Motivational interviewing in dentistry: A discussion worth having

Many years ago, I worked for a private practice where the owner dentist hired a consultant to improve business. Among many other things, the consultant talked about how to motivate patients. I remember at the time thinking how fascinating it was to hear all the different ways. Before that, I really never thought of it as a skill we needed to learn. When we are in school, we are taught how to educate and counsel our patients. But how many of us think beyond that? Do we think about skillful ways to actually motivate patients? Needless to say, I became intrigued.

As oral health-care providers, we often go through our days providing care along with home-care instructions, and then send our patients on their way with the hope that their oral health-care behaviors will change. While we do reach some patients, there are others who may not be as easily reached. The latter have a resistance to change. We may wonder if we are doing enough. Could we have done better? What motivates patients to want to change? These questions triggered me to look deeper into the skills needed to better communicate with our patients, motivating them to want to change.

The concept of motivational interviewing (MI) has been around since the early 1980s.¹ It is an approach that is used to help people who may be struggling to make decisions in any aspect of their lives. The focus of this article is to discuss how MI can assist us in having a conversation with our patients regarding change in their oral health care. 

The focus of MI is to counsel patients who may be uncertain or doubtful about behavior change and trigger their inner motivation to become successful in behavior change.² Although we counsel and educate our patients all the time, some of us may be doing so on autopilot. Clinically, we see something wrong or something that needs attention, and we naturally want to correct it.³ In MI, this is known as the righting reflex.³ Unfortunately, the righting reflex may cause pushback from the patient, hindering any change. Altering the way we deliver information to the patient may mean the difference in patient behavior change outcome. Instead of simply telling a patient what you see and how their behavior needs to change, we should include the patient in the discussion and allow them to decide their course of action and identify needs that they are willing to change. Try to lead them to recognize what they would like to see change.

There are four aspects to MI. These aspects include partnership, acceptance, compassion, and evocation.² The basis of MI is to form collaboration with the patient, while remaining nonjudgmental and developing a level of understanding. Support the patient in their struggle to change, and explore what is important to the patient in order to make this change.² Resistance to change is normal. As the saying goes, “If it were easy, everyone would be doing it.” The same concept holds true with MI. If change were easy, the behavior would be changed already.³

As dental hygienists, we follow a code of ethics and hold core values.⁴ One of those values is autonomy. If we think about the science behind MI and what it entails, it is apparent that it is based off of this core value, allowing patients to make their own decisions about their oral and overall health.² Instead of simply telling patients what they need to do, we can work collaboratively with them to motivate them toward behavior change.² In the end, patients make their own decisions about change, and we remain respectful of their autonomy.

So how is the MI technique put into practice? It is not easy. It is a skill that needs to be practiced over time. There are many articles, research, and courses available on the practice of MI. While all are a great start, in order to master this skill, continued education and coaching are necessary.^5,6 However, there are some core skills known as OARS (open-ended questions, affirmation, reflective listening, summarizing).^2,3 Open-ended questions do not just elicit a yes or no response. Allow patients to enter into a dialogue with you. Affirm that the change is not easy. Try to help patients recognize their own strengths. Listen to and understand your patients and their needs while remaining supportive. Summarize the session with each patient to ensure that you have fully understood what has been discussed.

Now that we have discussed certain interviewing skills associated with MI, let’s review the steps or processes. The steps are engaging, focusing, evoking, and planning.² While we move through these steps, we want to utilize core skills mentioned above in our interviewing conversation.

The first step is engaging. This is where we build trust with the patient. Ask them questions and let them know what you will be discussing. This could include any concerns they may have with their oral health. 

The next step is focusing. Focusing is a way to guide the patient toward the behavior change. Help them focus on what they want to change. This could be discussing interdental care or their toothbrushing technique. For example, after performing a papilla bleeding index, discuss the findings with the patient and ask them, “Shall we discuss ways we can improve the bleeding in your gums?” This will bring attention to the fact that the patient is making that decision.

The third step is evoking. This promotes the patients’ own reasons to change. Ask them what they know about bleeding gums. What is their perception on bleeding gums? Offer them more information on what you are seeing clinically. Let them come to the conclusion that a change needs to be made. Let them be the one to state that change is needed, and then plan to make that change with them.

This brings us to the final step, planning. Ask the patient what it is they can do to make that change, and offer assistance in helping them make that change.

As you can see, the use of MI is a more patient-centered approach.² Recognizing that the patient needs to feel responsible for their own behavior change is a theory that some of us may not have given much thought to. Yes, as I mentioned earlier, most of us will say we listen to our patients and try to include them in decision making. However, MI extends beyond that.⁶ With MI, we are mere facilitators in someone else’s change.

It is important to note that MI can be time consuming and may be difficult to achieve in a faster paced practice or clinical setting. In fact, when interviewing other hygienists who were trained in MI, time was a major barrier to delivery of effective MI.⁵ Traditionally, MI can take anywhere from 5-20 minutes; however, in the dental setting a briefer version may be practical due to time constraints.²

For more information on MI, please visit https://motivationalinterviewing.org/, where you will find many resources as well as online and live workshop events.

References

1. Kay EJ, Vascott D, Hocking A, Nield H. Motivational interviewing in general dental practice: a review of the evidence. Br Dent J. 2016 Dec 16;221(12):785-791.
2. Gillam DG, Yusuf H. Brief motivational interviewing in dental practice. Dent J (Basel). 2019 May 1;7(2). pii:E51.
3. Rosengren DB. Building Motivational Interviewing Skills: A Practitioner Workbook. The Guilford Press. New York, NY. 2017.
4. Bylaws & Code of Ethics. American Dental Hygienists’ Association. June 2018. https://www.adha.org/resources-docs/7611_Bylaws_and_Code_of_Ethics.pdf. Accessed July 31, 2019.
5. Curry-Chiu ME, Catley D, Voelker MA, Bray KK. Dental hygienists’ experiences with motivational interviewing: a qualitative study. J Dent Educ. 2015 Aug;79(8):897-906.
6. Miller WR, Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychother. 2009 Mar;37(2):129-140.

Melissa Damatta, MSDH, RDH, CDA, is an instructor for the dental hygiene program at Community College of Philadelphia, where she serves as clinic coordinator for the second-year students and teaches radiology and a preclinical course to first-year students. She has practiced dental hygiene for 16 years, with experiences in periodontal, pediatric, and general dentistry. She is former president of CNJDHA and continues to practice as a clinical dental hygienist for a private practice in New Jersey.