Ep #29: Mastering Motivational Interviewing with Lynn Carlisle

Welcome to Practicing with the Masters for dentists with your host, Dr. Allison Watts. Allison believes that there are four pillars for a successful, fulfilling dental practice: clear leadership, sound business principles, well-developed communication skills, and clinical excellence. Allison enjoys helping dentists and teams excel in all of these areas. Each episode she brings you an inspiring conversation with another leading expert. If you desire to learn and grow and in the process take your practice to the next level, then this is the show for you. Now, here’s your host, Dr. Allison Watts.

Allison:       Welcome to Practicing with the Masters podcast. I’m your host, Allison Watts, and I’m dedicated to bringing you masters in the field of dentistry, leadership, and practice management to help you have a more fulfilling and successful practice and life.

When Lynn started practicing in ’68, and he was in practice for 40 years, he did say that he had some frustrations with his relationships with his patients and team members and that’s how he became interested in communication and helping.

So he began studying with Dr. Pankey, Bob Barkley, Carl Rogers, and Art Combs. He took those people’s work and if you guys don’t know, Carl Rogers and Art Combs, are they psychologists? Is that right?

Lynn:          Yes.

Allison:       They’re not specific…

Lynn:          Yes, I’ll talk about them some I think.

Allison:       Okay, yeah, they’re not specific to dentistry but he applied all of their work. You know Pankey and Barkley were in dentistry but he took their work and Carl Rogers and Art Combs and applied their work to his dental practice. So then he became a pioneer in relationship-based dentistry.

He’s the author of some highly-acclaimed books which I’ve read both of and enjoyed them thoroughly. The In a Spirit of Caring and In a Spirit of Caring Revisited. I know that you are in the process of writing Motivational Interviewing in Dentistry.

Lynn:          Yes.

Allison:       How close is that to being out?

Lynn:          That’s a good a question.

[Laughter]

Allison:       Summer?

Lynn:          Actually Bill Wathen just finished reading it and giving me some good feedback. I’m now at the stage of trying to decide whether to find a publisher to do a traditional publishing or to do an e-book, or to self-publish. But I would guess it will be ready sometime between the fall to early next year.

Allison:       Okay.

Lynn:          This is not a fast process.

Allison:       Oh, I can’t even imagine. I’m totally impressed with people who write books. I’d love to do that one day but I know you were on the board at Pankey and you were president of the Bob Barkley Foundation. Then an associate member of the Center for the Studies of the Person.

Lynn:          Yep.

Allison:       After many many years in dentistry and now being retired, he has taken all of this wisdom and all of his stuff that he’s kept in his basement for however many years it’s been and is using it to help dentistry. So he’s got a website called In a Spirit of Caring where he shares this pure gold, these articles, and all this wisdom that he’s had. He’s able to share it now on the web. So I enjoy your website thoroughly. If any of you guys are interested in that, we can pass on the website information to you. Do you want to say anything about In a Spirit of Caring or just want to move forward?

Lynn:          About my website?

Allison:       Yeah.

Lynn:          Well I think it’s a goldmine for relationship-based dentistry and for dentists that are interested in that. There’s probably over 600 articles on it by the pioneers in relationship-based dentistry and Allison has an article on it. Lee Ann Brady has an article. I’m trying to not just have us old people that are on it.

If you’re interested in this, it is a goldmine. That’s my partial statement and you can either type in, Google “in a spirit of caring,” and it will take you to it. You can wander all around and see if it fits for you. It is a membership website and I would encourage you to do it.

I’ll also keep everyone up to date via the website on the status of my book. Then probably I’ll talk about the workshop we’re going to be doing on motivation in Santa Fe, New Mexico May 1-3. So all of that stuff is on there.

Allison:       Okay, perfect. Thank you for that. So as we start, is it okay if I just start with a question?

Lynn:          Oh, sure.

Allison:       I didn’t know if you had some way you wanted to introduce this but I was thinking before we got on the call and I know we talked a couple of days ago, I was thinking, I think the biggest question I would have and I’ve sort of talked to you a little bit about this, but what is the difference between motivational interviewing and what we’re already doing with our patients? Like when we sit and we ask them questions and we think we’re listening to them. Can you talk a little bit about what the difference is between that and what we’re already doing? Or maybe when we think we’re doing motivational interviewing?

Lynn:          I’ll talk about traditional dentistry but I have a hunch a lot of the people on this teleconference are already fairly far along in becoming adept at the people part of dentistry. So I’ll compare it to traditional dentistry. Traditional dentistry is generally doctor-centered. I talk about the biggest difference in motivational interviewing or the person-centered approach. It’s, traditional dentistry is very doctor-centered. The doctor is the expert, the all-knowing person that really lectures their patients. Often they don’t listen that much.

Motivational interviewing and the person-centered approach is about 180 degrees from that. I’ll read a definition that Bill Miller and Steve Rollnick, who are the developers of motivational interviewing wrote. It says, “What is motivational interviewing? It’s a form of collaborative conversation for strengthening a person’s own motivation and commitment to change. It is a person-centered counseling style for addressing the common problem of ambivalence about change by paying particular attention to the language of change.

“It’s designed to strength an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” There’s a lot of words in this that are a little unfamiliar to dentistry but the words come from the work of Carl Rogers and then a student of his, Art Combs.

Carl Rogers, in the 40s, believe it or not, from his own personal experience, he was a psychologist, he found that he could be much more effective as a psychologist if he listened to people instead of telling them what to do. Telling them what to do is the Dr. Phil approach. I don’t know how many of you watch Dr. Phil but he’s the classic doctor-centered therapist. Where Carl Rogers is a 180 degrees away from that.

The words in here really come from Carl Rogers. They talk about eliciting and exploring the person’s own reason for change within an atmosphere of acceptance and compassion. That frequently doesn’t happen. In the book I’m writing on motivational interviewing in dentistry, I wrote about dentists, an example from social psychology. Two of my biggest challenges in talking about person-centered approaches to dentists are one, dentists don’t think it’s important. That they think that if they’re technically excellent, that’s all they need to do.

But the other one is in social psychology they call it a self-serving bias. The self-serving bias, they give examples of research that’s been done. For instance, in medicine they did a research study that found that, these aren’t exact, but they found that 60 percent of the physicians put themselves in the top ten percent in their ability to communicate. Another one found something very similar with college professors, where a similar percentage put themselves in the top ten of being outstanding professors in their field.

Then there was another one that was kind of funny that 60 percent of people put themselves in the top ten percent as far as looks. So I would say to answer Allison’s question is the big difference is that motivational interviewing and the person-centered approach is centered on the person or the patient. It’s not centered so much on the doctor. Motivational interviewing and I go into great detail about that.

Allison:       Yeah, I was kind of alluding to what you said was that I think we have, at least for me, the deeper I go into this, the more that I know that I don’t know. Even as I started reading the book, I’m thinking, “Well, I do this.” Then the more I read the book, the more I thought, wow, this takes a—I don’t want to use the word incredible—but it takes quite a bit of presence and intentionality.

Lynn:          Yes, being fully present and attuned to the patient and not what’s going on inside yourself.

Allison:       Yes. So I think that, I mean there are people who are very well along that path of being that way but a lot of us have a lot of stuff going through our minds in our daily practice life and I don’t think we’re fully attuned a lot of times. So yeah, it just seems like it takes—and that intentionality. I can’t remember, that thing about ambivalence?

You mentioned that on your other call but I really think that’s worth talking about. Can you get into that and explain that in a way, where it talks about you want to change but you don’t want to change and how you ask questions based on the—you don’t want to steer them toward the not wanting to change.

Lynn:          And that’s a major point that Miller and Rollnick make about M.I. that is different than a lot of the other traditional approaches. Miller and Rollnick put a lot of faith and trust in the person, that the person we call the patient, that as Omer Reed says, really knows what’s best for them and they’ll really make the decisions that are best for them if—and it’s a big if—if they’re in a climate of acceptance and compassion as I mentioned in the description of motivational interviewing.

That’s a big difference with motivational interviewing. They talk about ambivalence as a way to look at it. They say that people really aren’t stupid. They aren’t resistive. They do want to be healthy but they can be ambivalent. A good definition of ambivalence is I want to do this like, to use a very generic example, they want have a healthy mouth. They don’t want to have bleeding gums. They don’t want to have a lot of decay. They want to look good. They want to feel good. They want to be pain free.

So they want, most people want all of those things. But in yet, they don’t want to pay the money. Or they really don’t like to brush and floss and those kind of things. The example I use in my book, a personal example, is that when I retired, I retired, I practiced in Fort Collins, Colorado for the 40 years or so. Then when I retired, I moved to Carbondale, Colorado which is in the mountains, near Aspen, for two reasons.

My wife’s mother was failing and she wanted to be near her and I’d always wanted to live in the mountains. So I moved here but when I moved here I had an old bridge that was probably 30 years old and it was wearing out. I knew it was wearing out. I was getting some gum recession. The shade match was off. It was just worn out. And I knew it needed to be replaced but I put it off for, oh, two, three, four years probably.

The reason I put it off, I did exactly what used to really irritate me about my patients because I put it off because I didn’t want to get an anesthetic and have fat lips. I didn’t want to have the high speed hand piece rattling my head. I didn’t want all of that gooey stuff put in my mouth. So I came up with all these reasons why I didn’t want to have the new bridge in. It’s kind of like on the one hand, I wanted to have it done and then on the other hand I didn’t. That’s about the best definition of ambivalence that I can come up with.

But I think for the people listening to this, that’s a really key thing to remember. I mean, you can really get kind of disgusted that patients don’t do what you want them to do even though you think it’s in their best interests and it really is. But they don’t. But instead of just being resistive and not interested or a croc as some people say, that they’re just ambivalent about it.

With M.I., motivational interviewing, helps you explore that ambivalence with the patient. There’s a lot of different ways that motivational interviewing can help you do that. So that is my best description of ambivalence.

Allison:       Well in one of the examples that they talked about and I’m probably a third of the way through the book but they talked about…

Lynn:          This is Motivational interviewing in Healthcare book.

Allison:       Yes.

Lynn:          By Miller and Rollnick.

Allison:       Yes.

Lynn:          Not mine.

Allison:       Right, not yours yet. I’m waiting. I’m ready to get it anytime.

Lynn:          Yeah.

Allison:       But one of the examples they gave is when a patient you ask them on a 1 to 10 scale, how much do you want to change? Or something. And the patient will say a 5 or whatever.

Lynn:          Yeah, how important is it to you? Yeah.

Allison:       Yeah, then if they say a 5 instead of saying, “Why aren’t you a 10?” You say, “Why are you a 5 instead of a 1.” Then they give you the positives instead of telling you the negative. The way they spin it is so different from what I’m used to that I thought, “Wow, this is really neat.”

Lynn:          With motivational interviewing, there’s a lot of good concrete evidence-based. They’ve done a tremendous research on motivational interviewing. There’s a lot of good, concrete ways like what Allison just talked about of working with patients to help them. You’re really there more as a facilitator to help them discover. What we’ve talked about with ambivalence is a good example of that.

Allison:       So over your years of doing this, why do you think it’s so important to have this kind of practice or to have these skills?

Lynn:          For dentistry?

Allison:       Uh-huh.

Lynn:          I was influenced by Carl Rogers in the early 70s and I spent about ten years in concentrated study with him and his colleagues. Bob Barkley was influenced by Rogers’ work when Barkley was working with preventive dentistry and the five-day plaque control program. He discovered, and most of us that worked in preventative dentistry then, discovered that the way we’d learned to do it and growing up in school, dental school, didn’t work worth a darn with patients.

So he became a student of behavior. That’s how he found Rogers’ and Combs’ work. So that’s the facilitative part of it. But for me, I didn’t use motivational interviewing in my practice because I didn’t read Motivational Interviewing until about two years ago. I really wish that I’d had it when I was in practice. It would have filled a lot of the voids or gaps for me. But this is how I’d answer your question about why motivational interviewing is important to dentistry. I wrote about this actually as a promotion for this workshop we’re doing in May.

I wrote, “Although we know how to avoid most dental caries, periodontal disease, and other oral health problems by simple homecare and preventative techniques, patients often do not follow through.” And that’s what I talked about earlier, that’s the ambivalence part.

“But instead of the tell, show, then do approach that’s so prevalent in dentistry, M.I., which is the abbreviation for motivational interviewing, focuses on awakening the patient’s own reasons to change their dental care habits and say yes to the treatment recommendations.” So it’s, motivational interviewing is really a kinder, and gentler, patient-focused way of doing what I just said.

And dentistry, I think every dentist that’s ever practiced dentistry has, including me, has lamented, “Why don’t my patients do what I recommend? It would help them so much.” Again, we’ve talked about this but most information we have as dental professionals is generally pretty simple in concept and implementation but it’s the dental professional’s delivery of this valuable information needs help. It’s a pretty big gap because of their education, inclination, and interests have paid little attention to closing this gap.

That’s why I’m so evangelical about motivational interviewing is that there’s really, in my opinion, never been anything like this in dentistry. Even what I wrote about in my book, I always felt like it was a deficiency in my book. I wrote a—and I send this to the new members of my website—a checklist for developing exceptional doctor-patient relationships. I go into Carl Rogers and Art Combs’ work about this but this is about five or six pages long and this book I’m writing is going to be probably 200+ pages long.

That’s the difference between what I wrote about ten, fifteen, twenty years ago and now and what motivational interviewing has. Because for the people listening, to really learn motivational interviewing will be a tremendous help in helping your patients improve their healthcare habits and say yes to your dental treatments.

Allison:       Yeah, I found, definitely to the extent that I’m—I wouldn’t say I’m doing what M.I. is teaching—but to the extent that I am able to have this relationship-based thing where I do believe the patients know what’s best for them. They do rely on us for a certain amount of information but the extent that I use these skills and practice this way and communicate this way with my patients, I’ve had a much more rewarding practice and I’ve had a much more…

Lynn:          Yeah.

Allison:       I can definitely say people accept more treatment when you take the time to listen on the front end to what they really want and help them get what they want. Instead of trying to give them what you think they need.

Lynn:          Yes. Here’s a good example of that, another example that’s very similar to your experience. I’ve recently, in the past month or month and a half, I’ve had an extended conversation with a dentist in Brazil. How he found my website, I’m not really sure. It might have been Googling. But he has said that he was really at the point of considering leaving dentistry and that somehow he got ahold of my website and started reading the articles there and I think he’s read my books also.

But he said it changed his life and he’s gone from being burned out to being excited about practicing dentistry. That’s an example and he did this all on his own. He has, he said there’s no one else that he knows of in Brazil that’s practicing this way or that’s interested in it. So that’s an example of what can happen when you really learn how to be relationship-based in your practice.

Bob Barkley said that he really felt like building good doctor-patient relationships was really more important than the treatment your render. I don’t know if I’d go that far but I’d say it sure is equal to the dental treatment. I think what he meant was that you really can’t help your patients become healthier and achieve comfort, function, health, and aesthetics as L.D. Pankey said unless you’ve developed a relationship with them and they come to trust you.

Because you really, I mean you can do maintenance kind of dentistry but if the person we call the patient has more complex problems that involve more treatment, more expense, they really, and that’s the lament I talked about of, “Why don’t they do this?” It’s because they don’t really trust you to do this and they’re ambivalent about the cost of it versus maybe going on a vacation or buying a new car or buying a sofa or you know, the list is endless on that.

Allison:       Oh, and don’t you find, I think one of the things that I love about it, there was a turning point in my practice a few years ago and actually I spent time with Herb Blumenthal who teaches TMJ and that kind of stuff at the Pankey Institute. I had him come into my office but there was something about that and all the work I had done…

Lynn:          Oh, he’s…

Allison:       Yeah.

Lynn:          The director of education, isn’t he? At Pankey?

Allison:       I don’t know if he is or not but he does a lot of work with TMJ and he may used to have been. I don’t know how much he’s still involved there. But you know, there was a turning point where I felt like I could, I knew where my responsibility and the patient’s responsibility ended. Like, I didn’t feel like I was responsible for everything.

Lynn:          Right.

Allison:       There’s something in this kind of relationship where the patient is not blaming you for…

Lynn:          Yes.

Allison:       Like they take responsibility for the decisions and they take responsibility for the—so I think there’s an added benefit there in terms of it being less likely to have patients who have buyer’s remorse.

Lynn:          Yeah, it’s like it’s not a tug of war anymore.

Allison:       Yeah, and less likelihood of being sued and that sort of thing.

Lynn:          Yeah, absolutely.

Allison:       That’s an added benefit. But you were talking a little bit about the how of it. Can you get into a little bit of the how? Like how do you help pull out their own reasons for things? Their own motivations for things?

Lynn:          Yeah. I’ll tell you kind of a funny story. We’ve talked about, in reading the book Motivational Interviewing in Healthcare, much of it was very familiar to me. The language was a little different but much of it was very familiar because of my experience with Carl Rogers. And actually, Bill Miller in his psychotherapy training was trained in Rogerian client-centered therapy. So that comes through this a lot. There’s some differences that I’ll talk about.

But I read about ambivalence and I had never thought about ambivalence. With ambivalence, like I talk about, patients really don’t want dental treatment. I mean, why would you? Because of all the things I mentioned myself. And dentists generally are among the worst patients you can have because they know all of this stuff can happen to them. But what they do want, is they want to be free of dental disease and dental problems and that’s an example of ambivalence.

When I read the book, I thought, “Oh my gosh, that really helps me understand the classic lament better.” Which I had. But the other thing I really enjoyed was they talked about the righting reflex. Not as in writing, handwriting, but correcting people. They said that traditionally—and they talk about not just healthcare but they talk about counseling. They have correction officers that are using M.I. and there’s a lot of different fields that come under the heading of helping professions.

But they talked about righting reflex and they said almost every helping professional wants to help their patients and correct their problems, whether they’re psychological problems or dental problems or any other kind of problems. And this is important, they’re going to do it whether the patient wants it or not. It’s the, righteousness is another way of talking about that.

Then they talked about the expert/savior trap. They said that when you come from the expert stance or the savior stance of trying to save patients, whether they want to be saved or not, it sets up resistance in patients or clients. That they’ll overtly or covertly resist what you’re saying because it’s kind of like whether you’re doing this physically or not, it’s like if you’re coming from the expert/savior stance and a righting reflex, it’s like your forefinger is wagging in their nose saying, “You should do this.” And all of us that have gone through dental school have experienced that in the dental school environment.

So those three things really helped me but with Miller and Rollnick, they just came out with a third edition of Motivational Interviewing. In this third edition, they’ve gone from being very concrete, skilled method-oriented to being more process-oriented. They’re still much more skill-oriented than the traditional Rogerian approach, but they talk about four processes of M.I. This is the answer I think to the question you asked.

The first one is engaging. They talk a lot about reflective listening, which is their term for active listening. They say that’s the foundation of everything that follows. They talk about the core interviewing skills. They use the acronym OARS, the O is for open-ended question. The A is for affirmation. The R is for reflection and the S is for summarizing. Summarizing means that you reflect back to the patient what you think they’ve heard.

They don’t talk too much about building trust but that’s what engaging is all about is you start building trust with your patient. You let them know, and that’s the title of my book, that you really care about them and you want to help them get better. For everyone listening to this, in the workshops I do, I ask people to do a little visioning exercise to remember a time in your life when you really felt cared for and the person was concerned about. Then I ask people to put words to that.

Generally those words are the core conditions that Rogers talked about of empathy, unconditional positive regard, and genuineness or congruence. So engaging is the foundation and they use these interviewing skills, Rogers never did this. He never talked about specific skills but for learning this, if you can learn these skills, the core interviewing skills, or OARS, that will be the foundation for everything you do.

My opinion is, if you don’t do anything else, if you learn how to do that, it will make a tremendous difference. But then Miller and Rollnick leave Rogers and they talk about three other processes. One is focusing, which they call a collaborative process. In this, you start, you know it’s a great word, focusing the patient more and help them clarify what their health values are. And you start helping them to do some critical thinking about what they really want to do with, in our case, their dental health.

They talk about three styles of focusing. One is directing, which we’ve talked about. That’s the Dr. Phil approach. The second is guiding which motivational interviewing uses guiding a lot. The last one is following, which is more the non-directive Rogerian process. Then here’s something else that I really enjoy because I thought, “My gosh, we as dentists have all this great information that can help people.”

How can you give them this information? And they talk about the EPE Process. That’s when you have information or advice to give that you think will help the client, you ask permission, which seems ridiculously simple. But think, how many times have you really asked for your patient’s permission to give them some information? Generally most of us just give it to them whether they’re interested or not. So EPE is elicit, you ask their permission. And the P is you provide the information. Then the last E is that when you’re done, you again ask them, “How’s that sound to you? Does that makes sense?” about whatever the information is.

So that’s a very brief description of the focusing process. These are in their Motivational Interviewing book and then the book for dentistry I’m writing. The book is really divided into four parts. The four parts are engaging, focusing, evoking, and planning. So there’s a lot in the book I’m writing and the Motivational Interviewing about how to focus. It’s just wonderful for us dentists who like techniques and tactics. You get that in the bucketfuls in Motivational Interviewing.

Then the third one is evoking. They call that evoking the patient’s motivation to change. Again, they say it’s important to understand patient/client’s ambivalence. Then they talk about recognizing and responding to change talk. They recommend using OARS for that but there’s a particular way you listen for change talk. They talk about sustained talk, which is talk of just staying in the old way. Change talk is when they really first start, considering, “Well, you know, maybe I can do a better job of taking care of my teeth and gums. Maybe I can start implementing some of the things that that hygienist has been telling me every time I come into the dental office.”

So there’s a specific way of listening for that talk. They talk about preparatory change talk that they call DARN, that’s desire. You listen for the patient’s desire. Ability, they talk about, “Well, yeah, I can do that.” The reasons, the reasons would be, “I won’t wake up in the morning with blood on my pillow and every time I brush my teeth I won’t spit and have all the blood in it.” Then need, “Well, you know, I really need to do a better job to get healthier.”

Then they talk about mobilizing change talk, that they call “calling the cats.” That’s listening for patients’ commitment. “I will do this.” Activation, they’re talking about specific ways they’re going to do that, “Well maybe I can get that sonic toothbrush they talked about.” Or “maybe I can change my toothpaste to that one they talked about.” Then they talk about taking steps, which are what I just talked about.

Then they talk about evoking hope and confidence. They feel like one of the helpers, or in our case, the dentists really prime role is to give the patients hope and confidence because like using periodontal disease as an example. If it’s the first time they’ve heard that they’re really getting into trouble periodontally, you just don’t dump that on them and not give them any hope or confidence that they can improve.

Then another thing they talk about is developing discrepancies. That’s the values clarification process and ambivalence. They talk about, “Well, you know, my health is really important to me. My dental health is really important to me.” But then they don’t act on it. They don’t do the home care as an example.

Allison:       Does that mean—I’m sorry, Lynn.

Lynn:          Sure.

Allison:       Does that mean, developing discrepancies, does that mean you’re figuring out what the two sides of the ambivalence are? That you’re seeing that their value is this but they’re not acting on it? Is that what that means?

Lynn:          Yeah.

Allison:       Okay.

Lynn:          And the developing discrepancy is to help them recognize, to use ambivalence as an example, that they are ambivalent about this. There’s some specific ways they have of that where you can help the patient start saying that, “Well you know, I said it’s important, but I think you’re right. I really don’t do much on that, do I?”

They say developing discrepancies helps them, you talked about this, they start becoming responsible for their own health. You talked about shared responsibility earlier, that’s a result of helping them developing discrepancy. Does that answer your question?

Allison:       Yes, that is a lot of information.

Lynn:          Yeah.

Allison:       I’m in information overload.

Lynn:          Yeah.

Allison:       I can see why you’re having a workshop because I’m thinking, “Oh my gosh.”

Lynn:          That’s true because when I was writing the motivational interviewing book, I was thinking, “Oh my God, this is a lot of information they have.” So along the way in the book, I kind of took timeouts and talked about—and it’s like Bill Wathen mentioned to this after he read my manuscript—it’s really important to just take this a piece at a time, at your own pace. If you try to do this all at once, and it’s one problem I have with motivational interviewing, exactly what you said.

You can go on overload and Rogers and particularly Combs talked about that it’s the person or the helper or the dentist and their beliefs and not methods and techniques are most important. It’s important to keep that in my mind. But they talked about the beliefs that are most important in a helping relationship. That the helper cares about the person, they’re person not thing centered, they’re other centered, not self-centered. They have a positive view of people. They’re empathic. Nonjudgmental. Self-confident. They truly want to help the person. They’re authentic or congruent in their communications.

Again, there’s a lot of things behind that. But really what they’re saying here is if you believe those things and if you do those things, then the methods and techniques that you use will kind of fall in line. But what Miller and Rollnick do, and they aren’t quite where Rogers and Combs were, they’re getting there, but they aren’t quite where Rogers and Combs are with that. But they talk about the spirit of motivational interviewing. They’re talking about that more and more. That’s what I wrote about in my Spirit of Caring book. So they’re getting there.

But the last thing and then I’ll shut up is the planning stage. They call that the bridge to change. That’s when the patient starts using more change talk than sustain talk. This is wonderful for dentists because then you can help them with the plan, to develop a plan, which is in Barkley’s co-diagnosis process, I don’t know how many that are listening in use that process but when I was writing the book, I kept referring to how this would work with Barkley’s co-diagnosis process which I used for most of my dental career. So I’ve written an e-book on this, on implementing the co-diagnosis process in your practice.

But I went back and I looked at what I’d written and what Barkley had talked about. He wrote that, he developed the co-diagnosis process in the 1960s. I went back and I thought, “Holy cow. He almost followed this, what I’ve just talked about here with these four processes.” I said it’s like he’d read Miller and Rollnick but he was something like 20 or 30 years ahead of their time.

Then they have ways to help them develop the plan, to strengthen their commitment and to help evoke their intention. So all of that, I don’t know how far you are in their book, but they really do a good job of I would say just like we talked about, don’t get overwhelmed with this. Just take it a little bit at a time. As I said earlier, I would particularly focus on the engaging or reflection, EPE, and recognize.

The other thing I’d encourage people to do, is like tomorrow if you’re seeing patients, just kind of be aware of how you’re talking to patients. Ask a question of yourself, “Am I being the expert when I do this? Am I trying to save them? Am I trying to right their behavior?” Just see what you do.

The other thing I’d say is that motivational interviewing is not a quick fix because of what we’ve just talked about. It takes a while to learn how to do this. For most dentists, as I said, it’s 180 degrees from the way they do these. In my book, I use the analogy of it’s the old thing of how do you get to Carnegie Hall? The answer is practice, practice, practice. Well it’s the same way with M.I.

You really have to work at this but the great thing is, like particularly with reflective listening, you can mistakes all over the place. This is wonderful for us perfectionistic dentists. That it’s okay to make mistakes. If you make a mistake, patients will say something like, “Nope, that’s not it.” So you try again and when you listen well, listen with real understanding, then they’ll kind of nod their head and say, “Yeah, yeah that’s it.”

Allison:       But don’t you think in our attempt to even try to truly listen we’re still differentiating ourselves from most the doctors and dentists they’ve been to?

Lynn:          Oh, absolutely.

Allison:       Yeah.

Lynn:          Yeah, it is so unusual. It’s like that example of when you did that interview with Bill Wathen for his Baylor College of Dentistry program?

Allison:       Uh-huh.

Lynn:          That’s what you talked about, don’t you agree?

Allison:       Yes.

Lynn:          I mean, you spent that whole hour or however long it was talking about that. And it does differentiate you because healthcare professionals, in our case, dentists, rarely do this.

It’s really, it’s like someone mentioned one time that a lot of businesses now are using active listening or reflective listening. They’re specifically training their employees, particularly the people that answer the phone how to do this. Banks talk about relationship-based banking and car dealers talk about building relationships. But rarely will they do it in a true person-centered way. If people start using M.I., it automatically differentiates them from car dealers, from other dentists, from physicians, you know, just go down the line.

Allison:       And I’ll just say one more thing.

Lynn:          Sure.

Allison:       Then, right, we can open it up?

Lynn:          Yep.

Allison:       I just wanted to add to what you’re saying. I think that it’s not only differentiating us but it’s creating loyalty. You said the other day even, in the face of all the changes happening in dentistry, the corporate dentistry and the insurance, and all that stuff, that it’s creating loyalty and creating patients that aren’t going to leave you for the cheaper place or aren’t going to leave  you for the—you know. They aren’t going to leave you so easily.

Lynn:          Yes, and I believe that 100 percent. It takes a lot of trust to make the commitment to do this because what’s happening with corporate dentistry, Obamacare, and the insurance companies reducing their copayment amounts, it’s almost forcing healthcare professionals to do more in less time because they’re getting paid less so they have to speed up and go faster, faster, faster.

It does take time to develop these relationships and as long as you’re the captain of your own ship, you can really determine how you run your practice and what you do. But if you start working for someone else, you start losing that ability. But I think we’re at the question stage now.

Allison:       Yes, we are. I’m going to try opening up the full line and see how… not too noisy. So everybody, you guys are unmuted. If you want to ask a question, we can try it this way. Okay, Edward, you’re unmuted. Go ahead.

Edward:     Yeah, I have a question for Dr. Carlisle. This is a wonderful information, I just want to get the title of the book so I can order the book for M.I.

Lynn:          There’s two books I’d recommend. One is the one we talked about Motivational Interviewing in Healthcare. That was written about 2008 I think. And Miller and Rollnick have changed the way they talk about M.I. Then the other book I recommend, The Motivational Interviewing, 3^rd edition, which just came out in 2013.

Edward:     Okay.

Lynn:          They’re much more process-oriented in that book. So those are the two books I’d recommend, the Motivational Interviewing in Healthcare is about half as long as the Motivational interviewing, 3^rd edition.

Edward:     I see. How about your book? You have In a Spirit of Caring, that book?

Lynn:          You can go on Amazon.com and type in “In the Spirit of Caring Revisited.”

Edward:     Revisited, okay.

Lynn:          I wrote the first In a Spirit of Caring 20 years ago this year as a matter of fact. Then I read it maybe five years ago and thought, “You know, I think all of this still applies to what’s going on now, maybe more.” But there were some things I wrote about in there that didn’t happen, so I kept the body of the book the same but along the way I’d comment from a 21^st century perspective. It’s just an e-book, it’s not in paperback.

Edward:     Right, sure. Thank you so much for the information. That was wonderful.

Lynn:          Well thanks for being on this call.

Edward:     Yeah, I learned so much. Thank you.

Allison:       Thank you. Does anybody else have a question? Oh, go ahead.

Lisa:           You were talking about using this and all the different processes, especially at the end when we talked about having loyalty and the changes, corporate, I really started thinking about our team members and right now our office has been transitioning. We have several new team members. I’m wondering if you had worked with anybody about using this process with their team members and seeing the fruit of that?

Lynn:          In your relationships with team members? Is that your question?

Lisa:           Yes, in my relationship with our team members and also bringing them along into new ways of thinking.

Lynn:          Yes.

Lisa:           Because our office is different than what they’ve experienced in the past. And definitely when we hired, we hired for their character and their heart and for their desire to have things be different.

Lynn:          Yes.

Lisa:           And even if… they really don’t have the skills to be able to operate that way.

Lynn:          Yeah, I think everything I’ve talked about applies in your relationships with your team members. You know, if you think about what we as dentists do, I had and have a massive righting reflex. It would come out, I talk about the closer something or someone is to you, the harder it is to change your behavior with them. I would say the same thing about spouses and kids.

It’s a lot easier to do this in your practice with your patients than at home with someone you live with almost 24/7. But it applies 100 percent like particularly with the engaging, the reflective listening, I use it all the time in all sorts of different ways.

For instance, going through a checkout line at the grocery store. You can do little bits and pieces of active listening or reflective listening. You can practice this really in any encounter you have with a human being. The hardest part is to become aware of what you’re doing because so much of what we do in our life is just automatic. That includes communicating with people.

So when you’re going to change these behaviors it really takes a lot of work to stay fully present and to be aware. That’s what a lot of meditation is about. Is just sitting and being quiet and then just observing your mind chatter and to recognize that a lot of this mind chatter is just that. It’s not really that important although we make it seem like it is. But yes, you could use this with your team members.

The other thing, you need to practice this. I feel like I’ve just backed up my information truck and dumped it on you with this but in this teleconference, that’s about all you can do is an information exchange. Then if you do workshops like the one we’re going to do, then in the workshop, there’s a lot of opportunity to actually practice this. But then when you leave the workshop, you still aren’t there yet because you have to practice, practice, practice.

Like with this workshop, they’ll be six follow-up teleconference calls to ask questions and to say, “Well, I did this and it really didn’t work out that well. Can you give me some feedback on what I can do differently?” Then the next one after that, study groups are a great way to learn this because you have kind of built-in follow up.

Then the last one, and Miller and Rollnick have done a lot of research on this, is really one-on-one coaching. To have someone come into your office and just watch how you actually do it because it’s the value indicator versus value of what we talked about with the self-sustaining bias. You might think you do a pretty good job but then when you have someone come in and watch and coach, then they can give you feedback, hopefully in an M.I. way that will help you see, “Oh yeah, I see. Yeah, okay.”

The best way, which is harder now, is to tape yourself. But with all of HIPAA and everything, it’s harder. You have to get express permission and it has to be a written document and all of those things. But I was just appalled when I first started doing this when I taped myself. I wasn’t anywhere close to where I thought I was. But yeah, you could use it almost in any way with anyone.

Allison:       Lisa is my office administrator. Maybe we should do a book study, Lisa, at our office on this next.

Lynn:          Yeah, you could use the book or when mine comes out. Like with my In a Spirit of Caring books a lot of study groups used it as kind of a teaching tool.

Allison:       Yeah.

Lynn:          Study groups, I have a huge bias about study groups. I think that’s one thing dentistry does really well. It’s a wonderful way to learn. I had a study group for years and actually still do. We don’t meet technically as much but I think I learned more with my study group than anything else I did and I did a lot. But it’s a wonderful way to learn.

Edward:     How do I get involved with the workshops that you have, you were talking about?

Lynn:          If you go to my website, In a Spirit of Caring, there’s information on the website about the workshop. As I mentioned, it’s going to be in Santa Fe May 1 to 3. I’m going to co-facilitate with Kam Venner who’s a colleague Ph.D. colleague of Bill Miller’s. They both teach at the University of New Mexico in the psychology department. That department has done probably most of the research on M.I.

So you’ll get from me, you’ll get more of the history of the relationship-based, person-centered approach. You’ll get the Rogers part. But Kam will do more of the traditional M.I. training and the research that they’ve done. Then a great thing is Bill Miller, who’s the co-developer of M.I., he lives in Albuquerque and he’s going to come up and spend most of an afternoon with us. He just volunteered that out of the blue. I was just blown away.

But I will say that I don’t know if I’m going to be able to get the three of us together in the future because it’s been a little challenging to get three of us in Santa Fe May 1 to 3. So I would encourage you to take advantage of us.

Edward:     I see.

Allison:       What days of the week is that, May 1? Okay, so it’s Thursday, Friday, Saturday.

Lynn:          We’re going to start at 5:00 Thursday evening and we’ll have heavy hors d’oeuvres then we’ll start the workshop that evening. That’s mainly to check in with people to see why they’re there, what they want out of the workshop, and to talk a little bit about themselves and their practice. Then I will probably talk some about the history of the person-centered approach in dentistry.

I probably, I might repeat myself a little bit with what I’ve talked about today, this evening. But that will get that out of the way so on Friday morning we can just hit the ground running and really get into the nitty-gritty of this to do the exercises. They’ll be some demonstration interviews that Kam does, that I do, and that Bill Miller, probably Bill Miller does, to show you.

Then on Saturday, it will be another full day that wraps up at 5:00. Then people, I think most people will—Santa Fe is about an hour from the Albuquerque airport. So I think most people will leave on Sunday.

Allison:       It’s for doctors and team?

Lynn:          Oh yeah, yeah. Maybe I didn’t make that explicit enough. In the blurbs, marketing blurbs, I talked about dental professionals but it’s great for anybody like in hygiene. This is absolutely in the wheelhouse for a hygienist because it helps them become dental educators again instead of just a profit center where they’re just cranking out prophies or scaling and planings or those kinds of things.

Allison:       If you guys have trouble finding Lynn’s website, you can just email me and I’ll send you a link. But I just Googled it and it’s InASpiritofCaring.com. Actually, in a spirit of caring, if you just Google that, it’s InASpiritofCaring.com but right in the middle of the page and then over to the right there’s the link for the workshop.

Lynn:          And there’s an article I think under “articles” right in the middle of, lower middle, of the page.

Allison:       Okay. All right. Any other questions?

Ryan:          I did have one, Allison. This is Ryan Coulon here. I’ve been listening and I kind of just want to hear some advice and hear what y’all have to say just tying this whole topic into the whole money thing. In other words, you have a patient who’s really taking ownership of their healthcare. You can tell they really do want to change and it’s always kind of hit with the preliminary statement, “I just don’t know if I can afford it.” That sort of topic.

What is your recommendations in terms of how much of the money topic do you get into with the patients versus kind of keeping it more doctor-patient relationship and letting the front desk or the treatment coordinator or somebody else deal with the money side of things? How do you address that when they bring that up and what does that say about their real motivation?

They’re saying “I want to change” but it’s with a “only if it costs a certain amount of money.” Is that an indication that maybe they’re truly not fully onboard to want to change and they’re just saying that? What is your take on that from that side of things?

Lynn:          You’re asking Allison that or me?

Allison:       No, he’s asking you. I’ll comment too if you want me to.

Ryan:          Either way.

Lynn:          I would ask you some questions, do you use the Barkley co-diagnosis process?

Ryan:          No, I don’t.

Lynn:          That would probably be my strongest recommendation, that you really learn how to do that and you become adept at it.

Allison:       I can work with you on that, Ryan.

Ryan:          Okay.

Lynn:          Because if you do that and really learn that and if you do it in the M.I. way like I’ve talked about, then you’ve done all these things that I’ve talked about. You’ve engaged them, you’ve helped them focus on how important their dental health is to them. You’ve evoked and listened to change talk and you’ve helped them do more change talk. Then you’ve done some planning with them.

The Barkley co-diagnosis process does all of that in spades. It’s on my website as an e-book but the best way to learn that is like Bob Frazer and Mike Schuster do specific workshops on that. I do them, particularly for study clubs. It’s a great way with a study club to learn how to do that. You use it, don’t you, Allison?

Allison:       I do. Yeah, actually I did…

Lynn:          You do some coaching about it.

Allison:       Yes.

Lynn:          So that would be my, to really learn how to do that. That for me and I think that’s—I talk about crossing the threshold with this and the thing that helps you cross that threshold from going from the traditional way of practicing to the relationship-based way of practicing is to really learn and use the Barkley co-diagnosis process.

Again, it will probably take you three to five years but if you don’t start on it right now, then it will be however long it takes you to start using it plus three to five years. So on my website, there’s an e-book about it that really goes into detail. It gives you questions to ask. It gives you forms you can adapt. But the best way of learning it is to work with Allison or me or Bob Frazer or Mike Schuster.

Ryan:          Okay.

Allison:       Your e-book, Lynn, is that something you have to be a member to get?

Lynn:          Yeah.

Allison:       Okay.

Lynn:          But it costs a whopping $1.00 on my website.

Allison:       Yeah, and I think your membership site is like $49.00 for three months.

Lynn:          When the recession was going on, I made all of those $1.00 to help dentists who were feeling very poor. Your first name is Ryan?

Ryan:          Yes, sir.

Lynn:          How did you feel about me saying that?

Ryan:          What’s that?

Lynn:          Do you think that’s something you’d be interested in or does it sound too much?

Ryan:          No, I’m definitely interested in it. To be honest with you, completely honest with you, I don’t have a clue what the Barkley co-diagnosis is.

Lynn:          Yeah.

Ryan:          I’m not familiar with it at all. I may be incorporating some of those things into it already, but I don’t know what it is to know whether I am or not.

Lynn:          How long have you been in practice?

Ryan:          I’ve been in practice for about eight months.

Lynn:          Well, there you go.

Ryan:          Yeah.

Lynn:          What happens now is people don’t know Bob Barkley, they don’t know of his work, they don’t know who he is. It’s people like the Pankey Institute teaches a version of his co-diagnosis process but I think they’re kind of losing that some. The other, like Spear or Kois or LVI, they really don’t teach that much. But to me, particularly if you want to be a relationship-based dentist, and I go into a lot of detail on this on my website.

My website is really a good low-key way of learning about this because you can read about a lot of this at your own pace and you don’t do like what I’ve probably done on this teleconference is backing my information truck up and dumping it on you and overwhelming you to the point of thinking, “This is just too much.” But I’d encourage you to do all of those. If you join my website, I will kind of help walk you through that when you do that.

Ryan:          Okay.

Lynn:          Then this workshop, I’ll tell you, if you can learn this at the stage you’re at now, it will prevent you years of angst. What happens, the longer you’re in practice, the harder it is to change. Particularly something that’s 180 degrees from the way you’ve learned. So I hope I haven’t blown you away so much that when this call is over you’ll think, “I don’t think I’m going to do that.” It takes a while.

Ryan:          Yeah, no. It’s been very very good information.

Lynn:          I’m sure Allison would be glad to help you. I’d be glad to help you with this. But at some point, you need to take the workshop like I talked about. Then you need to really start applying it in your practice. Make the mistakes and you’ll gradually learn more and more until one day you think, “You know, I think I’m doing this.”

Ryan:          Right.

Lynn:          It is transformative for your dental practice.

Ryan:          Yes, sir.

Lynn:          I’m highly biased but…

Ryan:          Right.

Allison:       A little disclaimer there.

Lynn: Yeah.

Thanks for listening to Practicing with the Masters for dentists, with your host, Dr. Allison Watts. For more about how Allison Watts and Transformational Practices can help you create a successful and fulfilling practice and life, visit transformationalpractices.com.