doctor asks, and she says, thanks for thinking of me, what are the best ways to break the ice when starting an interview?

Well, I think a really good one, which I alluded to earlier, that kind of serves the dual purpose of being agenda-focused and also letting the patient do the talking is to say, I'd love to hear from you today your thoughts on X. And if it can, if you don't have much time and you want to get right into it, hey, I see that we've got, I'm looking at your chart. I see there's the question of the diabetes. There's a question of how things are going at school right now.

There's a question of your leg. I know you got that injury playing soccer last year or anything else you want to talk about. Where do you think we should get started? So that's a way that we will often do it is we'll list two or three things that are on our agenda that we want to talk about. And then we'll say, or anything else, what would you like to talk about? And really open the door wide open. That's one way to do it. That's great.

Another practitioner says, I think I really need a whole course on this. If he has any good suggestions, anything would be great. And I know we've talked about so much here. It's nearly impossible for us to do this with our time constraints though. Right. Right. Let me just double down on what I sort of think are maybe a couple of the really core things I would want to convey. One is, if the person, thinking of this person, think of what is the target behavior?

What is the change I'm hoping to help this person make? Take the medication, start exercising, eat more vegetables, do the vaccination, whatever it is, and then say to yourself, as I'm starting talking with this patient, are they more on the resistant side or more on the open side? Okay. And if they're on the resistant side, your goal is to validate. Show them that you're really listening to the source of their resistance, validate that, and then get to what we call the double-sided reflection.

The double-sided reflection is, on the one hand, I know you don't want to do this. And on the other hand, I hear there are those things pulling you toward considering doing it. Okay? So that's if the person's mainly on the stuck. And if the person's mainly on the change side, you want to evoke it as always. And then you want to reflect. It sounds like you're sort of leaning toward this. And then you want to try to elicit a change plan from them. Where do we go?

Where do you want to go with this what sort of step or action do you want to take that and then the other thing i would emphasize is darn desire ability reason and need exploring the person's motivation how do you feel about this possible change if you wanted to change how able do you feel to do it what are your reasons pulling you to do it or not do it and how important is it desire ability reason and need.

And everything that you just said, the final question I was going to ask is a lot of doctors get, the parent has looked at Dr. Google or chat PC and they feel that they're right about it. So that takes a lot of time. Do you have any advice there? So for when a patient maybe has consulted like Google doctor and maybe has some misinformation, is that kind of what you're saying?

Yes, they've done their Google searches or found, you know, other places they have misinformation and they think they're right about it. Yeah. So that gets into this territory that we call psychoeducation or I guess just education. In psychiatry, we call it psychoeducation. Education, patient education. The principle, so we have a principle called illicit, provide illicit.

So when the patient, when you want to give some information, like to disabuse them of some incorrect information or whatever, we start out by eliciting. What do you already understand? I can tell that you've already done a lot of research. That means this is important to you. I'm glad that this topic is important to you. I think it's an important topic too. So validating, right? Then what have you already learned? What do you already understand?

Draw it out from them. And then the question, how can I flesh out this puzzle for you? What pieces of the puzzle might I help you put together? What don't you know that I could provide you? So I'm really an information resource. And then if I hear some blatantly incorrect information, I might say, hey, some of the information you shared with me is inaccurate or some of it doesn't fit with the scientific research. Would you like to hear that?

So then offer to give corrective information. Don't shove it, but offer it. And then if they say, no, I'm good. Yeah. Then we say, of course, it's up to your choice. It's up to you to make decisions on the basis either of the facts or whatever other information you want to go on. Of course, you have to make your own decisions. I'm here. Should you decide to include sort of a factual or scientific basis in your decision-making, I'm here for that.

David, this is so insightful. It's such an honor to talk to you.

Is there anything you wanted to mention right before we wrap or have we we covered i think we've done we've done a really nice smorgasbord i really appreciate how you float around with me with these different topics and yeah if anybody has any interest in learning more about motivational interviewing and especially practicing any of this i would just encourage them to reach out to me either with the link or with my email david roberts here at utesca and

we will be doing an interview for our Pediatrics Now for Parents podcast that that can be found wherever you listen or pediatricsnowforparents.com where you could tell your patient, a parent who comes to you, my kid won't help with the dishes. You could listen to that episode. So we'll do that when you have more time, David. Wonderful. That sounds great. Okay. So Dr. David Roberts, an expert on motivational interviewing. Thank you so much for being here today on Pediatrics Now.

Thanks, Holly. It was wonderful. I had a great time.