In this episode of the Move to Value Podcast, we continue the conversation about Motivational Interviewing with Sebastian Kaplan, PhD, who talks in greater detail about Motivational Interviewing, touching on empathy, provider burnout, and optimal patient care.
Dr Kaplan has additional Motivational Interviewing resources available here: https://www.guilford.com/author/Sebastian-G-Kaplan
If a provider would like to incorporate MI into daily practice, where would a good starting point be?
Well, a few places to start. I mean, if people like to read, obviously there’s a lot of books out there on motivational interviewing. The two main authors are the founders of MI are William Miller and Steven Rollnick, and they have written many of the texts out there. And its now, the main motivational interviewing text is now in its third edition. They’re in the process of writing the fourth edition currently. And so that’s, it’s a great book. It’s not overly jargonized or dense with all kinds of statistics. It’s a really approachable, easy read. Guilford Press is the one that is the publishing company that has the majority of MI books out there. Both in general and kind of a general sense, but also there’s, like there’s an MI in healthcare book that’s out there. There’s MI for all kinds of, you know, applied settings and problems. So, that would be one.
The other thing though, and is to find a MI trainer, you know, like myself. Or there’s a, we have a website, motivationalinterviewing.org. And on that website, there are, you know, hundreds and hundreds of trainers all over the world and you can reach out to somebody and we’re a very friendly, you know, friendly bunch and we’d be more than happy to steer people in the right direction.
A lot of people go to a workshop, you know, one-day or two-day workshop. You know, I think there’s a lot more flexibility in training now with Zoom kind of experiences and that sort of thing. But, and so, there’s some reading, a workshop would certainly be useful. But ultimately what we know about training, there’s been some studies done on the training of motivational interviewing specifically, is that for those people who really want to get it and really want to develop proficiency with MI, what’s most needed is somebody who listens to samples or examples of MI conversations that the learner is trying to do and giving that person feedback. You know, getting that coached feedback is really the key.
What is the righting reflex and how can we avoid that trap as a provider?
Yeah, so the righting reflex, this is something that Miller and Rollnick came up with, you know, as far as a term. And righting it’s helpful to know is r-i-g-h-t, so like the word right, to get it right, or to do right. So, the righting reflex. And it is, it comes from a very well-intentioned place. Any healthcare provider, or not any, I would imagine the vast majority of healthcare providers went into whatever field of specialty that they’re in at some level because they wanted to be helpful to other people. And over the course of our training and our experience, we probably know a lot about what is helpful for humans to be healthy. And so, what the righting reflex is, is when is the potential for any healthcare provider to jump in really quickly in a conversation with all the reasons why a person should make a change. And really kind of focusing solely on that information giving, or the sort of encouraging and cheerleading and all those types of things, that are, that still kind of maintain that traditional hierarchy of expert, patient, you should change because I’m giving you this information or because I’m telling you slash encouraging you. So that’s really what the righting reflex is. It’s not a, you know, a bad quality or characterological flaw. It is the tendency for us to want to be helpful and sometimes to kind of rush into that without really checking in first where the patient is in terms of their change process.
What are some roadblocks to watch out for when getting started with MI?
Well, so some roadblocks to get started. One roadblock would be, and this might be a situation where its actually harder for someone whose more experienced because they have had a lot more time to really like dedicate themselves to asking questions. And so that shift from question-centric conversation to reflection-centric conversation, that’s a real challenge. You know, Nurses, physicians, in particular that I’ve found just have a hard time making that shift because their so well trained to ask all these excellent questions. So that would be one.
I would say, you know, another trap is, you know, sometimes people will, even if they get the kind of change in style when using reflections initially, they, when it comes time to like talk about change itself and what “needs to happen for the patient to get better” it’s really easy to slip back into that here’s what you need to do kind of mindset. Now a provider might do it in a friendlier way, you know, a much more gentler, compassionate style. They might do it in that way. But, you know, it can be so easy to slide back into the ok and you know we know what you need to do now, right, so you need to do x, y, or z, and kind of leaving out the evoking style, drawing out from the patient what their ideas are about it.
Another thing that could be challenging is if you are working with patients and you’ve started to change your style, they may not be used to that. And so, it would be something where you kind of need to be patient with yourself, patient with the patients, as you’re adapting and adjusting your style because they might be more used to you being more of that expert in the room.
Is MI considered a best practice for optimal patient care?
Yeah. I’m glad you brought that up actually. You know, so yeah, that, as far, I was thinking more kind of barriers within the provider in a way, and you know that kind of sort of environmental or systemic barrier for sure would exist. You know whether it’s feeling like you don’t have enough time because you have, your primary care doc has, what, average of 7-9 minutes per patient. And so that’s another thing that, you know, we feel like if we don’t have that much time, well we don’t have time to sit and reflect on somebody’s story even for 1-2 minutes. Or maybe feeling like, you know, that they would need to have a lot more time to use that reflective listening style. And what we find, more so anecdotally certainly, is that there can be a lot of efficiency that comes with using motivational interviewing.
You know, if I spend 3 minutes telling a patient how they should change without finding out what their experiences are with change, or where they’re at with change, or what their thinking about change, I perhaps have wasted 3 minutes because maybe they know exactly what I’m already saying. Maybe they have tried these things and it hasn’t worked. And I should know that before lecturing them on it. And maybe they’re just not ready for change, and the conversation would be more helpful to be focused on that kind of exploring what would help them get ready to change as opposed to how to change. And so, we sometimes under the time crunch that many healthcare providers are in, we kind of you know unwittingly waste time actually. Because we want to, you know, get the job done, get the patient in and out. So that would certainly be another barrier is the time pressure, for sure.
You mentioned empathy in healthcare in your Move to Value presentation. Can you speak more on how empathy and motivational interviewing play a role in providing effective care?
Right, so the word empathy is you know, it’s one of these words everyone kind of knows what it means. Although it’s also easily confused with other words that are similar, you know, sympathy and compassion and things like that. So empathy, the way I think about empathy, the way I teach you know students and residents about empathy, is that it is a non-judgmental understanding of another person’s experience. It’s as if you are putting yourselves in another person’s shoes or seeing the world through another person's eyes. And that’s a, I’m quoting Carl Rogers there, a famous psychologist from previous century.
So, that is, the experience of empathy internally for the provider, the key thing with MI though is what we are trying to do is express it, express that empathy verbally. And that’s where the reflection comes in. So, a reflection, again, it invites a person to move on in the conversation, but it’s also a way, it is the way to express empathy. Questions are great but they don’t express empathy. And we know from a lot of different research, not just research on MI but researchers have looked into the impact of empathy in health care. Not just in, you know, mental health settings but in primary care settings and you know all kinds of other settings. And the more that patients rate their providers as empathic, the better outcomes. Whether its health outcomes or patient satisfaction scores or increased comfort and confidence in talking about difficult topics.
So, empathy in healthcare, is it’s one of those things that its, across specialty, you know, it’s just something to seems to really enhance the healthcare experience. And empathy is a real central part of motivational interviewing. You know, again, like that reflective listening is a way to communicate that kind of human experience. And you know, human beings really appreciate being heard, and listened to, and not being judged. And by the way, it’s important to note we’re also not saying that we necessarily agree with everything that people choose to do. You know, so I can talk with a young, you know let’s say a teenager who harms themselves. Right. Really concerning behavior. Concerns a lot of adults. They’re usually quite upset about different things in their life. And I can express a non-judgmental understanding about this kid’s experience and even about the ways in which harming themselves is helpful at some level. That doesn’t mean I endorse it, or I approve it, or I encourage it. But I can express an understanding of how that’s something that they’ve resorted to at this point. And also, curiously explore with them what they think about change and what other ways they might consider taking care of themselves. It’s a bit about empathy there.
Anything to add to conversation?
I guess it’s maybe addressing what is the most common challenge or barrier to go back to that question. And that is the concern about time. Is there enough time? Probably not. It certainly doesn’t feel like there’s enough time. Burnout is, for better or for worse, is, you know, well it’s for better in terms of we have shined a light on the problem of burnout in these last few years and COVID only you know brightened that light. So, and one of the sources of burnout for healthcare providers is just being on the hamster wheel and the lack of time and the pressure to do all this other stuff that they don’t feel is related to actually sitting down with people and helping them. And so, a lot of people I train are concerned about not having enough time.
And I guess, first of all, I’m not here to say that that’s make believe. So, starting there. But I guess then the question is in the time that you do have, what are the ways that you can maximize it? And because what a lot of people think that they need to do in the short amount of time that they have is they need to get to the punch line where they deliver the answer. And I would imagine any healthcare provider that is listening to this would connect with or agree with the idea that if the patient doesn’t leave that office with an intention or any kind of enhanced motivation to follow through on the wonderful ideas that were likely shared, then you know did that period of time, however long it was, did that serve a purpose. And if you, it doesn’t require a 45-minute conversation. In many instances, it can all it can take in many instances, and there’s evidence to suggest that, you know, MI is a brief intervention that only really needs a few sessions or a few conversations to show greater change than maybe more traditional methods. To just act as if you have more time and to almost take a breath and slow down, listen for a little bit, draw out what the other person’s ideas are, and then there’s an opportunity to share ideas that you have provided that the patient is open to hearing them and doesn’t have ideas of their own. And that is something that can be done in a relatively brief period of time. And what you are also doing, especially for providers that see patients repeatedly over time, is you’re starting to establish that relationship where the person is going to be happy to come back, and likely more open to share, and you know building kind of that long-term relationship that can help with change as well.