Motivational Interviewing

Preston: [00:00:00] Isn't it funny how, even within medicine, we're siloed in our acronyms? 

Margaret: Mm hmm. Yeah, we are siloed in 

Preston: that. Someone, the other day, I put like RIS in a note, and someone was like, What is RIS? I was like, Oh, Responding to Internal Stimuli. 

Margaret: Oh, yeah. 

Preston: And anything, even within like, RTIS? What's RTIS? 

Margaret: Responding to Internal Stimuli.

Preston: Oh. 

Margaret: See, even in our field, we have different abbreviations. Yeah, we don't use the T. This is not interesting to none. West of 

Preston: the Mississippi. So today we have a really interesting guest. This is one of my own professors. Dr. Roberts, who he actually teaches. Am I motivational interviewing? I've heard he's a cool guy.

I'm just kidding. I know he's a cool guy because I'm in class with him. So he'll be kind of like, 

Margaret: Oh, I was gonna say, what do you feel like you need motivational interviewing about this week? Yourself? Me? 

Preston: Mm hmm. 

Margaret: Where you feeling ambivalent, but maybe you're ready to starting to change 

Preston: honestly using using chat GPT to run my life I think I'm ready to do that.

I do [00:01:00] 

Margaret: because earlier 

Preston: Earlier I had to cite some articles and I just asked, I just punched in the hyperlinks and I was like, can you cite these in alphabetical order in MLA format? And it was like, sure. And it did it in 20 seconds. And I was like, oh my gosh. All right. That's a 

Margaret: decent, that's a, i I will consider that use My 

Preston: entire life will be better if I use Chatt PT.

But a part of me is worried that my brain's gonna rot and I'm just, that's no longer use the, the part of my brain that I want. But also I'd be saving so much time. All this like clerical work that sucks. 

Margaret: It only this data entry where I worry is where it gets. In the way of humanity, like, did you ever see that New York?

I think of the New Yorker, a New York Times article that was like, should we make up if we could make a pill that would mimic the effects of exercise? So you didn't have to exercise, should we? And I was talking about people like, I think the writer like loved running and other people like these other things.

But like, I think of like going to the grocery store, like when we couldn't go. Sure, it's annoying, but also, There's like fun parts of like picking out your food and the sensory experience of like seeing which apple [00:02:00] you want. And so that's where I worry with like, I feel like where AI and chat GPT start to get in the way of that, like with writing or creativity, creativity is where I'm like, 

Preston: definitely the process of brainstorming.

Whereas I think. I don't know if there's magic in me, me looking up Emily formats and trying to paste hyperlinks, so I'm okay with that. But yeah, maybe I'll find the balance somewhere. And so without further ado, we can get into this. What? I'm trying. I'm trying to you're in a rush. I 

Margaret: know I'm in a rush, but like, we still have to do the like, what's going on with your brother 

Preston: or 

Margaret: we can just use this as honestly, this is more yeah.

Preston: I think this is a pretty good check in. Um, well, you want to hear about my life? Let me, I'll tell you about my life. 

Margaret: Magnolia and Lilac 

Preston: are fighting. 

Margaret: Every day. I can't, I'm eating alone in 

Preston: my room. 

Margaret: Because 

Preston: Lilac tries to eat everything off my plate. I'll ask you a personal question. Hey Margaret, what's going on in your life?

[00:03:00] What, what do you need motivational interviewing for? 

Margaret: I need motivational interviewing to get through this interview. Laughter. And next on you 

Preston: enjoy talking. With me about these things. Huh? Tell admit it to the audience. Tell them Admit 

Margaret: that I like talking to you about topics. Yeah. 

Preston: I, I, 

Margaret: you're right.

Preston. Margaret was excited to come on 

Preston: the podcast. 

Margaret: To come on podcast. 

Preston: There wasn't any, there wasn't any motivational Yeah, when she, when I first asked her months to go, I'm Preston's 

Margaret: employee . I'm just here to go, Chuck. There's no Chuck . Um, what do I get motivated for? It's getting kind of dark and cold out here in Boston, which I actually don't mind, but what I do mind is waking up and like trying to work out in the morning and it doesn't get light out until right now.

It doesn't get light out to like 7, 715 because there hasn't been daylight savings yet. And it's kind of brutal going to sleep when it's dark and then getting up and it's just being still pitch black out right now. 

Preston: Yeah, 

Margaret: you missed that. Well, I guess you have the light part in Texas, but you know, the weather's not 

Preston: it's [00:04:00] like where seasonal affective disorder was invented 

Margaret: Probably 

Preston: Northeast 

Margaret: Yeah, so I need some motivation to stay engaged with the world of light It 

Preston: sounds like a like a fantasy novel Honestly, it feels like if there's an experiment where someone's like hey I wonder if taking the Sun away from human beings will make them depressed Like, do you think that would work?

And they're like, yeah, the experiment's Boston. 

Margaret: It's just Boston. I like, okay, but I like the season two. I actually don't mind it. I just mind it right now when it's like, why is it so dark in the morning, especially? Because at night I can be like, even when it's a 4pm dark time, it's not the best, but I'm like, okay, it's the afternoon night.

I can make dinner. I can light my candles. But when I wake up in the morning and it's like, start my day and it just feels like night. It's so demotivating. It's how am I ever going to get the gains I need to get for this podcast? It's just not going to 

Preston: happen. So, I need motivational interviewing to use chat GPT, you need MI to get out into the light of the world.

Right. And we have an expert guest who is here to help us. 

Margaret: He's going to [00:05:00] cure us. 

Preston: Yeah. So, he's actually going to help us learn. Don't tell him that he needs to cure us, just, we just need to ease him into it. 

Margaret: Yeah. We're going to get secretly, we're getting free therapy with you guys on this right now. 

Preston: All right.

So let's bring on Dr. Roberts.

Welcome Dr. Roberts, and I am here to introduce you to Margaret. So Margaret is my co host. She's a psychiatry resident in Boston. 

Margaret: Allegedly. 

Preston: Yeah. I actually have no way of verifying this. I haven't, I haven't seen it in actuality. So. We're excited to have dr roberts here because he is, um, one of the favorite mentors and professors I've had in therapy since I started psychiatry residency.

And my introduction to him was actually through motivational interviewing, which I think was this nebulous Jedi mind trick that I thought about as a medical student, he does a great job of breaking it down and kind of making it digestible and also like applicable to your practice. [00:06:00] So without further ado, I'd like to introduce dr roberts and I would, as we kind of get into the episode today, I just kind of want to hear a little bit about your background and what What even got you into motivational interviewing.

Dr. David L Roberts: Well, certainly. Thanks Preston for the intro and thanks for the invite. Um, it's been a pleasure getting to know you through our training experiences together. And I don't know if you know this, but you and I share, um, an alma mater. Uh, I want to, I want, I want to grad school at UNC. 

Preston: Oh, wow. Yeah. Yeah. How about that?

Yeah. And I absentmindedly wore my regalia today. Right. 

Dr. David L Roberts: Right. So that reminded me of it. Um, but yeah, I actually went to UNC for graduate school in clinical psychology. I'm a clinical psychologist. I'm not a psychiatrist. Um, in order to focus on doing psychotherapy with schizophrenia. And I remember when I was trying to get into that, I called up this famous psychiatrist who did a lot of.

Work in that area. And he said, you should really save that for the psychiatrists and the [00:07:00] social workers. There's not really a place for psychology in, in psych, in sort of schizophrenia treatment. And I resented that at the time, but I really, for the first decade of my career was very focused on, on, on psychotherapy for schizophrenia, but not surprisingly, one of the real challenges through it all was, um, it's hard to get change.

It's hard to get big changes. It's, and you know, I was doing research on psychotherapy approaches for schizophrenia and I was not getting large effect sizes in those. Um, but I was, um, getting a lot of experience training therapists because I was going around. We had developed an intervention approach for my dissertation that got some, um, notoriety and some, um, momentum.

So I got a chance to go around and train people to do it. I do a lot of work in a variety of community settings. With frontline clinicians through that, I kind of became increased, sort of increasing dissonance. About feeling like I was training people to do something that doesn't work. [00:08:00] Um, and I was always looking for what's going to be the next sort of psychotherapy approach that I can really believe in and have a lot of confidence in and teach people.

And so I'm, I'm naturally a teacher. 

Preston: So you're taking on this. Almost insurmountable, insurmountable task trying to apply therapy to severe persistent mental illness and psychotic illness, which is something I mean, we invented, um, asylums in the early 20th century because of how challenging this problem is.

So I can definitely resonate with how that could feel frustrating to you. It's really interesting and admirable that you could take it on for a long time. So, so then how did you kind of pivot into this? Pursuing the new topics of psychotherapy. 

Dr. David L Roberts: Yeah. So, I mean, I honestly, I, you know, I, I was already aware of motivational interviewing, um, before about eight years ago when I really started focusing on it, but I think what happened is I moved here to San Antonio, [00:09:00] um, to UT health and started working in, um, this community clinic setting, um, Which is, is the transitional care clinic, the now clinic, these two sort of, I like to think of them as academic community mental health centers, where really the population we're working with is sort of a public health population.

And, and, and in that context, working with psychiatry residents and also increasingly with counseling interns, I, um, each year I was, um, doing intro to psychotherapy type training, but I was frustrated. I was frustrated that. I was finding that the psychiatry residents, no, no offense to you two, 

Margaret: were I'll take it.

Whatever. You haven't heard what I'm going to say. Carte blanche. Carte blanche. Nantes. 

Preston: I deserve it, whatever it is. 

Margaret: I'll, I'll internalize it, whatever. Oh. Um, 

Dr. David L Roberts: I was finding that psychiatry residents often were a little bit too directive. I felt in their psychotherapy. So [00:10:00] I 

Preston: feel about my psychotherapy. Well, I feel about 

Dr. David L Roberts: your psychotherapy too.

Um, so psychiatry residents were a bit too directive. Not surprisingly. Trained as, trained as, as, as medical providers, sort of procedurally oriented. 

Preston: And just so for anyone who's not familiar, what are the kind of different styles? being like directive or guided or following to help someone kind of get some context for this.

Dr. David L Roberts: Right. And I wasn't even thinking of this in terms of motivational interviewing, but you can kind of think of a spectrum of, um, of a counselor or a therapist from on the, on the far right hand side, let's say, um, being a highly directive, which I define as Um, telling the client what to do, picking up airspace, picking up more airspace in the room.

So even if you're not telling the patient to do something, you're educating the patient or you're talking or about something else, just taking up more airspace, taking up more authority space in the room, um, being cracking the whip. Um, and then on the flip side, so I was finding that more psychiatry [00:11:00] residents were kind of like that on the flip side.

I was also working with counseling interns, and I was finding that these master's level counseling interns were the exact opposite. They were too non directed. They were too sort of soft and following and in some cases, sort of ineffectual with their clients. Um, and so I was sort of looking for a middle ground and that's when I sort of.

Saw motivational interviewing as something that could really meet that middle ground. And, but, um, what we were finding was like, how would I was finding psychiatry residents is that with community populations and also with veteran populations at the VA, um, residents were vulnerable to feeling frustrated.

By their patient's resistance and vulnerable to frustration. It's taken me time. I used to not like psychiatry residents very much. Yeah. 

Preston: Well, I know. And, and like, I've seen this in our debriefing sessions, people make contemptuous and vitriolic statements about the patient population and, and like, maybe I, maybe I'm like more judgmental, but like.

I [00:12:00] definitely resonate with his vulnerability of frustration and how it's easier to, um, have less of a generous interpretation of your colleagues when it happens. 

Margaret: I definitely think our formation pathway, as you said, is it kind of lends itself towards this interventionist approach. Um. And then we come into residency, and so much of it is like inpatient emergency consults, like change the medication.

And so to get more familiar, like you're saying, with a different sort of orientation, I think is really important. I'm, I'm a fourth year and I'm our outpatient chief. And so I think that that's one of the hard parts of third year is not being so directive or having less kind of rules of containment than you do when you're an inpatient.

Preston: Condensing the human soul into a medical model so that she can assign an ICD 10 code to it. 

Margaret: Yes, it's 

Preston: challenging, but you have 15 minutes, so figure it out. 

Dr. David L Roberts: Yeah, yeah, and you have such a limited amount of time to learn all the psychotherapy that could make you. 

Preston: Yes, correct. [00:13:00] Yes. So what is motivational interviewing?

Dr. David L Roberts: Oh, so yeah, good question. So motivational interviewing is not psychotherapy. Isn't that ironical that we're talking about it in this content? But what it is is so, um, half the people say it is a. Non directive counseling approach. And I think the other half of the people say it's a directive counseling approach.

But what it is, is a counseling approach for sure. It was developed in the early eighties. Um, the story I tell, and I think it's pretty close to the truth is that it was, uh, um, in the context of research on substance use disorder, especially cognitive behavioral approaches. And what, what the researchers were finding is that, um, CBT works excellent for people with alcohol use disorders who were eager to change and eager to just sort of drink less, but it wasn't working so hot for those patients who had alcohol use disorder and were not, um, eager to change.

They were defensive or they were afraid or they were everyone around certain. And in fact, I think CBT was being experienced [00:14:00] as too pushy. Right. Some of 

Margaret: these clients. Right. 

Dr. David L Roberts: So it was in that context that the developers primarily Bill Miller, not the barbecue king of South Texas, the developer of motivational interviewing.

He sort of said, we need to use. Some of the techniques that I was trained to use in grad school, which are these counseling techniques, these Rosarian counseling techniques of sort of rising with a patient, unconditional positive regard, following techniques, um, and then finding a way to balance following techniques with a change motor or a change orientation.

And so I think that the real, most of psychotherapy is old wine and new bottles. But I think that motivational interviews, I mean, I really think that's true. No, I like that. Yeah. Right. And it's not a bad thing. It's just, we're, we're, we're learning what the, what the active elements are and repackaging them to try and find the best, but I think that the original for me, the, the real original contribution motivational interviewing is the, is this thing called evoking change talk and basically [00:15:00] what it is very briefly is Um, having the patient make their own argument for change, drawing the patient in, and this is why it's sometimes called like a Jedi mind trick or whatever, drawing the patient into articulating their own argument for change.

So that they don't feel pushed into change and they feel like they see themselves making yard. 

Preston: Okay. So if I if I understand you, right, CBT was effective when people wanted to change, but it was not effective. If that desire wasn't there. I don't know why this quote came to my head, but remember in Jurassic Park when they were like, you asked how, but she didn't ask why.

Yes, how to make the dinosaurs, if you should. So I think that's like kind of the two questions. CBT is how do you build a dinosaur? But motivational interviewing is should, you know, CBT is how do you change? But am I as should I is change even worth it? And I think it's really fascinating because I think a lot of people hadn't had almost seen the culpability or the responsibility of change as on the patient, not something we [00:16:00] can help with.

So it's, it's really interesting that evoking change is now something we can do. 

Margaret: I think one of the things also is like that therapy has developed over a historical perspective. And so I feel like one of the things from my understanding of the history of therapy is that am I sort of bridged towards slash was co occurring in terms of like evolution is towards like third wave therapies, which I feel like have like I'm.

Trained and act. And so I feel like, am I an act both with somewhat similar Rogerian stances and then some obviously differences beyond that, but are so coherent together. But if you were like a pure behaviorist or like, I don't know that. I don't know what CBT was like before. Am I in terms of like.

Historically, but kind of that all of these therapies develop sort of in conversation with one another, which I think is fascinating, um, and also cool to see how we develop and where we might go next. 

Dr. David L Roberts: Well, we agree. I think another interesting connection along those lines is the [00:17:00] links between motivational interviewing and dialectical behavior therapy.

Yes. What do you view those links as? Well, I think, um, a core link is the, is the dialectic, um, in, in, in, in dbt, it's the dialectic and especially the sort of foundational dialectic between acceptance and change verse. And then comparing that to ambivalence and motivational interview between status quo and change.

And, and, and both of them are, how do you deal with this? Um, dbt, I think was the first is sort of way out in front of them. My, in terms of Looking at, uh, sort of, uh, synthesis of, of, of opposites or superordinate solutions, whereas when MI was developed, it was about, are you going to drink or are you going to not drink, which are you going to pick?

But I think as it evolves, and as we apply it more in psychotherapy, it becomes a less a dichotomous, a tool for helping the person answer a dichotomous question in the right way, and it becomes closer to DBT. Yeah, 

Margaret: and an integration. And for [00:18:00] those not familiar with DBT dialectic, meaning kind of two things at once, or kind of the idea that there's a little bit of the opposite in every.

Opposite. Uh, I don't know. There's like, there's often like the yin and yang symbol in that, but yeah, I think that makes sense how you're explaining in terms of like holding ambivalence, which is definitionally, like, I kind of want this and I kind of don't and holding multiple feelings and not having to get rid of any of them and say, no, that one's wrong.

Kind of exile it. Yeah, 

Dr. David L Roberts: that's 

Margaret: right. 

Dr. David L Roberts: That's right. And even saying like, um, which is. Which of these incompatible opposites is the right one or is it and moving toward? Maybe it's not and 

Preston: then why are they incompatible? So I guess now we've identified like. Am I is this useful tool for helping a vote changer helping someone navigate their ambivalence?

So, I guess my question following that is when is it useful to use in a clinical setting and was it not useful? I think we already maybe saw it's not useful if [00:19:00] someone doesn't want to change or sorry if someone is already motivated to change maybe. 

Dr. David L Roberts: Yeah, the way I've come to sort of think about this.

Links back to, uh, Bill Miller and other motivational interviewing experts saying motivational interviewing is not a psychotherapy for me. That has bothered me for a long time. So I dig into why do they say it's not a psychotherapy? And I, and, and I think what they say is it, um, is good for getting you motivated to change, but what psychotherapy is, are those techniques that actually target the specific pathological process.

And facilitate the change itself. Um, for me, as I've, and fair enough, fair enough. So, um, I've started saying a problem then with MI, a way to understand that is MI doesn't, the way I say it, MI doesn't pass the OCD test. Which means if you have a patient who comes in and says, I have OCD, can you please help me beat my obsessive compulsive disorder and a CBT therapist would say, you bet sit down and we're going to get to work, [00:20:00] but an MI therapist would say, well, gosh, if you already are motivated to do it, there's nothing I can do.

You need to go meet with the CBT. So in that way, MI is not a psychotherapy, but I think that that hinges on the idea that. Psychotherapy is more about the technical process of changing the thing. Once you have motivation and it's not about being a human who is trying to change actively, but the human is trying to change actively.

And if you see those as two elements, I think that they're co equal. I think that at least as many patients need to find the motivation to change as need to learn the technical procedure to change. And so I would say it's 50 50 M I is, uh, you should always start with the question of resistance or lack of motivation, and then see how much am I you need to use to get to step two, which is the technical procedure.

Preston: And I think even within the OCD test, there's different stages. Of change that the person is willing to to work with or help with, [00:21:00] like, I want my OCD to go away, but not this one compulsion like, like, like, when I count sevens in the morning, that one can stay other compulsions can go and so so then now all of a sudden you're applying.

Am I with him? Like, why? Why are you okay with one compulsion, but not the other ones? And so I think to your point that they're equally used. It's almost impossible to just use CBT without applying a little bit of. Yeah. Evoking change talk and you know that there are 2 sides of a different hammer or or it's kind of saying like, I guess what came into my head is saying, you know, you're not a true construction worker.

If you only use a saw and you're like, well, I also use a hammer. And they're like, no, the, the, those who use the hammer to punch in nails, those are the fake construction workers. The true ones use screwdrivers, 

Margaret: I think from as well from my like experience with some of my therapy patients who I'm in New England, I'm in kind of a psychodynamic program that we then also do CBT like everyone doesn't.

I've chosen act as well. Um, [00:22:00] But even in the ones where I'm, like, doing ACT or doing Psychodynamic, the idea that motivation and the kind of directionality of the work is going to be totally linear and self sustaining once you, like, find the right answer is sort of this kind of fantasy, I think, that when we're learning therapy, it's like, Oh, if we can just find the exact right path, then we're going to go down it and it'll be smooth sailing and they're never going to need motivation.

They're never going to have trouble showing up to sessions or doing the homework in between for exposure and response prevention. And I think the tool that MI gives as well as at the start is throughout asking, like, it's hard for you to show up to these sessions. I've noticed you've not been able to make it.

Maybe there's life things, but also maybe, does this not feel like it's something that's aligned with you and what you truly want? Uh, like as an ongoing thing that might help or might be meaningful to endure the pain of therapy, uh, towards these values. And I think that's something that is really valuable about MI throughout the whole shebang, basically.[00:23:00] 

Dr. David L Roberts: I hear you. I hear you as an ACT therapist coming through. Is it? 

Preston: Yeah. Looking at your values. I take that as a compliment. Yeah. I didn't, I didn't recognize that. I don't know anything about ACT. To be, to come someday. Yeah. 

Dr. David L Roberts: Yeah. Yeah. Well, I think I'm going back to the question of values and what really matters to you.

And I think in M. I. We say, is this important is what we're talking about? Important is change important or is it not? Because if it's not, it's not. 

Margaret: Yeah. 

Preston: So I want to get a little more granular about motivational interviewing now and break down what are the really detailed aspects of it. And so since motivational interviewing interviewing at its core is assessing someone's capacity or desire for change.

I guess we can start with what are the different stages of change that humans can be in around any kind of decision? 

Dr. David L Roberts: I think that's a good question. Let me say a couple things about that. One, I think that, um, the stages of change model de Clemente is like, um, really closely linked with motivational interviewing and they're highly [00:24:00] compatible.

And they're, but, but, but surprisingly, they're not actually the same thing. They were developed at the same time historically and they get along really well together. And they've always 

Preston: been taught to me in the same context. 

Dr. David L Roberts: Yeah, there, there, it makes it, it's almost a pity that they're not the same thing because they're, they're so compatible with each other.

But so, you know, um, pre contemplation, contemplation, um, preparation. That's the version we're taught in 

Margaret: med school. Yeah. 

Preston: Yeah. I think, I think I had that MI talk probably six or seven times in med school. Yeah. Pre contemplation is like the idea hasn't even popped into your head that you want to change yet.

And I think I, I almost found that one to be a little silly. I was like, isn't everyone in like pre pre contemplation phase of like everything? Like I'm pre contemplated for becoming a domestic terrorist right now. Technically, technically, right. Cause the idea hasn't even popped into my head. That I could do it so 

Margaret: I wonder if delineating because one of the things I learned actually like two months ago from one of my addiction mentors is.[00:25:00] 

Thinking about the like co use of that the wheel or the kind of pre contemplate stages of change, but also the like engaging evoking planning stages of am I or that that's I didn't even know that was like a frame and so using those together, I guess, if you would want to talk about that and how you think that we should think about it as psychiatrists or just health care workers in general, because that was confusing to me a little bit of like, Is there a difference here or are those the stages of change in terms of how I've been presented it prior?

Dr. David L Roberts: Preston, do you want to add anything before I reflect on this? Um, 

Preston: yeah, so So what you're saying margaret is that when you have the pre contemplative stage that matches a certain Tenant of motivational interviewing and then the contemplative stage. So thinking about change matches another tenant 

Margaret: I think I actually don't know how they overlay on each other so but yeah, I think that that's where my question is is like the The, yeah, what [00:26:00] if it's not, yeah, if it's not the wheel of kind of change that I feel like all of us are taught in med school that it's like, Oh, maybe we should teach our med students this one on one lecture.

Um, how does someone who's truly in the MI world think about the stages or how that kind of like stages of change or readiness works? 

Dr. David L Roberts: Yeah. So stages of change is a description of a process taking place inside of a patient. Um, kind of over long periods, swaths of time in their life, right? Over years in their life.

So they go through cycles of. Recovery and relapse over two, three, four years. And then, you know, again, whereas the four processes of motivational interviewing, evoking, I'm sorry, engaging, focusing, evoking, and planning, those refer to what's take what the therapist is doing within the treatment, uh, within the treatment, within the patient, uh, uh, before the patient, and they're described as processes instead of steps because they're.

Not seen as always linear. [00:27:00] Um, there's of course, and then just like with the station of change, you have to cycle back, cycle back. You, you, you engage the client, which is the same thing as engaging in any sort of model, I think. Focusing being the second one. And what I like to say about focusing is. This is where motivational, where you can use motivational interviewing for greater efficiency.

One of the biggest complaints about MI, or apprehensions I think, um, among people who are about to be taught it for the first time, including psychiatry lessons. Guilty. Is, um, I don't have time. I don't, I have 15 minutes to bang out 27 required elements. I don't have time for a sprawling 10 minute chit chat conversation.

Get to know you, I don't have time for that. So what I like to say is, MI isn't like that. MI does not ask that doesn't require that. And in fact, MI can make your 15 minutes more efficient rather than less efficient. And one way we do that is by focusing, 

Preston: I found that to be true. 

Dr. David L Roberts: You have found that to be true?

Preston: Yeah. So I know I'm just, I [00:28:00] compliment him too much, but I'll come back to our sessions and be like, I landed a good reflection and it like sped up the conversation. And so to clarify my understanding, focusing is basically taking a surplus of knowledge and information and highlighting what is important, what is worth discussing with the patient.

Dr. David L Roberts: Yeah. 

Preston: Okay. 

Dr. David L Roberts: Yeah, I think that's a really nice way to say it. 

Preston: And then after focusing, what is it? Is it evoking? 

Dr. David L Roberts: Which is, which equals evoking change talk. I said, I think that that is MI's greatest original contribution. 

Margaret: So what might, what are things that you would hear if you were a fly on the wall and breaking HIPAA during a therapy session with one of us?

What kind of words coming out of the therapist's mouth would you be like? That sounds like Trying to evoke change talk. Cause I know that there's a ton of these. Yeah. 

Dr. David L Roberts: Yeah. I think a really nice way to think of it is in terms of what I call the four natural categories of intrinsic motivation, um, desire, ability, [00:29:00] reasons, and need, D.

1. R. N. is the acronym. I know that residents like akw, so desirability reason and need, and so you can, um, desire refers to feelings. So you, um, to start, um, you, you really only wanna ask for evok, ask evoking change top questions if the patient is in a change oriented mindset. Mm-hmm . Not if they're in a resistant mindset.

So the first step is to get them to the change oriented mindset. Once they're there, uh, uh, for, for desire or feelings you might say. What would it feel like? Um, if you attempted this and you succeed and you were successful, what would that feel 

Margaret: like? Yeah, 

Dr. David L Roberts: ability, um, or, uh, often referred to as confidence, the patient's confidence.

Um, you know, the main thing is actually a closed question, not an open question, but how confident are you that if you decided to make this change, you can make the change. So, so 

Preston: an example that would be, I'm the patient, I say, I wish I could just stop drinking, but I don't know if I'm strong enough. Ah. 

Dr. David L Roberts: And there are different techniques, I 

Preston: might say.

I know I've demonstrated my desire, [00:30:00] but I've questioned my ability. 

Margaret: And if we asked you, how confident are you from 0 to 10 that you could reduce this week, like, if we had made a plan for a reduction from a harms reduction standpoint? I'm a 4. And I would say, what makes you, why'd you say 4 instead of 3, do you think?

Preston: Yeah, um, I, I don't know. Um, I guess because I was able to not drink. At a party last weekend, and I was able to show history of that. Let's, let's break that down. So you started out with what makes you not a four, and then you switched to why are you a four? 

Margaret: No, I switched to, no, no, no, I said, What made you a four instead of a three?

And so that makes you that evokes change talk and that it makes you take the position of like well I mean a three would mean this and I actually feel like I have these strengths above it or whatever I could also ask you the next question. I would ask you would probably be What do you think? Maybe not when I first meet you and after you've had [00:31:00] success say What would it take do you think or what kind of support would be helpful to go from a four to a five?

In terms of feeling confident. 

Preston: So so I guess When I'm like, kind of layering the different sides and people are giving their scale 1 to 10, it's like, why are you not a 3 or why are you not a 1 and then what would have to occur for you to increase or for you to elevate your stage of change? And I think Dr.

Roberts, you have a great kind of tidbit as to why you use why going. Away and, and what would have to occur going forward or using like change versus sustained talk. And am I, am I way off base here? Or is this something. 

Dr. David L Roberts: Well, I'm just, I'm tickled pink because you use the exact phrasing that I like to use.

What would have to occur for that four to become a five or what could occur? 

Margaret: And 

Dr. David L Roberts: for me, the reason I like to phrase it that way, I think the typical thing that we do in counseling is we say something like, how can we get you into a six? 

Margaret: And, 

Dr. David L Roberts: and what that does is that creates a sense of. I'm about to give you a [00:32:00] homework assignment to try to make you do something and we're assuming because we're doing motivational interviewing that there's going to be an issue with motivation with this person.

We got to watch it. So if we say what could occur, it externalizes the locus of control, takes the pressure off of the individual. 

Preston: It's a passive suggestion. What would occur? It's more versus why are you harder is is an active almost interrogation. So. If someone asked me, like, why are, why are you drinking so much?

I feel like my response is a patient. And I think this is called like therapeutic reactants, which is almost like the desire to kind of just like resist unsolicited advice. Or if someone asked me why it comes across as accusatory. And so my desire is to resist that and go back the other way because I, because I have no choice.

You know, this out of my control, but when that accusatory like active language is being used on, why are you not drinking more than when you're resisting [00:33:00] it? Now you're going in the other direction more towards change talk rather than sustained talk. 

Dr. David L Roberts: And I love that about mi. I love that. There's a way in which you can play it like a game very strategically and I don't know how much we're going to choose to get into this, but I really think mi lends itself to Um, being simplified into heuristic strategies that are easy to remember and can be applied widely.

And that's really valuable for residents and other people who are trying to learn a million things. 

Preston: It's, it's like playing chess or sorry, playing checkers, I think is a better way, one move at a time, you're not thinking six moves ahead 

Dr. David L Roberts: and there's a lot of, um, Um, very specific phrasing and stem phrases that you can memorize or have on a piece of paper and try it out in the middle of session.

Preston: So, so let's get into some of those phrases. Um, and I know I'd love to hear kind of your description of this, but one, because motivational interviewing is identifying ambivalence and change, I think in a lot of ways, we're just holding a mirror up to someone's ambivalence and helping them navigate that.[00:34:00] 

We're literally reflecting that on the patient. So I guess I'm curious, what are reflections or how do you define reflections? And what are some of the different types of them? 

Dr. David L Roberts: Yeah. So I think of reflections as being the master technique or the foundational technique for working with people where there's resistance.

Um, or sustained, um, and what a reflection is, is just what a mirror does. So reflection can be either the definition, you know, reflection, meaning thinking about like I was reflecting on my youth or reflection, meaning, um, reflecting back like a mirror does to us. And so what, what we mean in therapy with reflections is mirroring back, sitting back.

And I think what's, uh, what MI has done for us is taken reflections, which, you know, Rogers brought in and really Carl Rogers in the fifties was emphasizing it, but, um, bringing in the idea of a complex reflection. So you have the simple reflection, which is when you're stating back, um, something that somebody, that a patient has said to you that without adding anything, I'm trying to capture it.

I went to 

Preston: the [00:35:00] grocery store last week. 

Dr. David L Roberts: Oh, last week you went and bought some stuff at the store. So I'm paraphrasing back, not adding, right? 

Preston: Wow. Whereas I feel heard. 

Dr. David L Roberts: You feel hurt. It's nice. But, but if I kept doing that too much, you'd get annoyed, right? And people ask that, but what about the patient who says, yeah, I just said that.

Why do you keep repeating back to me when I said, so you can't get stuck with the simple reflections. You've got to get into what we call the complex reflections or the deep reflections. And margaret, this is where I think mi really overlaps with psychodynamic therapy. Yes. Yes. As I was 

Margaret: thinking of the spectrum of like in psychodynamic, it's like supportive to kind of deep.

Interpretation and and where is the patient at? And when you're saying like complex, um, reflection, it's like maybe you're taking a couple steps towards, you know, you went to the grocery store and that was really important for you because you have been avoiding it because you felt so overwhelmed lately, 

Preston: you're trying to take control of your of your life more because maybe I didn't handle bills before.

So you're trying to like [00:36:00] reclaim the organization. So anyways, my friend went to therapy last week. It was his first session ever. And he said, Therapists just kept repeating the same stuff back to me. I was like, what is the point of this? He would be like, yeah, I mean, my girlfriend get in fight sometimes and the therapist say you and your girlfriend get in fight sometimes.

And he was like, I'm just getting kind of annoyed towards the end of it because all he was doing was like saying those things back to me. And I just want to be like, oh, he's just he's giving a lot of simple reflections, but he's not getting to that complex reflection. It was funny to hear it from his perspective as a patient who's never been exposed to this stuff.

Dr. David L Roberts: Yeah, so we think of that. I think of that as an instance of overuse of non directive technique. And then what we come to call circling the grain. So, yeah, that's referred to as stagnating. But one thing I wanted to say about reflections, which I think is a really important contribution that MI has highlighted is, uh, When we do an interpretation and we, [00:37:00] and the patient hears us saying, let me tell you what's happening with you.

We can sometimes become react where we don't, you don't understand me better than I understand myself or how you dare, how dare you tell me about my soul. Whereas in MI, we can accomplish the same end without the risk by doing it in the form of a reflection and attributing the insight to the patient.

What I think I'm hearing you say is that you see yourself as being similar to your mother this way and having the same vulnerabilities. That's what I think I hear. And the patient might say, well, golly, I didn't say that, but I do think that's what's going on. Right. And then you're great. You're bold. 

Margaret: It's interesting.

Cause I am in a psychodynamic, uh, like year long fellowship at one. Here in the paper we read last week was one called In the Neighborhood, which was about interpretations and the whole idea is basically like you need to say something that the patient can hear in psychodynamic when you're interpreting, but similar in MI, because that's one of my fears in psychodynamic is like, I want to work with [00:38:00] trauma patients, like I want to make sure that I'm giving them autonomy.

And because we're in a power hierarchy in health care, and they wait three months to see us, I don't want to interpret something and have people just take it in. And I think that's why I really resonate with the MI stance of how do I meet you where you are? And we do the little bit of change that's difficult together.

But I say something that is not overstepping, but is maybe helpful with the tools that I have for my training. So maybe I say, Hey, Make that yeah, just that like one step of reflection say does that land? I'm curious if that feels resonant with you 

Preston: I love doing that just saying like now I could be I could be way off base here, you know But are you worried about your health because you're working out more often or or I think And when I get those reflections wrong or I'm off base, then it's almost more powerful because the patient states what's really happening.

So let's say someone says, I've been exercising more and I'm like, Oh, you're, you're worried more about your health and they're like, no, but I'm worried about my body image. 

Dr. David L Roberts: You 

Preston: know, I want to [00:39:00] look different. Like, wow, now, now we've like really taken the conversation from just exercising to something that's like more present and that's inside that maybe they didn't have.

But then when they sat with like, like what is working out doing for me that it's still. Let's just arrive at the same goal. 

Dr. David L Roberts: I think another way to, um, deliver reflections in a way that kind of softens or qualifies them is through, uh, what is sometimes called parts work, where you talk to different parts of the client.

And I, and I think parts work also is, is sort of simpatico with MI because, um, in MI we're very often talking about ambivalence. And so we're talking about a part of you, this, and a part of you, that. So to sort of soften reflections of parts work, you can say things like, um, sometimes a part of you thinks.

Blah, blah, blah. Some, it's almost like sometimes a part of you doesn't like your own father. There's this little part of me that wonders if sometimes there has ever been a way you didn't love your own father. 

Preston: So, and then to that is like something like, like I [00:40:00] said. If I see my dad, I'm just going to punch him in the face and then you would say sometimes a part of you wonders if you don't want to be a 

Margaret: backup.

That would be like reducing. That would be a step away from the patient, but if you said like, I'm not looking forward to going home for the holidays and it's because I feel weird about seeing whatever this my dad, then you said you would saying there's part of you that feels like. Yeah. Uncomfortable being around him, but it's whatever hard for you to point at that, or maybe it feels weird to hold that 

Preston: and I love that.

Just the starting with a part because it implies it was another part. That's right. 

Dr. David L Roberts: Yeah, that's right. You don't have to own it. You don't have to identify as right. You can be encumbered by that, but you're still walking around still. It's like it's like 

Preston: you slide in the nuance Transcribed Yeah, because they're like, all of me hates my dad.

And you're like, a part of you hates your dad. And they're like, wait a second. A 

Dr. David L Roberts: part of me doesn't hate him. You're right. [00:41:00] We can refer to that often. I think it's Trojan horsing. Yeah, you can use the verb Trojan horse. Yeah. Yeah. We can do that a lot with double sided reflections, even though mainly you totally love your dad and you really are thankful that all that he's done for you.

Um, in your life, there's this little part of you that sometimes feels this hostility, but that's far outweighed by all that he's done. And then the client patient's like, yeah, that's right. Well, then you've Trojan horse did the hostility and you can refer back to that later. And they will, and they'll own it because you'll be able to say, this is something you've already said.

Preston: Yeah. So kind of in summary, we have the simple reflection. Which is really just saying a summary statement. We have a complex reflection, which is an interpretation beyond what the patient is saying. We have double sided reflections. Which way the ambivalence or is this part to work? And then I think it was one more that I'm thinking of at least called the magnified reflection and amplify the amplified reflection.

And then I want us to, after we [00:42:00] talk about the amplified reflection, we're going to try out some of these techniques, um, following Dr. Roberts with, uh, one of our guests here. We have a, we have a patient, 

Margaret: just kidding. 

Preston: It's Aaron. He's our producer. Who's going to be, it's going to be doing this with us. Okay.

So what, so what is an amplified reflection? 

Dr. David L Roberts: Well, let me just start by saying the Amplified Reflection is no longer in the newest edition of Motivational Interviewing. What? I use it all the time. I know, I do too. I think it's fascinating that it's not in there. Why is it not? Or what's the 

Margaret: reasoning? 

Dr. David L Roberts: I have a thought.

Preston, did you have a thought about why it might not be in there? 

Preston: It can be seen as pretty snarky, I would say. 

Dr. David L Roberts: I think that's right. I think that the Amplified Reflection is the one technique in MI That potentially violates the spirit of motivational interviewing, which is really the Rogerian spirit.

And so I, so with the motor, the example I always give for the amplified reflection is that what it's a technique for rolling with resistance or for responding to resistance. And when a client is [00:43:00] being extremely resistant, or it feels to you like overly or exaggeratedly resistant. It's a form of siding with, and even exaggerating that with the intention that the client will then disagree with it or the patient will disagree.

For example, patient says, I don't like going to that. I'm not going to go back to that doctor. I don't like the way she talks to me. And it gets in the way of the online dating. And then the therapist says that. Online gaming is very important to you, more important than your health. 

Margaret: Yeah, I can see how that can not always land the 

Preston: best.

Or, or then you say, yeah, I don't want to listen to my mom, I just want to play video games. Your life would just be one big blank without online gaming. You know, it can almost feel like an insult. And I think if you have this like neutral curiosity, it can land well. And it can help someone reflect on the absurdity of their statement of their reasoning.

But it's it's a tightrope walk. I would say. [00:44:00] 

Margaret: I feel like one way that I like to use is sometimes working with patients who are suicidal. Um, and there'll be some patients that are like struggle with suicidality or suicidal thoughts. They're like for chronically a long time. And that is a heavy thing to carry and also sometimes there's the sense of I always feel this 100 percent of the time always never and like, why are we even doing this therapy?

I'm always, I've always felt this way. I'm always going to feel it and I don't want to be alive. I kind of, you know, whatever and I'll ask them like, do you think that's 100 percent because you're here in my office and you, you know, you got dressed today. You did this, this and this and you just talked to me about your cat that you really love and how you saw it, you know, so I know there's a lot of pain here.

Okay. But do you think it's 100 percent of you doesn't resonate with being alive or is there a point, you know, is there one or 0. 01 percent that does? And I think that's coherent with, am I maybe not under directly the exaggeration? Sounds 

Preston: like parts work. 

Margaret: Well, I don't know that it's parts work as much as [00:45:00] it's like the 100 percent is an exaggeration.

Like being like, Oh, like, and it's, it's less flippant, I guess, than a reflection. It's like 100 percent of you doesn't want this or 100 percent of you doesn't care about your health. And you're pointing out the 

Preston: inconsistencies. Yeah, 

Margaret: I'm inviting them into the question of, because also sometimes I've had people be like, yeah, it is a hundred percent and that doesn't work as a way in for us to connect.

And so I say, fair enough. And then we move on to something else.

Dr. David L Roberts: I think what I would do as an, uh, as an amplified with that situation would be more like, uh, There is, uh, there is not a single instant in any day when you feel anything other than abject misery, you know, kind of along those lines. 

Margaret: Yeah. 

Dr. David L Roberts: Yeah. 

Preston: Okay. So let's go to a break right now. And then when we come back, we'll bring on Aaron and we'll kind of do some practice with some of these techniques.

Let's run out. So Einstein's monster. Yeah. 

Margaret: Just kidding. I think we can, we can do a 

Preston: round robin, let Aaron practice on us. Yeah, I think 

Margaret: [00:46:00] that's, that's only fair. 

Preston: Okay.

I think we have a patient who's joining us. 

Margaret: Come in. 

Preston: So, so welcome to the clinic, Aaron. 

Margaret: Hey, 

Preston: so, uh, Aaron, it's nice to meet you. I'm Dr. Roche, and these are my colleagues. 

Aron: Hi, Dr. Roche and colleagues. 

Preston: Okay. So, so I, we already briefed Aaron a little bit on this. And before we kind of get into character, I think the, the purpose of this is to kind of see how some of these techniques work.

Live and so Aaron kind of has this character that he's gonna adapt So last time we talked you had a habit as a character that you're hoping to change. What was that habit? Well, 

Aron: okay I don't know. Maybe it's my own insecurities on it, but I don't have it feels loaded, but I like my social medias Okay.

Preston: Okay. Okay interesting. [00:47:00] So I guess without further ado we can get into talking about this This love of social media and, uh, Dr. Roberts, take it away. 

Dr. David L Roberts: You take it away. 

Preston: Yeah. 

Dr. David L Roberts: So it sounds like you're kind of of two minds about this. There's a part of you that really loves the, the social media, but you've come to kind of talk about maybe reducing it.

Aron: Well, I'm torn because I find myself completely dependent on it for a lot of aspects of core social interaction in my life. But on the other hand, uh, I, I, I understand that it's. Working counter to that, because I'll spend evenings and free time just scrolling through reading about people I don't even interact with anymore.

And I just, I don't know, I haven't yet found a good solution for it. And everyone on the internet doesn't seem to have good solutions for it, other than apps that make it block it for you and stuff. But I wind up creating loopholes in the apps. So it's just all this endless cycle of, of it. And I know this is [00:48:00] like, not just me, this is a generational thing, but, uh, yeah, it's, it's a thing.

Dr. David L Roberts: Yeah, I think you're right. You're not alone. And like, there's a lot of, a lot of us, myself included, who are struggling with, with social media and trying to figure out the balance, it sounds like you're certain that you want to make some sort of a shift, uh, to continue to get the benefits of it that are necessary for social engagement.

And yet there are some real downsides. It sounds like wasting time is one of them. 

Aron: Well, I have ADHD. So it's like, I'm so prone to need that stimulation. So it's just kind of hard to know what to do with it though. I don't know if we can help at all, but I, I haven't, I've learned that. I heard once you shouldn't learn guitar without a teacher because you can't learn guitar from someone who doesn't know how to play guitar.

So I'm trying to apply that here as well. 

Dr. David L Roberts: Well, say that, say more about that. 

Aron: Uh, about the guitar quote? Like 

Dr. David L Roberts: how that 

Aron: applies. Oh, uh, [00:49:00] I clearly am trying to rely on myself to overcome a problem that I have no background in understanding how to overcome. 

Margaret: And you've tried a lot of, you've put in a lot of work on your own kind of trying to overcome that.

Aron: I've spent so much time even downloading apps to help regulate my usage of apps. I, I don't know. I, I know it's insecurities. I feel kind of stupid, like, or not stupid. I feel kind of like helpless to it. And so it's like, I don't know where to go from here other than like completely remove my profiles and accounts, but it feels like I'm losing.

I don't know. I feel like I'm losing, like, a part of me, because, like, I have decades of stuff on Facebook, photos and memories of things, you 

Dr. David L Roberts: know? 

Aron: A part of you wonders 

Preston: if it's even possible. 

Aron: I know it's possible, I just wonder if it's possible to do it without, um, feeling that, like, vestigial limb all the time, of, like, you know, feeling [00:50:00] like it should be there and I'm missing something, but it, you know?

I 

Dr. David L Roberts: mean, you're, it sounds like you're also saying like with the guitar, maybe what will make it more possible is if you get help from people who have some expertise or something. 

Aron: Yeah. I mean, like I said, all I found is these extremes. People I know in the internet, I'll say you have to just delete your account and I don't want to just do that, but I don't want to feel helpless to myself.

So yeah, I, I, I would appreciate any, any ability to digest a little bit together, what I can do at this point, because I know that I cannot do this on my own, clearly. 

Dr. David L Roberts: You're, you know, you want to make a change. You're certain of that. 

Aron: Absolutely. 

Dr. David L Roberts: Kind 

Aron: of have to, otherwise I'm not going to like grow as a person.

Dr. David L Roberts: And that's important to you. 

Aron: Yeah. Yeah. I think, I think so. Typical millennial. I spend an overwhelming amount of time reflecting on myself. 

Margaret: What does grow as a person, you know, if. If you imagined a world where you felt less, you know, negatively connected with [00:51:00] screens, what do you think, what do you hope that would like allow?

What kind of things would that allow into your life or kind of living of values? If that was true, that was less of a barrier. 

Aron: Probably going out more, probably seeing more friends and family and just kind of, I think, I mean, this is probably how it used to be before as much technology. Was in our lives, right?

Is okay. If I don't have the ability to doom scroll, then I am going to go for a walk. I'm going to go out. I'm going to go see a movie. I'm going to go to a bar. I'm going to get a coffee. I, you know, I'm just going to find my, I'm going to find myself, uh, itching to get stimulus in another way. That'll get me more connected with people rather than, you know, knowing I could go out in a little while.

And then it's two hours later, and I've been scrolling through Facebook, looking at high school friends, deciding if I've aged better than them. 

Preston: So it sounds like you have. The desire to change and this is question of if that ability exists to change and I guess I'm curious on a scale of 1 to 10. How ready are you [00:52:00] to act on that change?

Aron: I don't know. I guess there's like 2 parts, right? Like there's a part of me that's very consciously present with it and I'm 100 percent 10 out of 10. I gonna use percentages instead of your numbers to mm-hmm . Sure. Show a little control of the, the conversation for me. , I don't know. 

Margaret: Hell yeah. , 

Aron: I'm gonna fight back.

Um, yep. What? Whatever metric you want. Yeah. Um, so definitely Tyrannosaurus Rex of the dinosaurs for how ready I am. Umhmm. But when it comes to, when it, like I said. I, I haven't, I feel very like, like a one or two when it comes to like commitment to do it without regret. Like I said, what keeps happening to me is like, I have this like montage of my head of all my life's memories since like late high school, which is when like Facebook came about for me.

Cause I'm old. And like, I just like, I'm like, okay, I'm going to like have a Thanos snap of my life story.

Preston: What would have to occur for that one or [00:53:00] two to become a three or four? 

Aron: Well, it's funny is actually removing Facebook allows you to like export all of your photos and memories and things from it. So if there was like a really good app that let you download all that and put it on that app, so it's searchable, then like, I think I'd be good, but I just don't want like a pile of files.

Margaret: What I'm hearing you say across kind of multiple things that you're saying is that Connecting with people and keeping memories is really important to you. And one of the reasons you want to change your relationship with your phone isn't because you want to get rid of all of it necessarily but because it's getting in the way of that core value and kind of taking it and maybe the doom scrolling is making so you don't Get that connection.

But one of the reasons you feel split about it is because you value those memories and those photos. And maybe there are some moments of connection on the phone that you do get to have that. It's hard to just let go of. 

Aron: Yeah, absolutely. Yeah. Yeah. It's almost like I hadn't thought about till now. But [00:54:00] like, I know we're coming out.

Apple's coming out with the Yeah. The AI stuff. And we have all this AI stuff coming out now. And I'm like, cool, maybe there's going to actually be an ability for me to be like, Hey, Siri, take, I'm going to download all of my Facebook stuff. Now, can you please like index it and make it searchable for me? So I guess maybe AI will solve a lot of this.

Maybe that'll be a big part of this for everybody. 

Dr. David L Roberts: How important is this change to you compared to some of the other, um, things in your life? We're all busy people. We all have a lot on our plate. How high a priority is that? 

Aron: Pretty high, actually. Um, I work a lot and I spend a good amount of time with family.

Um, but, uh, I live in a new city. I moved at the beginning of the year. Uh, and I already have a good base of friends here, but I really want to make more and build community and build a whole new life here, uh, uh, So for me, I almost feel like, again, ADHD, if I don't have [00:55:00] one thing to fill that hole in my head, I will go search for it elsewhere.

I know myself. So to me, it seems like it's a big obstacle for, for social growth. Yeah. 

Dr. David L Roberts: And it kind of feels to me like you're going to have to. Somehow, um, make it impossible for you to make the choice to use social media, the way you've been doing it. That feels like, uh, it has to involve that. 

Aron: Yeah, which is great.

Cause all of my work is in digital media for professions. So, you know, it's, it's, uh, It feels a little weird to do, it feels hypocritical to work in the realm of me, I work in media, uh, and content, digital content, but I won't be partaking, it definitely feels like I'll be a drug dealer who doesn't smoke weed, you know, like it, there's a little of that for me also, but I think I have to do it, I just find my, again, I think it's the ADHD thing, I just find myself losing hours doing it, and then I, Don't go do the activity that I don't go to the [00:56:00] writing group.

I found at the coffee shop nearby. I don't find myself going to, you know, board game night at the local board game place and making new friends. I find myself doing that and scrolling. Instead. 

Margaret: I wonder what if on one hand, I hear you saying you really want this change. This change has to happen and it has to be this way.

But then also that maybe you've tried this kind of cold turkey method before and it's been really hard. And I also hear you kind of saying. Yeah. There's a split between yourself like in yourself of like, do I actually want to get rid of all of this? Right? And I wonder if we went outside of these more extreme options and more thought of what small experiments We could do to change the way of relating to this and have a little bit more space so that it doesn't take up as much I wonder if that's 

Preston: not am I?

Margaret: Is it not 

Preston: i'm just kidding 

Margaret: Sorry, 

Preston: keep keep going. I don't know what you meant, but i'm just laughing with you guys. Yeah 

Margaret: What is that not am I I feel like that's am I Well, there was act 

Dr. David L Roberts: [00:57:00] in there, but 

Margaret: I'm sorry. It's 

Dr. David L Roberts: not. Yeah. 

Margaret: Yeah. Well, we're coming. I'm, I'm in the evoke. I mean, we're evoking and planning.

We're doing that. Sorry. I'll get 

Aron: it. Yeah, you're right. You're right. 

Margaret: Uh, guys, you're being so reductive 

Aron: about me as a person. This feels weird.

Margaret: Um, but yeah, what, what would, I wonder like what it would feel like to think about sort of creative in between solutions to change how much it's taking up or things for us to try. If we were in our fake clinic, 

Aron: I know the one thing that I don't know about you guys, because I think it's an everyone to some degree has this.

I don't think I don't think many people are immune to this in their lives to some capacity. I know having the apps on my main home screen is just a conditioned thing at this point that I check my work emails. I check texts. I check, you know, a couple of the main things and then If I don't have anything else to click on, I don't lock my phone put away.

I then by default click on Reddit or click on Facebook or [00:58:00] click on Instagram. So I wonder if almost like I'm clearly not going to forget they exist. But if I remove them from my hold screen and like hide them and like one of those back pages, none of us go to, but we keep our apps and maybe it's that conditioned clicking.

Preston: What would your life look like if you didn't have them on your home screen or weren't compelled? To view them on your home screen, 

Aron: I think I'd be like, you know, it keeps me and maybe I'm wrong, but it keeps coming back to me that I would be more encouraged to go do the recreational and social hobbies that I love.

I am a sculptor and I have had evenings after work where I'm like, okay, I'm going to sculpt for the next hour and a half and I then blink because time blindness and ADHD. So it's like I'll blink and it's 11 at night and it's like, well. Time to get a fig bar and go to bed because I missed everything I was going to go do tonight.

Um, so, you know, it's like that, or I play guitar. I could have been practicing guitar and felt, felt good at the end of the day. And the next day not [00:59:00] wake up feeling like I kind of burned my free time and I'm antsy and grumpy. So I just think for mental health, I'd just be a little more balanced. I'd feel a little healthier.

I'd be more social. 

Preston: Those are, those are high stakes on what you're looking at is kind of the ideal life that you may have and what's standing in the way of that is this phone screen and 

Aron: whoa, that's so much less guilty than the way I think of it because my head, my narrative, by the way, when you said that was the thing that's getting away of it as me, like, that's how I, that's how I feel that in my head.

As you were saying, it's hard to interrupt 

Dr. David L Roberts: seeing yourself as the obstacle contribute to your stuff.

Aron: It's a familiar guilt. Yeah. Again, you could probably tell I've done a lot of therapy and work for ADHD. Um, I, I have a lot of like long term guilt with knowing that I am my own obstacle in a lot of situations that wind up being things that I didn't even notice were problems in my life until later on.

And then [01:00:00] it, you know, it's kind of depressing to be like, cool. It's like, yeah, it's mental illness, but like, that's not healthy to throw that in the way. So it's me. It's like, I could have been working on that better. Earlier. And of course, it's always nice when I read articles or see things where people talk about, um, how like social media actually is a bit of like a crisis that has to be addressed and it is an actual, like, it can be a disease.

It can be like that is validating. And I think it's not just me. A lot of people probably find that validating that, you know, I don't know, like the AA of, you know, higher power needs, you know, it's like, I am helpless to it kind of thing. Yeah. 

Margaret: Rather than like you are someone who's struggled in the world of alcoholism Like someone had once put it as rather than viewing you as the person who has a problem with alcohol Maybe it's that alcohol is a problematic substance and maybe similarly with social media It's not that you are just specially messed up and everyone else is cool with this and only you don't know how to [01:01:00] use it It's maybe more likely this is sort of a substance that does this to people or it's a yeah and that's a much less guilty and kind of othering than Hey, you suck.

And that's why you can't do this. 

Preston: Like, like every time my, my plant dies, is it, is it because I didn't take care of the plant or could the plant just not keep up in a high paced environment like my office? 

Margaret: You're shaming your plant right now. Your plant right now itself is plummeting. The truth is, 

Preston: it's probably a combination of both.

And I think it's hard to hold that nuance together. 

Margaret: And that'll be our couples therapy episode is pressing these plants. Yeah, yeah, exactly. 

Aron: By the way, let me know, because I have a lot of like marital plant propagation things to work through also, so. It does feel like a drug though. It feels like just like any other drug that for me, I could have just as easily found that dopamine Delta fill in my brain with, with, uh, a drug, [01:02:00] right?

I mean, I guess I am on a drug. I'm on methylphenidate cause I take Ritalin, uh, to, to focus on work, but I guess. That still that difference to fill in could have been alcohol. It could have been harder drugs. It could have been extreme sports. I know a lot of people who, you know, rock climb and do crazy things, and that helps them with their ADHD.

So for me, I guess, yeah, Facebook, the other ones a bit more, but Facebook really gets me because I'll just be strolling through. And it's always novel, right? It's like always people that were a part of your life. And now you're learning something new. And why would you want to not indulge that FOMO? 

Margaret: Yeah, yeah, I wonder if we, if we time here, I 

Preston: think it's a great place to, to pause.

I 

Dr. David L Roberts: mean, thinking about this, this change with your social media, I'm wondering if you think back on your life, if, uh, what do you remember about other changes you've made that have maybe been similar? 

Aron: Sure. Okay. Well, how about this? Okay. I think this is the most helpful thing for [01:03:00] everybody and probably for me too, and I'll feel better about it.

I'm going to out myself as a producer on this show, and I'm, I'm, I'm, oh my God. Oh my God. Who 

Margaret: are you? 

Aron: Yeah. All the new listeners to this show, how to be patient. We are full of deception. It's like the worst kind of undercover boss review. I can see you 

Margaret: through all the prosthetics. Yeah. 

Aron: We want to subvert your trust in this, this show early on, guys.

Um, no. So, uh, they asked me to come on and share something real. And like, this is very real. I'm not like making any of this up with you guys, but no, but I'm tapping into something that was a problem for me, probably more like six to eight months ago. So I actually have dealt with this. Um, and so I think that's the best.

Thing to share, um, we get to fast forward it a little bit. Um, but I was being honest with you guys. Those are like the feelings I have about it and the risks it has in my life and what it did. What I did do is I wound up taking the apps that were eating the most time, which for me were Facebook, Instagram.

Definitely [01:04:00] YouTube, um, especially now with YouTube shorts. It just really, you know, You're 

Margaret: not watching us on TikTok, Aaron. You're the 

Aron: only, so by the way, I only have TikTok for work. I, I, I will not go on TikTok for anything other than professional purposes because I know what it can do to me. That's extremely fair.

Yeah. It's like intentional. I know I, I eventually had to, uh, Rob, one of the other producers on here, like, and Shanti, they would tell me like, you gotta go on TikTok to like, look at all this content. I'm like, I, you will never see me again if I start using it for recreation. So TikTok I already have hidden away, but what I did say, took the apps that already eat up the most time for me.

Um. Except LinkedIn, because I feel like LinkedIn is always useful, doom scrolling, because you can always look, you learn about your, like for me, I like learning about my industry and learning about things in it. So it's like, it's helpful. I grow as a person from it. And I put them all in like a hidden folder that I did put at the back pages and it's out of sight, out of mind and kind of was like, Oh, is that Pavlovian [01:05:00] conditioning?

Removal going to help me. And it really did. Um, I found myself not checking my email, checking texts, checking the basics and then seeing just, oh, read it or YouTube and clicking on it just idly and passively and then being sucked in and blinking and be like, Oh, I was not meant to take a break right now.

Um, And that made a huge change for me. And I find myself having a lot more intention behind what I'm going after. If I go on Instagram, or if I go on, if I go on YouTube, I'm going to see something I wanted to go see, learn about topic or, you know, I know that I want to lose an hour of my day and go watch some funny thing.

Um, and that's helped a lot. 

Margaret: What strikes me so much about how you describe what worked, and I feel like what would be evoked also in like this setting with MI is like the level of kind of Thoughtfulness and curiosity and kind of like mind of a scientist or, you know, behaviorist of experimenting with what worked and what that just, you know, I know you're telling us what has worked and kind of fixed it, but also that [01:06:00] that maybe in small ways, you might have said something similar that would have been like more concrete, more detail and helped with the feeling of being stuck of like, Oh, well, actually, that did kind of work.

And you. Wasn't, you know, throwing my phone into the river and give you some more space to maybe try and try out changes in the work that we would do together. 

Preston: And it was a middle ground that we were able to find. 

Aron: Yeah, and it continues by the way, like I yesterday had a little like worth myself of like, you brought YouTube back, buddy.

You started to trust yourself and you brought it back. Look what you're doing. Um, and now I have to move it again. So I'm starting to figure out which ones I can regulate better and which ones I can't. So it's, it's, but that one has felt the most organic doing it this way. 

Dr. David L Roberts: I think it's interesting from a motivational interviewing standpoint and the way I've come to think about, am I.

In terms of how you were presenting as a patient, because you were presenting, I think of it in terms of a scale of one to 10 with motivation from, you know, one or zero being absolute [01:07:00] lack of motivation. 10 being a lot of them, you were presenting in a way that's not the typical MI situation. The typical MI situation is a person saying, ah, My wife made me come, I don't want to be here.

Doctors are full of it. I don't want to make changes. Um, but you were saying I really, really desperately want to make a change and I, and I'm not able to do it. I'm, I'm, I'm struggling to figure out how. So in a way, there's a lot of the techniques of motivational interviewing around engaging and rolling with resistance didn't really come up so much.

But I think what, what did come up and maybe we, and we used it some, but not gobs was evoking change talk. Um, right, but even there, the issue I think wasn't, I'm not motivated enough to get myself to try to change. It was more. Strategery, right? Like, how, how am I going to go about it? What's going to work.

And maybe there was a little bit of, I don't, I maybe I won't even try because I'm not confident that it will work, even if I do try, or I don't think I have the ability, maybe. Preston brought it up. [01:08:00] Ability. I don't think I have the ability, so I'm not even gonna try. Was that, was that ever part of it for you?

I don't have the ability, so I'm not trying, I'm, I'm, I'm so guilty, I'm seeing myself negative around this, so I avoid and don't try it. Or was it, I just don't know how to do it. I gotta figure out 

Margaret: how. And there's part of it that you were like, this is impossible. Or like, I need to find someone who knows how to do this.

And I don't. Everyone has this problem, 

Aron: I think on a subconscious level. Like, just like a lot of us like it. Just as always, like, what am I going to do? Delete it. My friends who deleted it, like they disappeared from the world when they delete, like, what am I going to, like, it was, it was never really something I took too seriously.

I was always just like, yeah, it's not good for me, but whatever. And again, like I said, when I moved, uh, I, I just moved after 18 years living in Southern California to Oakland. And when I moved here and I have a new life now. That's what made me realize how much it was getting in my way versus when you have a established life, you don't notice how it's ingrained there.

Preston: Yeah. I found myself almost wanting to lean more into like [01:09:00] Socratic CBT questioning with how motivated he was to change already. So when you said, you know, what am I going to delete it? My friends who deleted it were erased from the face of the earth. I think my gut was to go with like, well, what happens if you disappear from the face of the earth?

What's so bad about that? Yeah. Like what? And it's kind of. What I saw is that we're almost equating this idea of like not having this connectedness to death and What does like death look like for you? And it seems that, like, that's a high stakes or I use a lot for my clients, like this is tough, right? If we get rid of social media completely, we have essentially died and and now saying, well, what is so bad about that?

Why is this? Why is this thing so scary to us? And I think that's more of a CBC approach. It was just fascinating to me to identify how ready you were to change and how I almost want to switch modalities. 

Dr. David L Roberts: I think I agree. I think hearing how where you were to To change and how important it [01:10:00] felt to you, my mind was going more behavioral towards, sounds like you're ready to start doing some experiments and figuring out what's going to work.

Preston: Yeah. 

Margaret: Yeah. 

Preston: So, um, briefly, I want to, I'll, I'll step into character for a second. I'll kind of be the more classic, um, MI patient. And I guess the scenario I'll give you is I'm a college student. I'm 19 and I'm drinking every day. So I, I, I drink a beer before I go to class. I drink in the evenings. I'm, I, when I stop drinking, I get the jitters and I, and I'm feeling, I'm feeling out of my classes.

So as a part of that, I've been mandated to go to therapy. And, and so I kind of, I show up here now in therapy and this is kind of the context and that's, that's what you're reading on the doorknob is like 19 year old student, all these alcohol problems. I've gone to the ed, let's say twice for, for alcohol poisoning.

I've been let go. I didn't have to have any inpatient [01:11:00] stays. So, Hey, 

Dr. David L Roberts: I think, I think a really nice way to start off this conversation is how, how are you feeling about your drink? Okay. 

Preston: Um, I, I didn't, I didn't think this was about my drinking. I thought it was about my grades. So I can 

Dr. David L Roberts: see right from the beginning.

It's there's some confusion about what we're even going to do here, figuring out if this is going to be 

Preston: a 

Dr. David L Roberts: useful conversation. 

Preston: Do you guys think my drinking is a problem? I thought it was because I was feeling the semester that I was being sent here. I 

Dr. David L Roberts: have some reports here. I have a report regarding hospitalization for intoxication, and that concerns me because I know that that could, that that could have health consequences.

But I really don't know the role it plays in your life. That's really what you understand, but I'd love to hear from you about, 

Preston: Oh, well, I mean, I'd like drinking as much as the next guy, you know, it's just, it, I feel good when I do it and kind of takes the edge off and lets me kind of get through the day.

It's really, it's, you know, but I don't think it's a problem. 

Dr. David L Roberts: You see a lot of other [01:12:00] lines too. It helps you in a lot of ways. 

Preston: Yeah, yeah, I feel good. Um, when I drink and like who, who doesn't want to. Like get through their day. Like everyone has their way of coping, you know, like, like I don't smoke cigarettes.

I don't do these hard drugs. I just drink. 

Dr. David L Roberts: Yeah. I'm, I'm, I'm, I'm, I'm seeing the grades and I'm, uh, your referral here. I'm gathering some people I've said to you, they're concerned about this. Can you tell me about that? 

Preston: Yeah. Well, I mean, my teachers have like pulled me aside and kind of said like, Hey, like I saw the beer can and the side of your backpack where you kind of smell like alcohol, like get your stuff together.

And so like, I know like they've noticed it, but I think I'm failing just because I'm not studying and doesn't have as much to do with the alcohol. 

Dr. David L Roberts: Alcohol is not related to your school difficulties. 

Preston: Well, I mean, sometimes it's kind of hard to wake up in the [01:13:00] morning because I've just drank a lot the night before, and then I'll like sleep through a class.

So that does make it hard. So, so I guess it's related in that way. But like, but outside of that, I guess not really. 

Margaret: What's your major? 

Preston: Um, political science 

Margaret: is 

Preston: so they always have the classes in the morning. I don't know why, like the poli sci department is like that, but it does, like, really suck because, like, I'll miss an 8 a.

1. lecture. And then, like, I try to watch the recording, but 

Margaret: Uh huh. 

Preston: They barely capture the audio. It's always like really spotty.

Dr. David L Roberts: It sort of gets in the way of, of, of your lifestyle, of the way you like to live your life, maybe more staying up, uh, not so much early morning. 

Preston: Yeah, it does, I guess. Like if I could just wake up earlier in the morning, then I could like go to class on time. And I probably wouldn't be like having these problems.

Dr. David L Roberts: You're saying that the, that, that there's a conflict between drinking and political science. [01:14:00] 

Preston: Oh, I, I guess so. I mean, I didn't really see it that way, but 

Dr. David L Roberts: what do you think? I'm not sure if I'm seeing it right. Is that, is that, is that what I'm hearing you say in terms of getting up in the morning? And 

Preston: yeah, I mean, I guess if I drink a lot, so, so if I drink like six beers at night and then I pass out and I don't wake up until 11, the next day, like that's going to make it hard to go to class.

Like it's a pretty easy connection. So I guess pretty obviously like the amount I drink is going to affect my grades. 

Margaret: Yeah. So. 

Preston: You know, I'm not an idiot. Like I can see that connections there. 

Dr. David L Roberts: What do you see looking forward? Um, let's assume you don't, um, you don't change. It sounds like you're not really looking to change.

Um, 

Preston: well, I don't want to get kicked out of college. Like I would, I'd love to be able to keep drinking the way I am and be successful in school. I'm just not sure if I just, I don't know if I'm going to like. Make it through the [01:15:00] semester. 

Margaret: You're not sure if you're going to make it through the semester because of 

Preston: because my grades 

Margaret: because of your grades.

Dr. David L Roberts: Yeah, you're seeing ways in which the the drinking at least with political science contributes to the grade there. But but you're not so sure about the other course. 

Preston: Yeah, it does. I mean, like for poli sci, if I could just drink a little bit less, I think I could probably salvage some of those because a lot of it is really just getting FaceTime with the professor.

Margaret: And 

Preston: then I think I do okay. And the other ones in the afternoon, we'll have time to like, get a shower and have some food and other things 

Dr. David L Roberts: drinking show up in, in other parts of your life. How does it affect relationships? Uh, other things that are important to you. 

Preston: Well, my, my girlfriend makes like some snide comments about it.

So she'll kind of be like another one. Like she'll roll her eyes. I'm going to go to the fridge. I almost, I almost feel like I have to hide myself. Like I go around the other side of the house when I go to the fridge to get another beer. Cause I don't want her to see [01:16:00] me, but she, she knows, but she hears the sound of it open.

So maybe like, like, I wish she would get off my back, but also I kind of get it. 

Dr. David L Roberts: You get it. What do you, what do you get? 

Preston: Um, I mean, she, she says, like, I'm like, I'm a different person when, when I'm drinking, so I kind of want to be the person that she wants to date. Like, I wouldn't want her to turn into a different person.

So I guess that's why I get it. 

Margaret: Yeah. What kind of, what kind of different person do you think you are, um, when you're, you know, maybe drinking versus when you're not as much or different at a different level? 

Preston: Um, I just think I get angry easier. 

Margaret: Yeah, 

Preston: like it. I know it sounds dumb because I said it takes the edge off earlier, but sometimes I also like just have a short fuse.

So it's kind of like, you don't know what you're going to get. I think I'm more unpredictable so that that can probably [01:17:00] make me be the person I don't want to be. I guess I think when we do get in fights, triggers, alcohol is usually a big trigger.

Dr. David L Roberts: It plays a bit of a challenging role in the relationship with your girlfriend. Alcohol. 

Preston: Yeah. So I guess school and my relationships kind of sucks. Maybe, maybe drinking isn't the best thing. I don't know. Okay. I think that was, that was great.

That was really good. I know. Yeah. And I think it's great because we can, we get to see what. And my looks like with patients on almost 2 opposite ends of the spectrum. So we have we have Aaron who is motivated and unsure about his ability. And then we have this person called Eric, who was unmotivated completely and originally didn't even recognize that.

Drinking [01:18:00] was a part of the problem. So yeah, Dr. Roberts, I thought you did a great job of like kind of just like sliding or seeping those connections between my issues and drinking and even just kind of like acknowledging that like you're seeing something and kind of leading me to it. I try to be kind of sticky, but not like the stickiest.

Patient ever, you 

Margaret: could feel that, like you, you really well, like kind of walking right along that line of having the conversation and not shying away from it or being too kind of non directive versus pushing him right back into the defensiveness. 

Dr. David L Roberts: Yeah. Yeah. You know, one of the things that sometimes comes up when I'm doing motivational interviewing trainings is people say.

I don't like all this pussyfooting around. I like to be direct. 

Margaret: I don't like all this mealy mouth. Yeah, 

Dr. David L Roberts: yeah, yeah. Like stop, like, BSing and just trying to be nice and be straight with the person. Um, and I think that that's a fair point. I think there's a way of doing MI that's more on the non directive end, which is more soft.

And for [01:19:00] some clients, it's even confusing. It's like, wait, what are you trying to say to me right now? Um, I think other people who do MI do it in a really much more directive way, and I think when I'm doing trainings and I hear somebody say, it's kind of like, Oh. I don't have 10 minutes to sit around and be mealy mouthed and not really saying anything, right?

That's when I think we want to say, okay, no, you need to get in there with some specific MI techniques, right? And you can, uh, but, uh, but by the same token, I saw Margaret, you smile at the end when Preston near the end of that little role play when he's like, oh yeah, maybe drinking is a problem. It's like, that's not how it happens either.

Yeah. People don't change that. 

Preston: No. And I think what's funny is that three visits from now I come in and I say. I'm 100 percent ready to change. I just don't think it's possible because my, because my friends, they, my friends who stopped drinking, they disappeared off the face of the earth. They don't come out to party with us anymore.

It's like they don't exist. It's like they don't have 

Margaret: their social media. Yeah, 

Preston: it's like my friends who stopped drinking and died. And so, so you can see how me getting into this, like, I am like steps away from going to Aaron [01:20:00] as far as the stages of change. We're kind of on different ends of the staircase, but like a couple of session.

Yeah, also not really. 

Margaret: I feel like, though, like, this is like a person in therapy or am I or in my like outpatient where, like, if they kind of suddenly change. I think that there's this like, like disconnect that we're actually like, it's not a step backwards, but it is kind of a like door, like it's a barrier in some ways, because it's like, okay, I don't see how we got there, because like motivation is sort of a slowly grown thing, and so if there's a sudden change, I either feel like they're trying to be a really good patient and please me, they're trying to get me to shut up, um, they maybe also are someone like, I say this as a rationalizer myself, or intellectualizer, that's like, okay, you know what, now I've realized it, and everything's gonna change.

It's going to feel different. Uh, and so I get like, whoa, whoa, whoa. That's a big, like, I start reflecting back the like reasons, not for them to not change, but being like doing more than like double sided sort of statements maybe. 

Preston: So thank you so much for coming Dr. Roberts. Um, before [01:21:00] we kind of wrap up, I want to give you a chance to shout out anything, any projects that you're working on or stuff that you would kind of like to bring attention to?

Dr. David L Roberts: Yeah, thanks, Preston. Well, you know, one thing, um, I took a sabbatical a couple of years ago to write a book on using motivational interviewing as psychotherapy. And then what I ended up doing was getting sidetracked and developing a training approach because the more I thought about How to best equip people to use this approach.

It wasn't writing a book, it was creating practice opportunities. And so, um, we've created a website called reflective training. org. Um, you're welcome to come. I saw Margaret went on there earlier today. I 

Margaret: was trying to get in there. Trying 

Dr. David L Roberts: in there. Um, it's a very unusual website. It's free to individual users.

Uh, but, um, we train through one hour online, flexibly scheduled, essentially zoom meetings. We have a calendar there and then we do motivational interviewing, but we also do all sorts of other different counseling and psychotherapy approaches. So if [01:22:00] anyone's interested in participating, you can go on, sign up and you'll get an email from one of us.

Margaret: I already did. Yeah. And I'm not just on there. Maybe. 

Preston: The one thing I love about your training model is that. It quantifies the therapeutic skills. So being able to say, Okay, my goal was this many open ended questions or close ended questions. And it really helps me have an awareness or a barometer to the diction that's coming out of my mouth.

Because the only other way you can do that is by re watching recordings. But even then, it kind of gives me sleep. A lens and a criteria to be like, Oh, that was a good open and reflection precedent or that was a good complex reflection. Too many simple reflections here. Like, maybe I couldn't can nuance that.

So it it almost feels like watching back like my my soccer tapes or my or my sports footage with good critiques on how to get better. So I appreciate it a lot. 

Dr. David L Roberts: Well, thank you for that. I'll make a quick comment about that. Just I really, um, um, Found myself drawn more and more towards bringing objectivity and empiricism [01:23:00] into our psychotherapy training.

I think it's a little too loosely conversational. Most of the psychotherapy training and supervision we do, which is great. You got to talk, talk, talk it out and talk through it, but you also have to. 

Margaret: Right. I like think of it as like, you can read the Ikea furniture instructions, but that's a very different thing than actually.

Putting the furniture together. And I feel like watching sessions, doing sessions, recording, and then like actually having critique, even in a group when it's not you doing there, doing a session is like the equivalent of, we read the instructions. Now let's try to put this clunky chair together. Together 

Dr. David L Roberts: made in, made in Finland.

And then one last little thing is the, the, the process of practicing historically, we usually practice on our patients. And I think it might be time to start making an ethical argument against that. I think we might need to start ethically saying we need to practice with each other, not with our patients.

Yeah. Neurosurgeons do not practice on their patients. 

Margaret: Right. Right. Or we need to have simulations that [01:24:00] are more thorough, um, before we start diving in, in terms of like, like a misplaced. Interpretation or misdone therapy that isn't really thoughtful. I think, especially in psych residency trainings, like you don't just go to med school and then know how to do therapies.

And so it's kind of like being like, I think a misplaced interpretation or or therapy approach can be like insert the surgical equivalent would be like I'm just gonna throw this like scalpel in there and see what happens and it's like, no, we should maybe we should have a patient 

Preston: gets 

Aron: an infection.

It's their fault. Is this what you just did to me? Because this is feeling very weird. I'm 

Margaret: a fourth year. I've taken a lot of therapy trainings. Okay. Some say too many, but I think 

Preston: without proper feedback, like it breeds complacency. It's really easy, especially in psych to do a bad job and think you're doing great.

Okay. When you just kind of don't have any objective way to measure and and especially in psych You don't see the outcomes right in front of you like you do in other specialties So I I [01:25:00] really appreciate having that objectivity as a way to guide improvement And then Aaron we also didn't give you a chance Do you have any projects that you want to shout out or oh, wow are things you want to lend support to Wow?

Listen, 

Aron: let me just tell you guys that all the listeners Everyone out there just want you to know, watching it, whatever app, whatever streaming service, whatever you use to consume and enjoy how to be patient podcast, whether video or audio, that is the app to never take a break from that is the app to never put aside.

You're being a shill. You're being 

Dr. David L Roberts: an absolute 

Aron: shill. Um, I just love you guys, guys. The thing I'm, I'm proud of you guys in this show and you guys are awesome. 

Preston: Oh, well, thank you Aaron. 

Margaret: We're proud of you. Our patient . Oh yeah, 

Preston: that was, you did a, you did a scary thing and talking to 

Margaret: us, , 

Preston: I think anyone would feel a little bit nervous to go be vulnerable on a podcast in [01:26:00] front of a bunch of therapists and thought she did a great job.

Dr. David L Roberts: Nice, nice affirmation. 

Preston: Thank you. 

Margaret: Okay, I also want to say these aren't just tricks that we use. I like, I feel like patients are going to think. Yeah, I don't mean to 

Preston: gamify it. It's 

Margaret: not gamified. Yeah. It's kind of like, oh, we don't all just naturally know how to interact and relate well to each other. And there's.

A way of doing this. That's one of the things I fear when people hear these kind of podcasts that they're like, they just cut their magicians coming in with their box of tricks and pull and like, that's how they're going to trick me into this. And it's like, I really think it's more than that, even though when we talk about specific techniques, it can feel that way.

So I 

Preston: think like identifying information that's still coming from a genuine place is still just like having fun, putting a name to the very human interactions we have. I 

Aron: was open to talk to you. Because I know you, by the way, like you've earned my trust. Like I've seen how you process David, sorry to interrupt.

I've seen how you handle talking about emotionally open things with me by working together. And that's what allowed me to come in and feel like I can share with you guys, because [01:27:00] I feel safe talking to you. 

Dr. David L Roberts: I love hearing that. Oh, And that was the, that was the first discovery of MI that you have to build that safe before you can talk about the hard stuff and try to change, you know, sometimes we do trainings and at the end of the training, I say, or at the end of day one, it's two day training.

I say, now go home and practice MI with your family. And then people say, Oh. They don't like that. They'll say, Oh, why are you practicing your psycho babble tricks on me? You're making me, right. You're making me into a guinea pig. Right. And what I always coach them to say back is I'm just trying to deepen my relationship with you with more effective communication.

And, and, and then that really is what we're trying to do. We're trying to communicate deeper and more clearly and more effectively. And we should stop ridiculing kind of ourselves for like. Psychobabble connection. Yeah. 

Preston: Yeah. 

Margaret: Well, I feel more connected to all of you. Yeah, this has been 

Preston: very kumbaya. Okay.

Well, I think that's all we have today. Thank you so [01:28:00] much. Dr. Robertson Aaron for coming on and so 

Dr. David L Roberts: much for having me on that. Aaron and I will forever be grateful. 

Preston: Yeah. And so, um, we'll let you know if we, we want any other topics in the future, but, um, look forward to seeing you in didactics. I'll be seeing him like in two weeks or in a couple of weeks in the classroom.

This 

Dr. David L Roberts: is a blast. 

Preston: Oh, glad you enjoyed it. I didn't have any fun, but I think Margaret did. Just kidding. 

Margaret: Just kidding. Thank you. Okay. Well, 

Preston: that's it.

Thank you so much for listening. We had a ton of fun talking about motivational interviewing today. 

Margaret: Thanks again to Aaron and Dr. Roberts. Yeah. Thank you. 

Preston: And how'd you guys enjoy the show? I know it's a kind of a new thing for us to do these like pseudo patient interviews to get a chance to see how we're talking about these things live.

If you liked it, please let us know if you didn't like it. Also, let us know we may or may not listen 

Dr. David L Roberts: if you want to reach out, 

Preston: you can find us on our socials at human content pods, or you can contact the team directly [01:29:00] over at how to be patient pod. com special thanks to all listeners who are leaving the kind feedback and awesome reviews and special no thanks to all the listeners that left unkind feedback.

Margaret: Except for that one that was kind of useful, I appreciate the construction. And we 

Preston: should have it regardless. It is constructive. It's good 

Margaret: for us to build our inner strength. 

Preston: If you want to watch us on YouTube, you can find me on my channel at It's Presrow. Thanks again for listening. We're your hosts, Preston Roche and Margaret Duncan.

We have a new executive producer, Margaret Duncan. In addition to me, Preston Roche, Will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman, and Sean T. Brook. Our editor and engineer is Tracy Barnett. Our music is by Omer Benzvi. Please check out our show notes to see the references and sources we use for this discussions in the episode I don't think we mentioned too many articles, but if if we did it's gonna be there So check that out to listen to our program disclaimer and ethics policy submission verification licensing terms and our HIPAA release terms go to our website how to be patient pod comm or reach out to us at how to Be patient at human content calm with any [01:30:00] questions or concerns how to be patient Is a human content production.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the [01:31:00] background.