An episode of “Changing the Conversation” podcast
David Scales, Tyrel Starks, and host Ali Hall discuss using Motivational Interviewing strategies to address misinformation and promote healthy behaviors.
March 20, 2023
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Ali Hall, Host (00:05): Welcome to Changing the Conversation. I’m your host for today, Ali Hall. I’m a member of the Motivation Interviewing Network of Trainers or MINT and a MINT certified trainer. Our topic today is community oriented MI, promoting health behavior in an era of online misinformation. And I’m joined today by David Scales, assistant professor of medicine at Weill Cornell Medical College, and the Chief Medical Officer of Critica, as well as Tyrel Starks, associate professor of Psychology at Hunter College of the City University of New York. Welcome, David and Tyrel.
David Scales, Guest (00:43): Thank you, Ali. Great to be here.
Tyrel Stark, Guest (00:44): Thanks for having us.
Ali (00:45): David, in your work on community-oriented MI, you talk a lot about medical misinformation. I’d love to hear a little bit more about where medical misinformation fits in with community-oriented MI.
David (00:58): We all observed an unfortunate phenomenon during the pandemic of just how fast misinformation and misconceptions could spread through various different mechanisms. We saw this happen with a lot of Covid related things, not just about vaccination, but about social distancing, about masking, about lockdowns, various different aspects that were attempting to try to control the spread of the virus. There was always a lot of consternation and misinformation that spread around about it.
(01:30): And so with our work, one of the things that we were very interested in was just building on some of the prior successes that had been out in the field. And there’s a lot of work, particularly by Arnauld Gagneur at the University of Sherbrooke, who has used motivational interviewing in clinical settings to help try to reduce vaccine hesitancy among postpartum women. So the work that he did has had a track record of a lot of success, and so we were very interested in seeing if there’s ways that we could adapt motivational interviewing to some other settings to try to build on the success of MI and even just the spirit, the skills and the practice of MI and how that might work in some other situations, not just to address vaccine hesitancy specifically, but to try to address some of the other misconceptions that seem to be connected with the misinformation that circulates around other health related behaviors.
Ali (02:26): Thank you. And Tyrel, where have you found this true in your work as well?
Tyrel (02:30): It took a little while for me to get my head around the idea of motivational interviewing as a way to address the impact of misinformation. I think most MI providers are probably familiar with MI-consistent ways of providing information to folks. It’s not like we can’t do that, but until I started having these conversations with David, I never really thought about MI as a vehicle to counteract or as an antidote to misinformation per se. But the more I talked with David, the more I realized that the effect that misinformation or inaccurate information, or information that’s sort of taken out of context, the effect that has on the individual is to suppress motivation for a health behavior. In that way, MI really is positioned to be a potential answer or antidote.
Ali (03:34): Sure. And if I’m holding misinformation, it feels like to me then moving towards a particular change would not necessarily be important. On the other hand, if a provider was concerned about the misinformation I had and maybe shared with me some different ideas in the way that we know is MI consistent with exploring what I know, providing additional information or maybe even a different point of view with permission and inviting me to see what I think about it, actually my motivation for change might really shift what I’ve decided is important and the sources that I credit might actually shift a bit.
(04:09): So I appreciate both of your work about that. And I noticed that you’ve been focusing on MI that’s delivered in social media spaces such as Facebook chat rooms and other sorts of message boards. But why focus on those spaces? David, why is it important to think about intervening there?
David (04:28): One of the challenges that we face is there’s not always a lot of great information about exactly where people are getting a lot of their information. To give an example, a lot of patients, when asked where they get their health information, they report certain trusted sources perhaps out of a social desirability bias. But if you ask clinicians where they think their patients are getting their health information, by far they think they’re getting their health information from family, friends and social media. So it’s one of those things in clinical spaces at least there’s a perception that Facebook and social media is having a very outsized impact on people’s health perceptions and their health behaviors. And I saw this myself in some of the journalism work I did, looking at people who identify as having chronic Lyme disease, which is a type of illness that isn’t necessarily fully recognized by the most people in the medical community.
(05:28): And there’s a lot of misinformation that propagates about chronic Lyme disease. And one of the things I noticed is just how much misinformation there was about Lyme disease online and how in certain networks, community networks, communities of people who identify as having chronic Lyme disease, certain pieces of misinformation would propagate and certain misconceptions would propagate that sometimes would lead people down pathways where they would engage in health behaviors that sometimes made them feel better, but often also carried a fair amount of risk.
(06:01): And so I was very interested in what were some ways that we could try to address this and recognizing that a phenomenon like chronic Lyme disease was really something that grew up in the age of the internet through connecting in many wonderful ways, suffering patients together so that they could support each other. Some of the negative things that have come through that connection is sometimes the propagation of misinformation and misconceptions. And in order to try to address some of these issues, we need to be engaging the communities where they’re having these discussions so that we can best meet them where they’re at, understand their perspectives, and try to build alliances to move forward.
Ali (06:44): Yeah, that’s really powerful to understand where it is that folks are most accessing information, particularly when a provider is concerned either on an individual basis or as a public health matter that folks aren’t relying on trusted sources, how to re-engage around that and provide maybe new information, maybe from a different source, maybe something that the person hasn’t yet fully considered, but in a way that comes across as, and is received as non-confrontational so that a person can really try it on and have a discussion about it and perhaps be open to some new ideas.
(07:21): Really fascinating. And so Tyrel, I know that you have done so much work with community oriented MI, MI with couples, MI in group settings that may be different than what we sometimes think of as delivering MI in an individual context, a practitioner and one person sitting there together. But I’m just curious, what sets community oriented MI apart from other kinds of work, what it is that we need specifically to try to help implement MI in an online or social media format? What are your perspectives about that?
Tyrel (07:55): I think there are a few things that make this a really unique space to do an intervention in. There’s been a fair amount of work moving interventions into remote delivery. I think there’s a fair amount of evidence now that we can take an individual intervention or a couple’s one or a group one and deliver it vis-a-vis telehealth, but this isn’t what we’ve been doing.
(08:24): And what David has been leading is really different from that. This isn’t just an MI group conducted in a telehealth environment. We’re talking about going into an online social media space, something like a Facebook chat room, which is truly a community space. It’s a uniquely challenging intervention setting, which then also means there’s some unique potential there if we can figure out how to be effective in that setting. Some of the key differences to think about is that in most intervention settings, the interventionist has much more control over the environment or at least much more ability to negotiate the rules that are going to govern that social space with the people who are in a group or who are receiving the intervention. In a social media setting, the interventionist doesn’t have any control over who comes and goes from that space.
(09:24): They don’t have the ability to set rules for that discourse. They truly enter in virtually all respects as an equal to everyone else who is communicating in that space. And some of our listeners may feel very differently. When I first thought about thinking of this as a place to do an intervention, I was very, very intimidated by that. It was a position that I’m not used to being in as a counselor. And in some ways I’m much more comfortable if you sit me in a room with an individual, a couple or a group or something. But I think it is essential that we figure out how to be effective in this space. And I say that because one of the basic principles that seems to be governing the way social media is curated and managed is the idea that discourse is on balance good.
(10:26): That giving people a place where they can talk about their ideas and share their information and express their opinions is good. And if we are going to trust the rules of the marketplace for the sharing of ideas, then it is essential that physicians and counselors and public health providers be able to go into those spaces and conduct themselves effectively in that venue, or else we are abdicating those spaces to people who may be transmitting information with a very different intent. If we’re going to take the stance that the open exchange of ideas is ultimately an on balance good and will police itself, then we can’t have 30% of the points of views then retreat from those spaces.
David (11:22): One thing I would add is essentially what we’re trying to do with community-oriented motivational interviewing is shift a little bit the target of the intervention. Where it’s not just that… In couples MI or in group MI, at the end of the day, the goal is behavior change in many ways for those that are ready to move towards that step in their journey. But one of the things that we’re aiming at is the community at large. And one of the ways we do this is our practitioners very much need to be from the communities in which they’re intervening. And that’s because it’s very difficult for an outsider to come into that community and to be able to have the types of conversations that they have to have, because this isn’t, while we talk about misinformation, misinformation is a very important thing for us to talk about.
(12:14): That’s not the only thing we’re discussing. Because the examples I gave earlier during the pandemic of things like mask wearing, vaccines, social distancing, a lot of that at the time was a situation where people had to make a lot of decisions in settings of a high degree of scientific uncertainty. And a lot of those decisions come down to a certain amount of values. And the challenge with that from a practitioner’s perspective is unless you’re very good at exploring those values, being a member of a community that shares that identity and shares those values and can speak to those values is a very powerful thing.
(12:54): Because a little bit of what we’re doing is not just trying to have a discussion about health behaviors, but it’s a certain amount of trying to be able to have public discourse on contentious issues in this new online public square. I think the challenge of this is our focus is on health behaviors, but the way to get to these health behavior decisions and making decisions in scientific uncertainty is leveraging the practitioners who are able to be role models in this space for how they use their identity or their particular… The values of the community that guides certain decision making, how they can be moderators in this space. So this is some of the things that we’re trying to explore through this work that we’re doing.
Tyrel (13:44): And it’s this sort of thing that David is talking about right now, it was in hearing him talk about where do community norms, where do community values, where does community membership and identity begin to shape behavior? That was the point at which I began to see where MI sits in all of this, that what we’ve been trying to do is not to just provide more information or to combat misinformation with accurate information or whatever.
(14:23): It’s not that this is pitting information against information per se. It is that there is a place for these folks who are going into these social media spaces to think about activating community identity, developing a sense of cohesion, and then inviting the people who have come into this space together to think about what this information means and what this behavior means in the context of who they are as individuals and who they are to one another as a community. And in that context, all of a sudden I begin to see where MI has a place, because I think a lot of folks think about positioning a health behavior in the context of broader goals and values and that is a lot of what David has been training his epidemiologists to go into these spaces and do.
Ali (15:20): Thank you both for that. High level advice that you would give to those of us who are trying to help others or perhaps enter into these discussions in more of this community oriented perspective. This, how can we engage with others around contentious issues such as vaccines in online spaces? Last minute, high level thoughts?
David (15:44): I come from a world that’s very medical and clinical where there’s a heavy focus on knowledge deficit approaches to communication. Meaning, an assumption that if we just provide facts, people will have their behaviors aligned with those facts. And so in the audiences that I’m typically working with, I usually have to start with, it’s a lot more complicated than that. And so taking the spirit of MI of just attentive listening, rolling with resistance, really checking your righting reflex, these are really important things even in online spaces that we need to be very careful with as we try to engage people who have differences of opinion.
Tyrel (16:24): Right. And I think I am increasingly curious about how we can find ways to reposition health behavior as consistent with community membership and community values, that if people enter into a conversation with us believing that people like me and that people who I feel like I belong with do not, cannot, should not do this thing that you’re telling me to do, whether it’s get a vaccine or whatever, if people enter believing that people like me shouldn’t do this, we need to pause and imagine what it might possibly take for this person to begin to imagine that this behavior could in some way be congruent with the values and the norms and membership in this community that is meaningful to them. I think if we dismiss that, that larger social influence, we’re asking people to silo their healthcare decisions from the rest of their identity in a way that I think is probably pretty unlikely to be successful.
Ali (17:45): Facts and information certainly don’t change behavior. It sounds like relationships, values, an integrated identity and having an opportunity to discuss those in meaningful ways in a platform that makes sense to the person with providers who can set aside the righting reflex and really join and help others consider, it sounds like our best chance. Thank you both so much. Thank you David and Tyrel for joining us today and for all that you are doing to make the world a better place.
David (18:19): Thank you, Ali. Great to be here.
Tyrel (18:21): Thanks so much.
Ali (18:22): And to our listeners, please join us next time on Changing the Conversation.
Erika Simon, Producer (18:26): Visit C4innovates.com and follow us on Twitter, Facebook, LinkedIn, and YouTube for more resources to grow your impact. Thank you for joining us. This episode was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Join us next time on Changing the Conversation.
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