EP31: Dr. Gabriel Robles on motivational interviewing

What is motivational interviewing? As with any skill, motivational interviewing can take time to learn (with formal evaluations including transcripts used to parse every word spoken). For this podcast episode, Dr. Robles breaks down a few of the techniques in motivational interviewing into simple things that we can all do in our relationships, including within the healthcare system. Build rapport! Self-reflect! These are basics, but if you have found them missing when you go see the doctor, Dr. Robles gives tips on how you can redirect conversations. Dr. Gabriel Robles, PhD (he/él) is Assistant Professor at the School of Social Work and the Chancellor's Scholar for Inclusive Excellence in Sexual and Gender Minority Health at Rutgers University. Dr. Robles is a clinical social worker, an experienced motivational interviewing clinician, and a member of the Motivational Interviewing Network of Trainers. He conducts research on substance use prevention and sexual health among sexual and gender minorities (SGM). He has a strong interest in addressing health inequities among Latinx SGM populations. Dr. Robles received his PhD in social work at New York University, and his MSW and undergraduate degree in linguistics from California State University in Long Beach. Follow him on Twitter @GRoblesPhD.

Transcript

[00:00:00] Christine J Ko: Welcome back to SEE HEAR FEEL. Today, I'm very excited to be with Dr. Gabriel Robles. Dr. Gabriel Robles has a PhD; his pronouns are he/el and he is an Assistant Professor at the School of Social Work and the Chancellor Scholar for Inclusive Excellence in Sexual and Gender Minority Health at Rutgers University. Dr. Robles is a clinical social worker, an experienced motivational interviewing clinician, and a member of the motivational interviewing network of trainers. He conducts research on substance use prevention and sexual health among sexual and gender minorities (SGM). He has a strong interest in addressing health inequities among Latinx SGM populations. Dr. Robles received his PhD in Social Work at New York University and his MSW and undergraduate degree in linguistics from California State University in Long Beach. You can follow him on Twitter @GRoblesPhD, and that link will be in the show notes. Welcome to Dr. Gabriel Robles. 

[00:00:56] Gabriel Robles: Hello, Dr. Ko. Thank you so much for inviting me to this. 

[00:00:59] Christine J Ko: I was wondering if you might be able to give just a little personal anecdote or two before we start?

[00:01:05] Gabriel Robles: For sure. I do have two French bulldogs. They're very rambunctious; they like to wrestle with each other; and, they keep me on my toes throughout the day. On a more serious note, about two years ago, I was diagnosed with ankylosing spondylitis. It's an autoinflammatory, maybe autoimmune, disease. Imagine it's like arthritis, like how people have it in the knee or the elbow, but it's throughout my back. At the same time, I was starting to develop this need to create a better healthcare system. Or how do we create better, specifically primary care, services so that patients might do a better job at navigating the system? 

[00:01:44] Christine J Ko: Absolutely. Do you have any kind of simple conclusion?

[00:01:47] Gabriel Robles: Yeah, so the simple conclusion: you need to make sure you're telling your provider this, or ask about this. Skills that I already had and I knew, because I was teaching them to my own clients. But for some reason, when you're in the center of it, you're not knowing what to do, even though you know exactly what you should be doing. I would be like, Oh, I know I can advocate for myself. But, I actually wasn't doing it effectively. 

[00:02:11] Christine J Ko: You're saying to really self advocate, be prepared, and trust yourself. It's just, it's so much harder than it seems like it should be, right? I've had that same experience with the healthcare system myself, in navigating it for my son's medical needs, feeling like I should know what to do. This shouldn't feel so hard, but it does. I realize that it's because there's fear, and I'm not going in as a physician, I'm going in as a mom. And I might be afraid, I might be feeling ashamed. I might just be feeling angry as well. Also, I want to be nice. I don't want to make waves. I don't want to bother the doctor. I want them to be on my side. 

[00:02:55] Gabriel Robles: There's this cultural element that I, as a patient bring into this room, and perhaps you as a mother did, when you were interacting with the healthcare system. For the most part, on average in the Latino community, we placed this expert role on providers, physicians specifically. And we think, They know everything. 

[00:03:10] Christine J Ko: I agree. I realized, Why would I expect one of my patients, or me as a patient or patient advocate, why would I be good at really explaining my symptoms or explaining why I think it doesn't fit well? Why would I be so smooth and expert in it? I had to learn, I had to have practice in doing it. And I realized, I think that's true, at least for me with almost everything, I'm not automatically good at it from the beginning. Which comes to you being a motivational interviewing expert.

[00:03:42] First off, can you educate me, and anyone who's listening, what motivational interviewing is? 

[00:03:48] Gabriel Robles: Motivational interviewing: it's basically a person-centered strategy that we use so that we can elicit the patient's own motivation for doing a specific behavior. One that is considered positive behavior. And this is done often by building rapport and engaging with the patient. It's in this process that the patients start to explore their own motivation for wanting to do something that is positive, or wanting to do something that is mutually beneficial to the provider /patient goals. For example, this is used in substance use treatment.

[00:04:20] Christine J Ko: How do you build rapport and trust? 

[00:04:23] Gabriel Robles: It's those type of things that you're affirming to the client that, You made it here. I'm listening to you. You are a person. And ultimately, What you say goes. Small conversations can start to build some momentum for a more meaningful relationship, even if it's brief. The patient walks away thinking, Oh, Dr. Ko asked me about something or, You know what, she actually followed up about something at our last appointment. It gives the the patient this perspective that, Oh, I'm not just a number on your chart that day. I'm somebody that you actually see as a person. 

[00:04:57] Christine J Ko: You're right. I think that really does make a difference. People do appreciate that. I've noticed that when I go to the doctor, and they start with a little something, it gives me the impression that they actually have a little bit of time to spend with me, not just powering through their day. It's true really in any relationship. I've realized more and more that to have that kind of rapport and trust, and really do see that person as a human being, not just as a patient or especially not just as a diagnosis, because it gives you insight into what treatments they might be able to take and really use and incorporate, or what their lives are like. 

[00:05:34] Also though, there is medical mistrust and bias in the healthcare setting. How do you think motivational interviewing might be able to speak to how we can address that kind of medical mistrust and bias?

[00:05:47] Gabriel Robles: Those of us that have the the privilege of being a provider in any capacity, whether it be dermatology, primary care, or in my case, psychotherapy. What I like to say is that we need to make sure that we're engaging in critical self-reflection. Is there something that I'm doing that could be harmful? And can I change it? Even if it's small, like a small thing. Am I saying something that is perpetuating some sort of stereotype that certain communities just are not adherent to treatment protocols? Is there something that I'm saying that is conveying to the patient that, You're less than? That's a first step. In my experience, just hearing from colleagues, a lot of physicians and other providers do already to some degree think about this, when they leave a room, they think about this, even if it's a quick second. 

[00:06:36] Christine J Ko: That's useful. So just add on to, did I make the diagnosis right? Did I give the right treatment also? What is the psychosocial background? I could just try to think of one thing that hopefully I learned or gathered from the whole time that I had with a given person or patient.

[00:06:53] Gabriel Robles: Exactly. So there is some sort of reflection process that happens on the side of the provider or the interviewer, the person conducting the counseling session; and by counseling session, I'm not specifically talking about a psychotherapy. You need to go into the room, you need to have a couple seconds to just check in, look at them in the eye. Some people like to pat on the shoulder or on the elbow, like even just a quick little, Oh, I see you. That's the interviewer, but then a similar thing happens on the side of the patient or the client. If the provider reflects back, when you repeat to them what they just said, sometimes verbatim, sometimes you add a little bit of meaning or you paraphrase it, it prompts the patient to think about going through some sort of self-reflection process.

[00:07:35] Christine J Ko: That makes sense. You're putting the ball back in their court. The self-reflection component is really trying to validate that you're the expert in how your life runs, in how your schedule needs to be, and whether or not you're gonna be able to fit in even taking a pill once a day or something. Yes. Okay. So you just, in a way, reflect their own self back to them and have them hopefully think about it, but in a very validating manner. 

[00:08:02] Gabriel Robles: Exactly. Yeah. And so one thing that is always on the mind of a person that's a new to motivational interviewing: Okay, now I need to practice talking to people. This really wasn't a component of my education. People have to practice, that's important. Sometimes you get it wrong, or at least I've got it wrong a few times. I would say something back or be like, Oh, yeah you're too busy. That's just wrong. That's not what they said. But if you convey it in a nonjudgmental matter, then the client will correct you. More often than not the client will say, Oh no, that's not what I said. And then in that process now they're getting their thoughts together and they'll be able to better say, Oh yeah, it's not that I don't want to come. It's just that I can't come. And maybe if I change my appointment to another day and is there anything that you can do. There'll be more problem solving happening. If you just allow them the space to think about it.

[00:08:50] Christine J Ko: I think, unfortunately in medicine, I think we do judge a lot. We have these words, like non-compliance. But instead of blaming or judging, if we figure out, Why? With what you know about motivational interviewing, do you have some advice, like maybe one, two or three things that you could give physicians or people who want to strengthen their relationships with others?

[00:09:13] Gabriel Robles: The first real bit of advice is if you can't do a whole minute, just try when you greet the person, look them in the eye. Yeah. And if there's one thing you can do is just see the person as a person. I know that sounds very, basic or very elementary, but at the current state of the healthcare system, we even lack that.

[00:09:31] So that may be the first step. The second thing is that often, especially people giving motivational interviewing trainings like I've given, it's an all day training; sometimes it's a half day. There's so much information. We're not asking you to be experts. Like when I went through an motivational interviewing training, I went through several trainings. I get my patients interactions recorded. And then we transcribe each line and then you get rated like, Oh, this word was judgmental. Why did you use it? We're not asking you to engage in that level of motivational interviewing. If you can take some concepts, for example, the rapport building. Or the most common is the reflection. If you can start to incorporate some elements of that. 

[00:10:14] Christine J Ko: It sounds so simple. If I just enter the room, and I'm present. If I just remember, I'm really with another person. This person knows way more than I do about their own self and what they really need and what they're really feeling. It really does change the interaction positively. One thing that we can do to feel renewed is to feel like, Oh, I connected with this person, this patient, this client, this other person who was with me. And I found that I'm still tired at the end of the day, but it's changed things for me.

[00:10:47] Do you have any final thoughts? 

[00:10:48] Gabriel Robles: Sometimes we go into the room with the intention of being a good human. I'm going to listen. I'm going to ask my patient how they're doing. And for whatever reason, they're not in the space to reciprocate that. That's okay. Just go with. Roll with resistance. The worst thing is that they'll leave the appointment or the interaction or the counseling session thinking, Oh, Dr. Ko, she's always is so nice. That's not a bad reputation to have, if they walk away thinking like, Oh, she's always asking me about, whatever, that's okay. I'd rather have that reputation than one that like, Oh, she treats me bad or She doesn't listen to me. 

[00:11:21] Christine J Ko: Thank you so much for spending time with me today. I really appreciate your thoughts and being educated on motivational interviewing. 

[00:11:30] Gabriel Robles: Thank you so much. And thank you again for inviting me to this.