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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

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  • Motivational Interviewing in Pediatric Dentistry Part 2Lisa J. Merlo, Ph.D., M.P.E. Assistant ProfessorUniversity of Florida Department of Psychiatry

    **Thanks to Thad Leffingwell, PhD for his contributions to the slides

  • ObjectivesReview fundamentalsIntroduce Rolling With ResistancePractice MI-adherent advice-givingIntroduce MI protocol for prevention of early childhood cariesPractice using relevant patient scenarios

  • 4 MI FundamentalsExpress Empathy!!!a la Carl Rogers (important for all ages!)

    Roll with ResistanceUnderscored by psychological reactance (CRUCIAL with teens)

    Develop DiscrepancyDissonance person becomes motivated to reduce discrepancy (younger the patient, the less useful this is)

    Support Self-EfficacyBuilds on expectancy theory increasing confidence increases intent to behave (especially with kids)

  • 4 Principles: Video Example

    Write down a few striking statements you hear from the patient

    What are example responses that would highlight each of the following principles?Express empathyDevelop discrepancyRoll with resistanceSupport self-efficacy

  • Specific BehaviorsMI-Adherent (Prescribed) Behaviors:Seek permission to add target behavior to agendaEvocative questioningEmpathic reflective listeningOther MI-consistent behaviors

    MI Non-Adherent BehaviorsConfrontingAdvisingOver-directing

  • Seeking PermissionDemonstrate respect for autonomy and desire for collaboration immediatelyAsk for permission before transitioning to discussion of target behaviorDo you mind if we spend a few minutes today talking about fluoride?If you dont mind, I would like to spend a little time today talking about the impact of sugary snacks on oral health.

  • Other MI-adherent BehaviorsAffirm and support the patientReinforce good choices/ideas with praise and encouragementOffer statements of compassion or sympathyEmphasize choice, autonomy, or controlBe explicit about your respect for the patients choiceIt is up to you, nobody can make this decision for you.You know your child better than anyone.

  • MI Non-Adherent BehaviorsConfrontationAvoid 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 dont you, consider, try, how about, etc.

    Over-directingCommands, orders, imperativesYou should, you must, etc.

  • What should MI NOT look like?Evidence of disapproval of or disinterest in clientWrestling, not dancingFew reflectionsAdvising or educating without permissionMany closed-ended questionsConfrontation of resistanceClinician cannot accept that patient might choose to not change


    Video Example

  • Patient ResistanceResistance 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 ApproachTry LISTENING instead of LECTURING


    Focus on the BENEFITS of change, rather than the CONSEQUENCES of not changing

  • Handling ResistanceSimple ReflectionAcknowledge the patients point of view

    Amplified ReflectionReflect back what the patient has said in an exaggerated way (but without sarcasm)

    Double-Sided ReflectionAcknowledge both sides of the patients ambivalence by pulling together information the patient has offered throughout the visit

    Shifting FocusShift the patients attention away from the issue that youre stuck on; move on to something else

  • Handling ResistanceReframingAcknowledge the validity of the patients perspective and observations, but offer a new meaning or interpretation

    Emphasizing Personal ControlCommunicate to the patient that it is his/her decision whether or not to make a behavior change

    Coming AlongsideAgree 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 empathyEvidence of supportivenessDancing, not wrestlingMore reflections than questionsAsk permission before advising or educatingMost questions are open-endedClinician can accept that patient might choose to not change


    Video Example

  • Offering Advice & Setting Goals

  • Elicit-Provide-ElicitThroughout the MI encounter, we use the E-P-E strategyIt can be particularly useful when offering advice or suggestions, especially with youthE-P-E refers to: eliciting information/ideas/opinions/feedback from the clientthen providing information/ideas/opinions/feedback to him or herThen eliciting his or her ideas/opinions/feedback in return

    For example:Open question Reflection Open questionAsk Permission Offer Advice Ask for feedback

  • Offering AdviceAsk PermissionIf youre interested, I have some ideas for you to consider. Would you like to hear them? If youd like, I can tell you about some things that other people have tried successfully. Would that be okay?

    Offer AdviceBased on my experience, I would encourage you to consider ________________ .Given what youve told me so far, I think you might have some success if you tried __________________ .

  • Offering Advice (cont.)Emphasize ChoiceAnd I recognize that its your choice to do so.Of course you know best what will work for you.

    Voice ConfidenceIm very confident that if there comes a time when you make a firm decision and commitment to ___________, that youll find a way to do it.I strongly believe that you could accomplish __________if you put your mind to it.

    Elicit ResponseWhat do you think about those ideas?Im interested in hearing your thoughts about these ideas.

  • Developing a Change PlanPatient and clinician work together to develop a reasonable goalGoal should be broken down into manageable, behavioral stepsPatient and clinician complete Goal Statement worksheetEnd with a quick summary of the session and thank patient for his/her participation and willingness to work together

  • Pulling It All TogetherGive a brief structuring statementUse open-ended questionsListen reflectivelyElicit change talkAffirm and support wherever possible!Summarize periodically

  • Remember: Learning MI is like learning to play the pianoYou must practice, practice, practice!


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