1. 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

2. 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

3. 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. 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

5. 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

6. 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.

7. 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.”

8. 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.

9. 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

10. http://www.youtube.com/watch?v=3xrEaFP bYC8&feature=watch_response_rev Video Example

11. 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

12. 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

13. 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

14. 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

15. The key is: Always try to avoid the “yes, but…”

16. 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

17. http://www.youtube.com/watch?v=f8QSA_ 5PEFM Video Example

18. Offering Advice & Setting Goals

19. Elicit-Provide-Elicit Throughout the MI encounter, we use the E-P-E strategy  It can be particularly useful when offering advice or suggestions, especially with youth E-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 question Ask Permission  Offer Advice  Ask for feedback

20. 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 __________________.”

21. 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.”

22. 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

23. 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

24. Remember: Learning MI is like learning to play the piano You must practice, practice, practice!

25. RECOMMENDED READING:

26. Questions? lmerlo@ufl.edu www.motivationalinterview.org www.motivationalinterview.net