Have you noticed that when someone tells you to do something, it is less effective than if you decided to do it on your own? This is the core tenet of motivational interviewing (MI). It is said that we change that which we give voice to. What does that mean to you on a Monday morning when you have a challenging patient in your chair? Let’s look at a possible scenario.
Mrs. Johnson, who is 45, presents with profuse gingival bleeding and edematous tissue. Your first thought might be to question her about when her last prophylaxis was, only to learn that it was two years ago. Your likely follow-up question is, how often do you brush and floss your teeth? It is likely that Mrs. Johnson does neither regularly. But now you have her on the defensive, so she probably won’t share that she’s been taking care of her elderly mother, or that she’s become the caregiver for her grandchild during the week.
While it’s natural to immediately become an “expert” and feel obligated to disseminate your years of dental expertise with Mrs. Johnson, why not take a kinder, gentler approach? What if you tried MI?
What is motivational interviewing?
People have practiced MI for years; in fact, you probably already use it. Its major constructs are to identify change talk and to reduce resistance talk.1 Change talk is simply verbiage or body language that suggests a patient is ready to make a behavioral change. Resistance talk is the opposite—the person is not ready to make a change. This can be learned simply by asking a patient, “On a scale of one to 10, how likely are you to begin flossing two times a week?” You may remember this as the “Stages of Change” or “Transtheoretical Model.” Is the patient in the precontemplation stage where she is considering making a change, or is she not quite ready yet?
You also need to consider how you ask patients pertinent questions. Are they open-ended questions such as, “Tell me about your dental routine.” This allows patients to share more information with you than if you asked, “Do you floss?” which only yields a yes or no response.
When employing the MI technique, you may use OARS—open-ended questions and affirmations (provide support), reflections (repeat back what you understood your patient to say), and summary (“If I hear you correctly, you’re interested in a solution for your bleeding gums”).2
MI seeks what motivates an individual, and this is different for everyone. For Mrs. Johnson, it might be her appearance. The conversation may include asking her why she thinks her gums look and feel the way they do (O). She may say that it’s because she does not have time to brush twice a day. This might lead to praise that she manages to brush once a day with her chaotic schedule (A). The meeting may conclude by reiterating that she is heard, that she’s too busy to brush twice a day (R), but that she’s visiting the office to find a solution to her problem (S).
At this point, the groundwork has been laid. Now it’s time to determine what the goal is. It could be brushing twice a day, adding floss, and maybe even using an interproximal brush dipped in an antiseptic mouthwash for good measure. But those might be the hygienist’s goals, not necessarily the patient’s goals.
It is crucial to collaborate with your patients. They are ultimately the experts on their own bodies (autonomy) even though we are the dental experts. We must resist the desire to be “right” all the time and work together instead. We should develop SMART goals—specific, measurable, attainable, relevant, and timely.
In this case, the conversation might go like this. “Mrs. Johnson, I hear you saying that you would like your gums to look and feel better. How do you think we can improve them?” Her response might be, “I could try to brush more often.” “Great, what do you think would be a reasonable goal?” She might say, “I could try to brush twice a day for the next two weeks.”
This is MI in action. The patient is motivated to make a change, but no one told her what to do. She was simply guided in the conversation so that she arrived at her own conclusion.
Is MI that simple? Yes and no. It can be time-consuming, and we know time is precious in the dental practice. There will also be patients who won’t engage, and that’s OK. That’s called a paradoxical effect. It should be documented that there was a conversation, but that the patient was not ready to make a change.
The MI technique works well in many situations. Do you have patients who smoke? You might try the “miracle question.” “Mr. Smith, if you woke up tomorrow and were miraculously no longer a smoker, what would that be like for you?” He might say that he would feel better, would save some money, and would not smell like smoke. Continue by asking him to rate his desire to change on the 1–10 readiness scale. If he’s ready, set a goal.
The other aspect of determining whether a patient is ready to make a change is to evaluate the DANCR steps—desire, ability, needs, commitment, and reason. If your patient demonstrates these attributes, the person is more likely to make a behavioral change.
There are volumes of information available for those who want to explore this technique in more depth. Just remember, the most important thing you can do is stop trying to tell patients what to do and, instead, work as a team and allow them to reach their own conclusions. Guide patients; don’t direct them.
References
1. Gao X, Man Lo EC, Ching CK, Wai Chan KC. Motivational interviewing in improving oral health: A systematic review of randomized controlled trials. Jour of Periodon. 83(3);426-437. Published 2013.
2. Watt R. Motivational interviewing may be effective in dental setting. Evidenced Based Dentistry, 11(1-2), Pub Med 20348891. doi:10.1038/sj.ebd.6400702.
Diane Paz, DrBH, MEd, RDH, earned her CDA and RDH from Phoenix College, her BSDH expanded functions and master’s in education from Northern Arizona University, and her doctorate of behavioral health from Arizona State University. Dr. Paz currently instructs dental students at AT Still University (Arizona School of Dental and Oral Health) in Mesa, Arizona, and instructs online for Rio Salado College in Tempe, Arizona, concentrating on the Community Dental Health Coordinator program.
