Difficult Conversations: Using Motivational Interviewing to Convince People to Get Vaccinated

0:00:02.8 Ken Resnicow: Unsolicited advice is a funny thing. One of the rules we use when we train folks is that 95% of what you're gonna tell your patients, they've already heard, thought about, and rejected, and therefore when you tell it to them, they're simply annoyed by it. Because we have to really try and guide the person so that they come up with the advice or get them into a space where they wanna ask for advice. But unsolicited advice is particularly insidious because if the person is not ready, the ground is not fertile, you're like peeing in the wind, it's just gonna come back in your face. So we wanna be very careful, build the right motivation and ideally let them solve their own problems, let them fix their own barriers, and if they need advice, sort of get them to the point where they wanna ask for it.

0:00:49.7 Narrator: At some point over the past two years, you may have found yourself in a conversation with a family member, friend or co-worker who has different thoughts on the pandemic than you do. They may not think the pandemic is real or that, "COVID 19, it's not a big deal," or they may be strongly opposed to getting vaccinated. It can be frustrating to have a conversation with someone you care about when you see things very differently. And for most of us, our desire is to get our loved one to see things our way. In the case of vaccination, it's for their own safety and helps protect everyone around them. Many times these conversations end with nothing to show except for a growing gulf between both parties fueled by bad feelings. But maybe there is a way to rethink these conversations. 

Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. This episode is part of a series of special editions of our Podcast focusing on the ongoing Coronavirus pandemic. Ken Resnicow is a professor of Health Behavior and Health Education at the University of Michigan School of Public Health, and he's the Chief Scientific lead at the university's Center for Health Communications Research. One of his passions is the field of Motivational Interviewing.

0:02:08.9 KR: I was introduced to Motivational Interviewing in my first job while I was in New York in the very early '90s, and it was transformational for me. I think I've never looked back and like many other people who go through their MI training, you have many epiphanies, such as, "I can't believe how much unsolicited useless advice I've been giving my whole life," or, "Boy, it's annoying to have someone give you unsolicited advice." It was really a religious experience for me, to see the power of guiding versus directing and all the other ways that MI is different.

0:02:43.2 Narrator: What exactly is Motivational Interviewing? 

0:02:46.6 KR: It's a counseling style, it's a way to communicate both from professional encounters, doctors, psychologists, nurses, and even in your everyday life, the same skills are effective talking to someone at a party, a bar, or an airplane. And fundamentally, what MI teaches us is, "You're the rudder, you're not the steering wheel. Let the speaker drive. You can still subtly guide the encounter, but we do so not with advice, but with a lot of reflective statements." By reflecting back, you allow the speaker to feel they're still controlling the encounter and you're there to support, encourage and empathize, but you're not driving the encounter. You're not pushing your agenda, and they quickly sense that, and it really creates a very interesting dynamic where the client or the patient or the speaker is in control, and you're there reflecting back their feelings and their thoughts and their intentions, occasionally throwing in some questions, but fundamentally you're a sounding board for them.

0:03:47.3 KR: The short definition of MI is it's the balance of two forces: comfort the afflicted and afflict the comfortable. When we say comfort the afflicted, we mean express your empathy to the patient about their fears. So let's say someone wants to quit smoking, they may express fears about weight gain, withdrawal symptoms, high failure rates, missing the joy of their nicotine rush. As an MI counselor, you reflect back that fear, the discomfort they're anticipating, and we do so in an empathetic way. Then we have to afflict the comfortable. If we only comfort the afflicted, people don't necessarily move, so we have to set up a discrepancy between their behavior and what they value. So if they really value being a good parent and they realize, "Boy, if I quit smoking, I'm gonna send a message to my 13-year-olds that smoking isn't good for them, or that mom or dad really care about their health, you should too." That's the sort of afflict the comfortable, create a discrepancy between their risk behavior and what they value and let that drive their motivation.

0:04:49.4 Narrator: Resnicow and his collaborators have studied the opinions and beliefs of anti-vaccine and vaccine-hesitant individuals during the pandemic. He believes the lessons of Motivational Interviewing can be used to help move people away from potentially harmful choices and toward vaccination and other proven mitigation strategies.

0:05:08.7 KR: We have to, I think, divide the hesitant into several groups. Number one, the logistic barrier group. That's the group we see as the most open to change. They're fundamentally either positive or at least neutral about the vaccine, but they either feel they don't have the time, they don't know where to get it, they feel too busy, they're a little bit worried about missing work from side effects, not quite sure if it's gonna cost them any money. So those people need information like, "Does it cost anything. What's the likelihood I might miss work from a side effect? Where is the closest place? What are some of the other ways to 0overcome their logistic barriers?" So that's the first group. The second group is the wait and see group. That group is a little bit dubious about being experimented on. Many African Americans in national surveys fit into that group like, "Yeah, I think this is possibly good, but don't experiment on me, someone else step up.

0:06:01.2 KR: Let you be the guinea pigs." Now, the good news is that group is really waning naturally over time because they've waited and they've seen, and what they've seen so far is pretty good, high immunity and really low rates of side effects. So that group again, MI is helpful 'cause you wanna reflect back, "You don't want to be experimented on, you're open to it, but you're a little worried." Same techniques, although that one seems to be to some extent naturally fixing itself. Now comes the third group, and this is where MI, I think, is absolutely essential. It's the hard no group. It is a fascinating mash-up of political, religious and conspiratory beliefs. We've just published one paper this year and we’re about to submit another, where we've shown that people who are in the hard no group believe that they're putting chips into your blood and Bill Gates is behind it. They believe that this is this mark of the beast and the end of times and the apocalypse, they believe the government has exaggerated all of this for some nefarious purpose, and they believe in a whole realm of Trump-inspired distortions about the fraudulent election. They actually tie those two together, people who believe the election was stolen are twice as likely to be in the hard no group. This group also has a personality trait called reactance. Independent of COVID, they fundamentally don't like being told what to do. Counter-arguing with them is going make it worse.

0:07:23.5 KR: Reactant people, when you argue with them, dig their heels and entrench, so you're only gonna make them defend their positions stronger, you're not gonna sway them. The hard no group has these ideological objections that are really not about the vaccine specifics, it's the political party they think it's from, or the religious secular left they think it's from, and they believe, and it's gotten twisted into this, by not getting the vaccine you're standing up for America, you're standing up for God, you're standing up against the evil heathens, and it's become a holy war for them, both in a secular and a religious sense. MI at least teaches us that counter-arguing is gonna make it worse, let's affirm anything we can positive about them, even if it takes a lot of intellectual and emotional discipline to say things like, "You've thought about this a lot. You care about your independence, you don't wanna be pushed into it."

0:08:24.0 KR: Those are true statements, so those reflections are authentic, and will hopefully build some rapport rather than trying to counter-argue with them. At the advanced level we would like to use some strategies to try and move them. That's asking a lot because it's a very difficult audience, so we feel for someone who just has a little bit of communication skill, just reflect a firm... Don't scare them away, just keep them in the family. But if you have either a hard no who has a bigger crack in their door or you have some advanced skills, there are little tricks we can do where you try and emphasize part of you wouldn't mind being immune against COVID or part of you, who knows that, maybe it's serious and it's not all exaggerated. So use these sort of amplified statements to say, "It's not entirely fabricated, the whole thing is not entirely a conspiracy," and that's how you try and find a little chink in their armor.

0:09:23.2 KR: There are some things that you can try that actually are interventions, so yes, affirm, reflect, build rapport, show "I don't think you're an idiot, I still care about you." But there are some little tricks, so you could say, "What, if anything, could I do to help you here? Is there any information that might be useful?" Now often they'll say no, which tells you it's clearly in an emotional personality space, not in a knowledge space. And then there's some very confrontational type questions that you could ask in a soft way. One of them is that when you think of some of the great leaders of your movement, the host of Fox's evening shows, even some of them who are really controversial folks like Alex Jones, it's pretty clear that the Fox talking heads, Hannity and Carlson, are vaccinated. Now they pretend to not be or they pretend to be skeptical, but the fact is these very wealthy White guys are not stupid and they've been vaccinated. So to present that in a non-sarcastic snarky way, we call it the lieutenant Columbo technique.

0:10:24.8 KR: "Mmm, it's interesting that Hannity and Carlson actually seemed to be vaccinated, and yet they're pushing doubt, why is that? What's going on there?" So you use the same techniques that they use, "Oh, I'm just asking questions," and sometimes that works, sometimes that's a hard one for them to answer. And in fact, in the case of Donald Trump, some of his supporters moved away from him. It put them in such an awkward position the only way to resolve their dissonance was to renounce Trump for getting the vaccine. So some very skilfully neutrally worded questions should be considered, although we have to be realistic, it's not gonna generally in five minutes create a complete reversal towards vaccination, but it might raise some doubt that when they go home and they're lying in bed, maybe they'll think about it, planting seeds as we say.

0:11:17.1 KR: The hard no has basically been about 15% the last seven months amongst Whites, and it hasn't budged. What's interesting is the hard no group for Blacks and Hispanics has dropped by about 60%. So amongst Blacks and Hispanics, it's dropped from 15% to 9% and 18% to 10%, Black and Hispanic respectively. But it's the White evangelical Southern male, they have just stayed flat at about 15%, and that's the hard no group.

0:11:44.2 KR: The wait and see group has dropped significantly since December of 20. It was 39% in the US in December, right when the vaccine was coming out, and it's down to 10% or less now. That drop is even more significant in African-Americans where it was 52%, half the Black population was wait and see in December when the vaccine was just coming out, and it's down to below 15% now. So we really see that the group that is staying the course is White, Southern, male, evangelicals at 15%.

0:12:21.0 KR: We have to be sensitive to the needs of the hesitant and reflect back their concerns, and that's important. I think it's also important that we acknowledge the vaccinated folks are getting angry. You saw it in Biden's recent public appearances, and increasingly you hear more and more people on the left who are like, "Alright, enough already." I think it's important that we also respect that emotion. Now, I don't recommend necessarily expressing that to the hesitant to say how angry everyone is at you, I'm not recommending that, but I do think it's important for the people who are frustrated with the un-vaccinated to show them the same courtesy of affirming their emotions, which at this point for many people, include anger, frustration, disbelief, and it's impacting them.

0:13:12.9 Narrator: This has been a special edition of Population Healthy, a podcast from the University of Michigan School of Public Health. During the ongoing Coronavirus pandemic, we'll work to bring you analysis from our community of experts, help you understand what this public health crisis means for you. To stay up-to-date in between special edition episodes, be sure to check out our website publicHealth.UMICH.edu. Subscribe to our Population Healthy newsletter at PublicHealth.UMICH.edu/news/newsletter, and follow us on Twitter, Instagram, and Facebook at UMICHSPH.