Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and author of the book Health Literacy from A to Z. I also produce and host this podcast series, Health Literacy Out Loud.

Today, I’m talking with Laura Saunders, who is a social worker with expertise in motivational interviewing. She works with the University of Wisconsin-Madison at the Great Lakes Addictions, Mental Health and Prevention Technology Centers.

Laura leads motivational interviewing workshops for professionals in many fields, including healthcare, education, human services, public health and criminal justice.

She’s an active member of the international group of Motivational Interviewing Network of Trainers, otherwise referred to as MINT.

Laura and I met when we were both speakers at a virtual health literacy conference. I learned a lot from what she shared about motivational interviewing and clearly saw its relevance to health literacy. Thinking you might be interested in this topic, too.

Welcome, Laura, to Health Literacy Out Loud.

Laura Saunders: Hi, Helen. Thank you so much for your warm welcome.

Helen Osborne: Motivational interviewing. I have heard that topic a number of times over the years, but I don’t really know what it’s all about. Just take it from the beginning. What is motivational interviewing?

Laura Saunders: As a matter of fact, when the fourth edition of the textbook comes out in 2023, this science will have been around for 40 years. That will be 40 years after the first article appeared in peer-reviewed literature.

Helen Osborne: You also talked about a textbook. What textbook are we talking about?

Laura Saunders: The textbook is called Motivational Interviewing: Helping People Change by Drs. Miller and Rollnick. They are currently in the third edition of the textbook, but they’re writing the fourth edition. There’s a lot of interest in this.

Helen Osborne: Forty years of doing this work, four editions later, and you got on board . . . I’m guessing it wasn’t 40 years ago?

Laura Saunders: The first edition was my training ground.

Helen Osborne: Really?

Laura Saunders: Yes, I’ve been doing this for quite a while.

Helen Osborne: What motivated you to get interested in motivational interviewing?

Laura Saunders: I became interested in motivational interviewing as a part of a research project. What we were trying to do was talk to people over the telephone to get them to drink less alcohol, or not at all. I was handed the book and said, “I want you to learn this style of communication called motivational interviewing.” I thought, “What’s motivational interviewing?”

The things that happened in that trial really caused me to fall in love with motivational interviewing. It just fit like a glove with my natural style of communication, and I had quite a few successes. The people that I was helping were successful.

Helen Osborne: That’s what got you interested, when somebody just said, “Go do this. Here’s the book”?

Laura Saunders: I was forced, yes.

Helen Osborne: What did you learn about that? Put this into context for us. Really, what is that broader scope of what motivational interviewing is?

Laura Saunders: I said it fit with my natural style. The technical definition is it’s a collaborative conversation style for strengthening a person’s own motivation and commitment to change.

When you deconstruct that, there’s all kinds of richness there just in those big words, like collaborative.

Collaborative means I’m going to work with you as a partner. I don’t know more about you than you do. As a helping professional, I know all kinds of really good stuff and things that can help you. That’s all really powerful and wonderful, and yet I don’t know the most about you. You know the most about you, so we’re going to collaborate. We’re going to put my good stuff and things with your knowledge about yourself.

Helen Osborne: That’s the collaborative part. The next part you talked about was this conversation.

Laura Saunders: Yes. That’s one of the other things that’s really appealing to me about motivational interviewing. When it’s being done well, it looks like a smooth, flowing conversation between two equal partners.

It’s not a gimmick, a trick or technique. It’s not a way to convince people to do things they don’t otherwise want to do. It’s not some Jedi mind trick. It’s a way of being and a way of talking. It’s a conversation style.

Helen Osborne: I really appreciate that. Until you put words to it, I don’t think I would’ve said this out loud, but I feared sometimes it might have been a little bit manipulative to get to my way of thinking. But the way you frame it, it’s not that way at all.

Laura Saunders: No. As helping professionals, and I’m sure you have covered this many times, it’s our job to hold out hope and to want what’s “best” for our clients/consumers/customers.

However, us pushing, dragging, insisting or trying to persuade or give them advice in the direction of, “This is what you ought to or have to do,” actually, because of psychological reactants, works the opposite.

We can stay in that neutral place, “I’m okay with you deciding to do this or not do this,” or whatever the decision is they’re making, while still hoping that they’ll do the thing that will make them happy, healthy, live longer or all those things. We want those for our people, but we can’t drag them there.

Helen Osborne: Interesting. Can I just give you an aside? When I do all my work in health literacy, which is about communicating health information in ways patients and the public can understand, I sometimes talk about a concept I came up with the term, “ethics of simplicity.” How do we go about doing this? How do we say this clearly? How do we make choices about it?

One of the issues that I think is relevant and an overlap with motivational interviewing is, “Is our purpose to inform or to persuade?” It sounds like you’re well aware of that issue but perhaps say it in other words.

Laura Saunders: I am absolutely aware of that. We know from motivational interviewing, and we teach in our trainings, guidance and coaching, we try to take the persuasion out of the practitioner.

Offering information is offering information. There are ways to do that in a collaborative way. But if you’re persuading, giving advice or saying should, ought to, got to or must, from a motivational stance, that’s not a respectful way to offer information.

We have all these ways that we teach people. We try to change the way that you think about it, and then the way that you think once we’re able to get you to think about the power of information or advice.

We get you to think about it, and then we teach you how to say it. How do the words that are coming out of your mouth really influence what’s going to happen with this person?

Helen Osborne: Make it real for us. Give me an example.

Laura Saunders: I will. Let’s say, Helen, you and I were talking. In our conversation, I’ve been listening really hard to you, and it seemed like you could really benefit from some information about diet and exercise. You were thinking that you could lose weight by eating donuts, and I would be thinking, “I don’t think Helen is going to lose weight eating all those donuts.”

Using one of the techniques called EPE, I would say to you, “Helen, would it be okay if we just talk a little bit about eating and how that’s influencing your weight?”

I’d say, “How about if we just start by you telling me what you know about how a person could reduce their weight?” You would tell me whatever it is you know.

You might tell me that you thought that you could eat as many donuts as you want, because donuts are good.

That’s what we call elicit. Elicit from the patient, “What do you know?”

Then I would say, “Would it be okay if I fill in a little bit, Helen, and tell you a little bit more about that?” You would say, “Sure. Okay.”

Then I would tell you, “Donuts really aren’t,” and all the things that I would know.

I would have earned myself the opportunity to give you information, because I partnered with you. I asked you first what you knew, honoring that you aren’t just some ding-dong who dropped onto Planet Earth yesterday.

Of course, clients have their own knowledge, strengths and wisdoms. When we say, “What do you know?” first, it gets us out of that top-down distribution of information.

What do you know? Then I’d say, “Can I tell you what I know?” Then I would tell you some things. I might correct a few things. I might say, “Actually, this isn’t true. This is da-da-da.”

Here’s the best part. This is my favorite part. When I’m done with that, I have to invite you to comment. “What surprised you? What questions do you have? What do you make of that? What might you do with this information?”

Helen Osborne: I had already said that I wanted to lose weight, but donuts are the way I’m going about doing this. Then you talk about maybe the nutritional side of donuts and that celery has benefits in its place. Then we come to terms on that? Is that the next step?

Laura Saunders: Yes. I would say, “What do you think about that? What questions do you have? What might you do differently? Where does this leave us? What are you thinking?”

It’s elicit from Helen, provide from the practitioner, then elicit from Helen/client again.

Helen Osborne: Oh, that’s the EPE. I was wondering.

Laura Saunders: EPE. There you go.

Helen Osborne: I like that.

Laura Saunders: It’s that invitation, that autonomous “You are your own person. Here’s some information. You get to decide what to do with it.” That invitation for people to disagree with us is so powerful. I’m not going to just assume that this is what works for you.

When we do that, the way that it works is people are more likely to do the thing we want them to do when we’re really forthcoming about honoring their autonomy.

You get to decide. You’re the one who will decide. I can tell you everything I know about diet and weight loss, and then in the end, whatever happens is 100% up to you. It’s your life and you get to make those decisions, and you know yourself really well.

Helen Osborne: That is really interesting. You framed that beautifully.

I remember in the conference we both spoke at, that communication conference, you gave another example, too. When you give these examples, as you just did about the donuts and whatever, it really made it come alive to me. I like to think that these podcasts are a collaborative conversation, too. But it sounds like you have a structure for doing so.

Laura Saunders: Here I was saying that motivational interviewing is not a trick, a technique or a gimmick. That is just one strategy that we employ specifically for sharing information or advice.

Yet knitted into that is a whole bunch of complexity, a whole bunch of thinking about really using the spirit of motivational interviewing and a true belief that you are this person’s partner. You’re going to help them no matter who they are and what they’ve done, and you’re going to be compassionate.      

At the very foundation of all of our practice is empathy. It’s not just about information or advice. It’s how you offer it and when you offer it.

It’s also recognizing that information or advice isn’t necessarily the thing that will change a person’s behavior. People need good information or advice. They absolutely need that. However, it’s not always the thing that’s going to motivate people.

Sometimes people need good information or advice to even know something is a problem, or they need it when they go to make a plan. They need to know the options. They need to understand.

But it’s not necessarily magic, that once you tell somebody, “This could kill you,” that’s going to be the thing that makes the person say, “Then I’m going to abandon this lifelong behavior that I’ve loved so much and change immediately.”

Helen Osborne: Is your intervention, your conversation with them, a one-time-only? Or is this a structure for an ongoing relationship with that client?

Laura Saunders: Motivational interviewing is very much about a relational foundation. It is also a method of communication, a communication style, that’s meant to be a brief intervention. It’s not meant to be something where you’re wearing people down and convincing them to make the change over 20 episodes of meeting with them.

It was originally developed to be a brief intervention, meaning one to four sessions of talking about any particular problem.

Helen Osborne: It’s really identifying a problem, providing information and doing some problem-solving together. But ultimately, it’s up to the other person.

Laura, I used to work in mental health and psychiatry, in-patient and outpatient settings. This was a long time ago. I remember some people saying to me, “You have to motivate the person.” I didn’t quite know how to do that because I thought that motivation came from inside rather than outside.

I soon learned about internal and external motivation. Sometimes people do things because someone tells them they have to. At a job, you write that paper because you have a deadline. Or as I do in my own business, if I want to write a paper, I have to decide myself I’m going to do it because no one is telling me to do it.

Do you focus on that internal and external motivation?

Laura Saunders: We focus on motivation, and certainly internal or external motivations play into that.

The focus in motivational interviewing when we’re evoking what we call change talk from the client, what we’re trying to get the person to do is to say out loud things about this particular change that they want, that they could do, that they have reasons or need to do this, should do this, must do this, ought to do this.

But we have a style of communication in our relationship, the way that we talk to people, the way we ask questions and the things that we reflect. Those all influence the person’s expression of their language around change.

There’s not a differentiation between internal or external. What the focus is on is, “What about this thing is appealing to you?”

Helen Osborne: It’s that expression.

Laura Saunders: Yes, it is that expression. It’s saying out loud in the presence of another human being, “What about this change is good from your perspective? Or if you don’t make this change, what bad will befall?”

Again, this comes back to honoring of autonomy. I don’t know what any individual person’s drivers of change might be. Motivational interviewing says, “I don’t care what your drivers of change are. They can be anything you want. I believe you have drivers of change, and I’m here to help draw up out of that well that’s full of all this motivation. You may have forgotten it’s there, but I’m there to help draw up out of that well your personal motivations to make this change.”

Helen Osborne: That’s very helpful. Going back to that donut example, I might have come to terms with the fact that my family owns a donut store and we live right above it, so I am going to keep eating donuts. But maybe I will cut down or maybe I will have this other food more often instead.

Once you found out what was important to me and gave me the facts, then I can articulate or express a plan.

Laura Saunders: Right.

Helen Osborne: How do you know when your job is done?

Laura Saunders: Motivational interviewing, the meat and potatoes of it is getting people to talk about their personal motivations for making change. Then when you feel like they’ve resolved, when their ambivalence is leaning more in the direction of “I’ve really got to/ought to/should do something about this,” you use your usual human service style of communication.

You want to keep using motivational interviewing, but most practitioners know how to make a plan. That’s what you do. You make a plan with a person, help them set some smart goals and that sort of thing.

Motivational interviewing might come into play again when the person doesn’t reach their goal. The plan doesn’t work. In the follow-up session, they may need re-visitation of, “Let’s talk again about why you’re doing this. What has changed?”

Your motivations may have changed. “Now I’ve decided that I also want to add this to my list,” or, “I didn’t even anticipate this was one of the barriers. This is one of the things I really like about eating donuts 24 hours a day, and I hadn’t made a plan that sufficiently addressed that.”

It’s a back-and-forth throughout the process. You’re going to always be using motivational interviewing, but it has different purposes depending on where the client is in the change process.

Helen Osborne: Thank you, Laura, for so clearly explaining that.

Yes, I see a lot of overlap with health literacy. In health literacy, we do try to honor and respect the individual, the community receiving the message. We try to find out, albeit perhaps in different ways, what some barriers are. We also, of course, want to provide information. But information alone is not sufficient. It’s really what the other person is going to do with that.

I thank you for doing all you do. I encourage listeners to try to put this into your practice, too. I like this structure. It seems like a very comfortable structure, that elicit, provide and elicit again back-and-forth. That’s what we did on this podcast.

Thank you, Laura, so much for being a guest. Also, letting listeners know that on your Health Literacy Out Loud web page, we’ll have some links to some relevant resources, including that book that Laura talked about.

Thank you for being a guest on Health Literacy Out Loud.

Laura Saunders: Thank you, Helen.

Helen Osborne: As we just heard from Laura Saunders, it’s so important to engage the other person you’re communicating with in a respectful, meaningful way. But doing so isn’t always easy.

For help clearly communicating your health message, please take a look at my book, Health Literacy from A to Z. Feel free to also explore my website, www.HealthLiteracy.com, or contact me directly at helen@healthliteracy.com.

New Health Literacy Out Loud interviews come out every few weeks. You can get them all for free by subscribing at www.HealthLiteracyOutLoud.com or wherever you get your podcasts.

Please help spread the word about Health Literacy Out Loud. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

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