CHAPTER 7

Vaccine Whisperers and Mild-Mannered Interrogators

How the Right Kind of Listening Motivates People to Change

It’s a rare person who wants to hear what he doesn’t want to hear.

—Attributed to Dick Cavett

When Marie-Hélène Étienne-Rousseau went into labor, she broke down in tears. It was September 2018, and her baby wasn’t due until December. Just before midnight, Tobie arrived, weighing just two pounds. His body was so tiny that his head could fit in the palm of her hand, and Marie-Hélène was terrified that he wouldn’t survive. Tobie spent only a few seconds in her arms before he was rushed to the neonatal intensive care unit. He needed a mask to breathe and was soon taken to surgery for internal bleeding. It would be months before he was allowed to go home.

While Tobie was still in the hospital, Marie-Hélène was shopping for diapers when she saw a headline about measles spreading in her province of Quebec. She hadn’t had Tobie vaccinated. It wasn’t even a question—he seemed too fragile. She hadn’t vaccinated her three other children, either; it wasn’t the norm in her community. Her friends and neighbors took it for granted that vaccines were dangerous and passed around horror stories about their side effects. Still, the fact remained: Quebec had already had two serious measles outbreaks that decade.

Today in the developed world, measles is on the rise for the first time in at least half a century, and its mortality rate is around one in a thousand. In the developing world, it’s closer to one in a hundred. Estimates suggest that from 2016 to 2018, measles deaths spiked worldwide by 58 percent, with over a hundred thousand casualties. These deaths could have been prevented by the vaccine, which has saved roughly 20 million lives in the past two decades. Although epidemiologists recommend two doses of the measles vaccine and a minimum immunization rate of 95 percent, around the globe only 85 percent of people get the first dose and just 67 percent continue to the second. Many of those who skip the shot simply do not believe in the science.

Government officials have tried to prosecute the problem, some warning that the unvaccinated could be fined up to a thousand dollars and sentenced to jail for up to six months. Many schools shut their doors to unvaccinated children, and one county even banned them from enclosed public places. When such measures failed to solve the problem, public officials turned to preaching. Since people held unfounded fears about vaccines, it was time to educate them with a dose of the truth.

The results were often disappointing. In a pair of experiments in Germany, introducing people to the research on vaccine safety backfired: they ended up seeing vaccines as riskier. Similarly, when Americans read accounts of the dangers of measles, saw pictures of children suffering from it, or learned of an infant who nearly died from it, their interest in vaccination didn’t rise at all. And when they were informed that there was no evidence that the measles vaccine causes autism, those who already had concerns actually became less interested in vaccinating. It seemed that no logical argument or data-driven explanation could shake their conviction that vaccines were unsafe.

This is a common problem in persuasion: what doesn’t sway us can make our beliefs stronger. Much like a vaccine inoculates our physical immune system against a virus, the act of resistance fortifies our psychological immune system. Refuting a point of view produces antibodies against future influence attempts. We become more certain of our opinions and less curious about alternative views. Counterarguments no longer surprise us or stump us—we have our rebuttals ready.

Marie-Hélène Étienne-Rousseau had been through that journey. Visits to the doctor with her older kids followed a familiar script. The doctor extolled the benefits of vaccines, warned her about the risks of refusing them, and stuck to generic messaging instead of engaging with her particular questions. The whole experience reeked of condescension. Marie-Hélène felt as if she were being attacked, “as if she were accusing me of wanting my kids to get sick. As if I were a bad mother.”

When tiny Tobie was finally cleared to leave after five months in the hospital, he was still extremely vulnerable. The nurses knew it was their last chance to have him vaccinated, so they called in a vaccine whisperer—a local doctor with a radical approach for helping young parents rethink their resistance to immunizations. He didn’t preach to parents or prosecute them. He didn’t get political. He put on his scientist hat and interviewed them.

Calvin & Hobbes © 1993 Watterson. Reprinted with permission of ANDREWS MCMEEL SYNDICATION. All rights reserved.

MOTIVATING THROUGH INTERVIEWING

In the early 1980s, a clinical psychologist named Bill Miller was troubled by his field’s attitude toward people with addictions. It was common for therapists and counselors to accuse their substance-abusing clients of being pathological liars who were living in denial. That didn’t track with what Miller was seeing up close in his own work treating people with alcohol problems, where preaching and prosecuting typically boomeranged. “People who drink too much are usually aware of it,” Miller told me. “If you try to persuade them that they do drink too much or need to make a change, you evoke resistance, and they are less likely to change.”

Instead of attacking or demeaning his clients, Miller started asking them questions and listening to their answers. Soon afterward, he published a paper on his philosophy, which found its way into the hands of Stephen Rollnick, a young nurse trainee working in addiction treatment. A few years later, the two happened to meet in Australia and realized that what they were exploring was much bigger than just a new approach to treatment. It was an entirely different way of helping people change.

Together, they developed the core principles of a practice called motivational interviewing. The central premise is that we can rarely motivate someone else to change. We’re better off helping them find their own motivation to change.

Let’s say you’re a student at Hogwarts, and you’re worried your uncle is a fan of Voldemort. A motivational interview might go like this:

You: I’d love to better understand your feelings about He Who Must Not Be Named.

Uncle: Well, he’s the most powerful wizard alive. Also, his followers promised me a fancy title.

You: Interesting. Is there anything you dislike about him?

Uncle: Hmm. I’m not crazy about all the murdering.

You: Well, nobody’s perfect.

Uncle: Yeah, but the killing is really bad.

You: Sounds like you have some reservations about Voldemort. What’s stopped you from abandoning him?

Uncle: I’m afraid he might direct the murdering toward me.

You: That’s a reasonable fear. I’ve felt it too. I’m curious: are there any principles that matter so deeply to you that you’d be willing to take that risk?

Motivational interviewing starts with an attitude of humility and curiosity. We don’t know what might motivate someone else to change, but we’re genuinely eager to find out. The goal isn’t to tell people what to do; it’s to help them break out of overconfidence cycles and see new possibilities. Our role is to hold up a mirror so they can see themselves more clearly, and then empower them to examine their beliefs and behaviors. That can activate a rethinking cycle, in which people approach their own views more scientifically. They develop more humility about their knowledge, doubt in their convictions, and curiosity about alternative points of view.

The process of motivational interviewing involves three key techniques:

As Marie-Hélène was getting ready to take Tobie home, the vaccine whisperer the nurses called was a neonatologist and researcher named Arnaud Gagneur. His specialty was applying the techniques of motivational interviewing to vaccination discussions. When Arnaud sat down with Marie-Hélène, he didn’t judge her for not vaccinating her children, nor did he order her to change. He was like a scientist or “a less abrasive Socrates,” as journalist Eric Boodman described him in reporting on their meeting.

Arnaud told Marie-Hélène he was afraid of what might happen if Tobie got the measles, but he accepted her decision and wanted to understand it better. For over an hour, he asked her open-ended questions about how she had reached the decision not to vaccinate. He listened carefully to her answers, acknowledging that the world is full of confusing information about vaccine safety. At the end of the discussion, Arnaud reminded Marie-Hélène that she was free to choose whether or not to immunize, and he trusted her ability and intentions.

Before Marie-Hélène left the hospital, she had Tobie vaccinated. A key turning point, she recalls, was when Arnaud “told me that whether I chose to vaccinate or not, he respected my decision as someone who wanted the best for my kids. Just that sentence—to me, it was worth all the gold in the world.”

Marie-Hélène didn’t just allow Tobie to be vaccinated—she had his older siblings vaccinated at home by a public health nurse. She even asked if Arnaud would speak with her sister-in-law about vaccinating her children. She said her decision was unusual enough in her antivaccination community that “it was like setting off a bomb.”

Marie-Hélène Étienne-Rousseau is one of many parents who have undergone a conversion like this. Vaccine whisperers don’t just help people change their beliefs; they help them change their behaviors, too. In Arnaud’s first study, with mothers in the maternity ward after birth, 72 percent said they planned to vaccinate their children; after a motivational interviewing session with a vaccine counselor, 87 percent were onboard. In Arnaud’s next experiment, if mothers attended a motivational interviewing session, children were 9 percent more likely to be fully vaccinated two years later. If this sounds like a small effect, remember that it was the result of only a single conversation in the maternity ward—and it was sufficient to change behavior as far out as twenty-four months later. Soon the government health ministry was investing millions of dollars in Arnaud’s motivational interviewing program, with a plan to send vaccine whisperers into the maternity wards of every hospital in Quebec.

Today, motivational interviewing is used around the world by tens of thousands of practitioners—there are registered trainers throughout America and in many parts of Europe, and courses to build the necessary skills are offered as widely as Argentina, Malaysia, and South Africa. Motivational interviewing has been the subject of more than a thousand controlled trials; a bibliography that simply lists them runs sixty-seven pages. It’s been used effectively by health professionals to help people stop smoking, abusing drugs and alcohol, gambling, and having unsafe sex, as well as to improve their diets and exercise habits, overcome eating disorders, and lose weight. It’s also been applied successfully by coaches to build grit in professional soccer players, teachers to nudge students to get a full night’s sleep, consultants to prepare teams for organizational change, public health workers to encourage people to disinfect water in Zambia, and environmental activists to help people do something about climate change. Similar techniques have opened the minds of prejudiced voters, and when conflict mediators help separated parents resolve disputes about their children, motivational interviewing is twice as likely to result in a full agreement as standard mediation.

Overall, motivational interviewing has a statistically and clinically meaningful effect on behavior change in roughly three out of four studies, and psychologists and physicians using it have a success rate of four in five. There aren’t many practical theories in the behavioral sciences with a body of evidence this robust.

Motivational interviewing isn’t limited to professional settings—it’s relevant to everyday decisions and interactions. One day a friend called me for advice on whether she should get back together with her ex. I was a fan of the idea, but I didn’t think it was my place to tell her what to do. Instead of offering my opinion, I asked her to walk through the pros and cons and tell me how they stacked up against what she wanted in a partner. She ended up talking herself into rekindling the relationship. The conversation felt like magic, because I hadn’t tried to persuade her or even given any advice.*

When people ignore advice, it isn’t always because they disagree with it. Sometimes they’re resisting the sense of pressure and the feeling that someone else is controlling their decision. To protect their freedom, instead of giving commands or offering recommendations, a motivational interviewer might say something along the lines of “Here are a few things that have helped me—do you think any of them might work for you?”

You’ve seen how asking questions can help with self-persuasion. Motivational interviewing goes a step further, guiding others to self-discovery. You got a glimpse of it in action when Daryl Davis asked KKK members how they could hate him when they didn’t even know him, and now I want to unpack the relevant techniques in depth. When we try to convince people to think again, our first instinct is usually to start talking. Yet the most effective way to help others open their minds is often to listen.

BEYOND THE CLINIC

Years ago I got a call asking for help from a biotechnology startup. The CEO, Jeff, was a scientist by training; he liked to have all the necessary data before making a decision. After more than a year and a half at the helm, he still hadn’t rolled out a vision for the company, and it was in danger of failing. A trio of consultants tried to convince him to offer some direction, and he fired them all. Before the head of HR threw in the towel, she threw a Hail Mary pass and contacted an academic. It was the perfect time for a motivational interview: Jeff seemed reluctant to change, and I had no idea why. When we met, I decided to see if I could help him find his motivation to change. Here are the pivotal moments from our conversation:

Me: I really enjoy being the guy who gets hired after three consultants get fired. I’d love to hear how they screwed up.

Jeff: The first consultant gave me answers instead of asking questions. That was arrogant: how could he solve a problem before he’d even taken the time to understand it? The next two did a better job learning from me, but they still ended up trying to tell me how to do my job.

Me: So why did you bother to bring in another outsider?

Jeff: I’m looking for some fresh ideas on leadership.

Me: It’s not my place to tell you how to lead. What does leadership mean to you?

Jeff: Making systemic decisions, having a well-thought-out strategy.

Me: Are there any leaders you admire for those qualities?

Jeff: Abraham Lincoln, Martin Luther King Jr., Steve Jobs.

That was a turning point. In motivational interviewing, there’s a distinction between sustain talk and change talk. Sustain talk is commentary about maintaining the status quo. Change talk is referencing a desire, ability, need, or commitment to make adjustments. When contemplating a change, many people are ambivalent—they have some reasons to consider it but also some reasons to stay the course. Miller and Rollnick suggest asking about and listening for change talk, and then posing some questions about why and how they might change.

Say you have a friend who mentions a desire to stop smoking. You might respond by asking why she’s considering quitting. If she says a doctor recommended it, you might follow up by inquiring about her own motivations: what does she think of the idea? If she offers a reason why she’s determined to stop, you might ask what her first step toward quitting could be. “Change talk is a golden thread,” clinical psychologist Theresa Moyers says. “What you need to do is you need to pick that thread up and pull it.” So that’s what I did with Jeff.

Me: What do you appreciate most about the leaders you named?

Jeff: They all had vivid visions. They inspired people to achieve extraordinary things.

Me: Interesting. If Steve Jobs were in your shoes right now, what do you think he’d do?

Jeff: He’d probably get his leadership team fired up about a bold idea and create a reality distortion field to make it seem possible. Maybe I should do that, too.

A few weeks later, Jeff stood up at an executive off-site to deliver his first-ever vision speech. When I heard about it, I was beaming with pride: I had conquered my inner logic bully and led him to find his own motivation.

Unfortunately, the board ended up shutting down the company anyway.

Jeff’s speech had fallen flat. He stumbled through notes on a napkin and didn’t stir up enthusiasm about the company’s direction. I had overlooked a key step—helping him think about how to execute the change effectively.

There’s a fourth technique of motivational interviewing, which is often recommended for the end of a conversation and for transition points: summarizing. The idea is to explain your understanding of other people’s reasons for change, to check on whether you’ve missed or misrepresented anything, and to inquire about their plans and possible next steps.

The objective is not to be a leader or a follower, but a guide. Miller and Rollnick liken it to hiring a tour guide in a foreign country: we don’t want her to order us around, but we don’t want her to follow us around, either. I was so excited that Jeff had decided to share his vision that I didn’t ask any questions about what it was—or how he would present it. I had worked with him to rethink whether and when to give a speech, but not what was in it.

If I could go back, I’d ask Jeff how he was considering conveying his message and how he thought his team would receive it. A good guide doesn’t stop at helping people change their beliefs or behaviors. Our work isn’t done until we’ve helped them accomplish their goals.

Part of the beauty of motivational interviewing is that it generates more openness in both directions. Listening can encourage others to reconsider their stance toward us, but it also gives us information that can lead us to question our own views about them. If we take the practices of motivational interviewing seriously, we might become the ones who think again.

It’s not hard to grasp how motivational interviewing can be effective for consultants, doctors, therapists, teachers, and coaches. When people have sought out our assistance—or accepted that it’s our job to help—we’re in a position to earn their trust. Yet we all face situations in which we’re tempted to steer people in the direction we prefer. Parents and mentors often believe they know what’s best for their children and protégés. Salespeople, fundraisers, and entrepreneurs have a vested interest in getting to yes.

Motivational interviewing pioneers Miller and Rollnick have long warned that the technique shouldn’t be used manipulatively. Psychologists have found that when people detect an attempt at influence, they have sophisticated defense mechanisms. The moment people feel that we’re trying to persuade them, our behavior takes on a different meaning. A straightforward question is seen as a political tactic, a reflective listening statement comes across as a prosecutor’s maneuvering, an affirmation of their ability to change sounds like a preacher’s proselytizing.

Motivational interviewing requires a genuine desire to help people reach their goals. Jeff and I both wanted his company to succeed. Marie-Hélène and Arnaud both wanted Tobie to be healthy. If your goals don’t seem to be aligned, how do you help people change their own minds?

THE ART OF INFLUENTIAL LISTENING

Betty Bigombe had already hiked eight miles through the jungle, and there was still no sign of life. She was no stranger to a long walk: growing up in northern Uganda, she walked four miles each way to school. She subsisted on one meal a day in a communal homestead where her uncle had eight wives. Now she had made it all the way to the Ugandan Parliament, and she was undertaking a challenge that none of her colleagues would brave: trying to make peace with a warlord.

Joseph Kony was the leader of the Lord’s Resistance Army. He and his rebel group would eventually be held responsible for murdering over a hundred thousand people, abducting over thirty thousand children, and displacing over two million Ugandans. In the early 1990s, Betty convinced the Ugandan president to send her in to see if she could stop the violence.

When Betty finally made contact with the rebels after months of effort, they were insulted at the prospect of negotiating with a woman. Yet Betty negotiated her way into getting permission to meet Kony himself. Soon he was referring to her as Mummy, and he even agreed to leave the jungle to start peace talks. Although the peace effort didn’t succeed, opening Kony’s mind to conversation was a remarkable accomplishment in itself.* For her efforts to end the violence, Betty was named Uganda’s Woman of the Year. When I spoke to her recently, I asked how she had succeeded in getting through to Kony and his people. The key, she explained, was not persuading or even coaxing, but listening.

Listening well is more than a matter of talking less. It’s a set of skills in asking and responding. It starts with showing more interest in other people’s interests rather than trying to judge their status or prove our own. We can all get better at asking “truly curious questions that don’t have the hidden agenda of fixing, saving, advising, convincing or correcting,” journalist Kate Murphy writes, and helping to “facilitate the clear expression of another person’s thoughts.”*

When we’re trying to get people to change, that can be a difficult task. Even if we have the best intentions, we can easily slip into the mode of a preacher perched on a pulpit, a prosecutor making a closing argument, or a politician giving a stump speech. We’re all vulnerable to the “righting reflex,” as Miller and Rollnick describe it—the desire to fix problems and offer answers. A skilled motivational interviewer resists the righting reflex—although people want a doctor to fix their broken bones, when it comes to the problems in their heads, they often want sympathy rather than solutions.

That’s what Betty Bigombe set out to provide in Uganda. She started traveling through rural areas to visit camps for internally displaced people. She figured some might have relatives in Joseph Kony’s army and might know something of his whereabouts. Although she hadn’t been trained in motivational interviewing, she intuitively understood the philosophy. At each camp, she announced to people that she wasn’t there to lecture them, but to listen to them.

Her curiosity and confident humility caught the Ugandans by surprise. Other peacemakers had come in ordering them to stop fighting. They had preached about their own plans for conflict resolution and prosecuted the past efforts that failed. Now Betty, a politician by profession, wasn’t telling them what to do. She just sat patiently for hours in front of a bonfire, taking notes and chiming in from time to time to ask questions. “If you want to call me names, feel free to do so,” she said. “If you want me to leave, I will.”

To demonstrate her commitment to peace, Betty stayed in the camps even though they lacked sufficient food and proper sanitation. She invited people to air their grievances and suggest remedial measures to be taken. They told her that it was rare and refreshing for an outsider to give them the opportunity to share their views. She empowered them to generate their own solutions, which gave them a sense of ownership. They ended up calling her Megu, which translates literally to “mother” and is also a term of endearment for elders. Bestowing this honorific was particularly striking since Betty was representing the government—which was seen as the oppressor in many of the camps. It wasn’t long before people were offering to introduce her to coordinators and commanders in Joseph Kony’s guerrilla army. As Betty muses, “Even the devil appreciates being listened to.”

In a series of experiments, interacting with an empathetic, nonjudgmental, attentive listener made people less anxious and defensive. They felt less pressure to avoid contradictions in their thinking, which encouraged them to explore their opinions more deeply, recognize more nuances in them, and share them more openly. These benefits of listening aren’t limited to one-on-one interactions—they can also emerge in groups. In experiments across government organizations, tech companies, and schools, people’s attitudes became more complex and less extreme after they sat in a listening circle, where one person at a time held a talking stick and everyone else listened attentively. Psychologists recommend practicing this skill by sitting down with people whom we sometimes have a hard time understanding. The idea is to tell them that we’re working on being better listeners, we’d like to hear their thoughts, and we’ll listen for a few minutes before responding.

Many communicators try to make themselves look smart. Great listeners are more interested in making their audiences feel smart. They help people approach their own views with more humility, doubt, and curiosity. When people have a chance to express themselves out loud, they often discover new thoughts. As the writer E. M. Forster put it, “How can I tell what I think till I see what I say?” That understanding made Forster an unusually dedicated listener. In the words of one biographer, “To speak with him was to be seduced by an inverse charisma, a sense of being listened to with such intensity that you had to be your most honest, sharpest, and best self.”

Inverse charisma. What a wonderful turn of phrase to capture the magnetic quality of a great listener. Think about how rare that kind of listening is. Among managers rated as the worst listeners by their employees, 94 percent of them evaluated themselves as good or very good listeners. Dunning and Kruger might have something to say about that. In one poll, a third of women said their pets were better listeners than their partners. Maybe it wasn’t just my kids who wanted a cat. It’s common for doctors to interrupt their patients within 11 seconds, even though patients may need only 29 seconds to describe their symptoms. In Quebec, however, Marie-Hélène experienced something very different.

When Marie-Hélène explained that she was concerned about autism and the effects of administering multiple vaccines simultaneously, Arnaud didn’t bombard her with a barrage of scientific facts. He asked what her sources were. Like many parents, she said she had read about vaccines on the internet but didn’t remember where. He agreed that in a sea of conflicting claims, it’s difficult to gain a clear sense of whether immunization is safe.

Eventually, when he understood Marie-Hélène’s beliefs, Arnaud asked if he could share some information about vaccines based on his own expertise. “I started a dialogue,” he told me. “The aim was to build a trusting relationship. If you present information without permission, no one will listen to you.” Arnaud was able to address her fears and misconceptions by explaining that the measles vaccine is a weakened live virus, so the symptoms are typically minimal, and there’s no evidence that it increases autism or other syndromes. He wasn’t delivering a lecture; he was engaging in a discussion. Marie-Hélène’s questions guided the evidence he shared, and they reconstructed her knowledge together. Every step of the way, Arnaud avoided putting pressure on her. Even after talking through the science, he concluded the conversation by telling her he would let her think about it, affirming her freedom to make up her own mind.

In 2020, during the worst snowstorm of the winter, a married couple drove an hour and a half to visit Arnaud. They hadn’t vaccinated any of their children, but after forty-five minutes of discussion with him, they decided to vaccinate all four of them. The couple lived in Marie-Hélène’s village, and seeing other children vaccinated there made the mother curious enough to seek more information.

The power of listening doesn’t lie just in giving people the space to reflect on their views. It’s a display of respect and an expression of care. When Arnaud took the time to understand Marie-Hélène’s concerns instead of dismissing them, he was showing a sincere interest in her well-being and that of her son. When Betty Bigombe stayed with displaced Ugandans in their camps and asked them to air their grievances, she was proving that what they had to say mattered to her. Listening is a way of offering others our scarcest, most precious gift: our attention. Once we’ve demonstrated that we care about them and their goals, they’re more willing to listen to us.

If we can convince a mother to vaccinate her vulnerable children—or a warlord to consider peace talks—it’s easy to conclude that the ends justify whatever means are necessary. But it’s worth remembering that the means are a measure of our character. When we succeed in changing someone’s mind, we shouldn’t only ask whether we’re proud of what we’ve achieved. We should also ask whether we’re proud of how we’ve achieved it.