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Motivational Interviewing in Pediatric Dentistry– Part 2
Lisa J. Merlo, Ph.D., M.P.E.
Assistant Professor
University of Florida
Department of Psychiatry
**Thanks to Thad Leffingwell, PhD for his contributions to the slides
Objectives
Review fundamentals Introduce Rolling With Resistance Practice MI-adherent advice-giving Introduce MI protocol for prevention of
early childhood caries Practice using relevant patient
scenarios
4 MI Fundamentals Express Empathy!!!
a la Carl Rogers (important for all ages!)
Roll with Resistance Underscored by psychological reactance (CRUCIAL with
teens)
Develop Discrepancy Dissonance – person becomes motivated to reduce
discrepancy (younger the patient, the less useful this is)
Support Self-Efficacy Builds on expectancy theory – increasing confidence
increases intent to behave (especially with kids)
4 Principles: Video Example
http://www.youtube.com/watch?v=SnFIR6KBsAo
Write down a few striking statements you hear from the “patient”
What are example responses that would highlight each of the following principles? Express empathy Develop discrepancy Roll with resistance Support self-efficacy
Specific Behaviors MI-Adherent (Prescribed) Behaviors:
Seek permission to add target behavior to agenda
Evocative questioning Empathic reflective listening Other MI-consistent behaviors
MI Non-Adherent Behaviors Confronting Advising Over-directing
Seeking Permission
Demonstrate respect for autonomy and desire for collaboration immediately
Ask for permission before transitioning to discussion of target behavior Do you mind if we spend a few minutes today
talking about fluoride? If you don’t mind, I would like to spend a little
time today talking about the impact of sugary snacks on oral health.
Other MI-adherent Behaviors
Affirm and support the patient Reinforce good choices/ideas with praise and
encouragement Offer statements of compassion or sympathy
Emphasize choice, autonomy, or control Be explicit about your respect for the patient’s
choice “It is up to you, nobody can make this decision for you.” “You know your child better than anyone.”
MI Non-Adherent Behaviors
Confrontation Avoid disagreeing, arguing, correcting, shaming,
blaming, criticizing, labeling, moralizing, ridiculing, etc. Often turn conversation into a wrestling match
Advising (without permission) Language usually includes words such as: should, why
don’t you, consider, try, how about, etc.
Over-directing Commands, orders, imperatives You should, you must, etc.
What should MI NOT look like?
Evidence of disapproval of or disinterest in client Wrestling, not dancing Few reflections Advising or educating without permission Many closed-ended questions Confrontation of resistance Clinician cannot accept that patient might
choose to not change
http://www.youtube.com/watch?v=3xrEaFPbYC8&feature=watch_response_rev
Video Example
Patient Resistance
“Resistance” results from the interpersonal interaction between clinician and patient, not some personality flaw of the patient!!!
It should feel like a dance, not a wrestling match
Try Changing YOUR Approach
Try LISTENING instead of LECTURING
Express EMPATHY, not ACCUSATION
Focus on the BENEFITS of change, rather than the CONSEQUENCES of not changing
Handling Resistance Simple Reflection—Acknowledge the patient’s point of
view
Amplified Reflection—Reflect back what the patient has said in an exaggerated way (but without sarcasm)
Double-Sided Reflection—Acknowledge both sides of the patient’s ambivalence by pulling together information the patient has offered throughout the visit
Shifting Focus—Shift the patient’s attention away from the issue that you’re stuck on; move on to something else
Handling Resistance
Reframing—Acknowledge the validity of the patient’s perspective and observations, but offer a new meaning or interpretation
Emphasizing Personal Control—Communicate to the patient that it is his/her decision whether or not to make a behavior change
Coming Alongside—Agree with the patient that this may not be the best time/way to change. Often, when we take the negative side, the patient will then respond by presenting the more positive side of change
The key is:
Always try to avoid the “yes, but…”
What should MI look like? Evidence of empathy Evidence of supportiveness Dancing, not wrestling More reflections than questions Ask permission before advising or educating Most questions are open-ended Clinician can accept that patient might choose
to not change
http://www.youtube.com/watch?v=f8QSA_5PEFM
Video Example
Offering Advice & Setting Goals
Elicit-Provide-ElicitThroughout the MI encounter, we use the E-P-E
strategy It can be particularly useful when offering advice or
suggestions, especially with youthE-P-E refers to:
eliciting information/ideas/opinions/feedback from the client
then providing information/ideas/opinions/feedback to him or her
Then eliciting his or her ideas/opinions/feedback in return
For example:Open question Reflection Open questionAsk Permission Offer Advice Ask for feedback
Offering Advice
Ask Permission “If you’re interested, I have some ideas for you to
consider. Would you like to hear them?” “If you’d like, I can tell you about some things that other
people have tried successfully. Would that be okay?”
Offer Advice “Based on my experience, I would encourage you to
consider ________________ .” “Given what you’ve told me so far, I think you might
have some success if you tried __________________ .”
Offering Advice (cont.)Emphasize Choice “And I recognize that it’s your choice to do so.” “Of course you know best what will work for you.”
Voice Confidence “I’m very confident that if there comes a time when you
make a firm decision and commitment to ___________, that you’ll find a way to do it.”
“I strongly believe that you could accomplish __________if you put your mind to it.”
Elicit Response “What do you think about those ideas?” “I’m interested in hearing your thoughts about these ideas.”
Developing a Change Plan
Patient and clinician work together to develop a reasonable goal
Goal should be broken down into manageable, behavioral steps
Patient and clinician complete Goal Statement worksheet
End with a quick summary of the session and thank patient for his/her participation and willingness to work together
Pulling It All Together
1. Give a brief structuring statement
2. Use open-ended questions
3. Listen reflectively
4. Elicit change talk
5. Affirm and support wherever possible!
6. Summarize periodically
Remember: Learning MI is like learning to play the piano
You must practice, practice, practice!
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