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MOTIVATIONAL INTERVIEWING

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Motivational interviewing
CHANGING BEHAVIOURS: THE BACKGROUND

Most chronic dental diseases can be prevented, if patients stick to recommended self-care strategies for improving oral health, are successfully treated, and comply with guidance on routine maintenance.

Success is largely dependent on patient engagement, of course, and those not interested in changing their behaviours may react by not listening to the clinician or becoming defensive. Research has shown that, even in the best-case scenario, adhering to health providers’ recommendations tends to be low; 30-60% of information provided in the clinician/patient encounter is forgotten within an hour, while DiMatteo showed that 50% of health recommendations are not followed by patients. Combining knowledge and advice with behavioural strategies in professional recommendations shows an improved response and uptake.

Psychological theories are used to explain why some people engage in behaviours that favour good health, whereas others, despite knowing they’re in poor health, fail to adopt healthier behaviours recommended by healthcare professionals.

"The term motivation refers to factors that activate, direct, and sustain goal-directed behavior... Motives are the ‘whys’ of behavior – the needs or wants that drive behavior and explain what we do. We don't actually observe a motive; rather, we infer that one exists based on the behavior we observe" (Nevid, 2013).

WHAT IS MOTIVATIONAL INTERVIEWING (MI)?

Motivational interviewing (MI) is a directive, client-centred counselling style for eliciting behaviour change, by helping clients explore and resolve ambivalence. Compared with non-directive counselling, it is more focused and goal-directed.

EVIDENCE OF MI DIRECTED INTERVENTIONS

The effectiveness of the MI approach for more lasting behaviour change with improved health outcomes, has been documented in clinical trials related to brushing frequency, plaque control, periodontal outcomes, dental caries, and dental visits.

One of the largest and most highly rated studies on MI and oral health, was a longitudinal study of children 0-5 years old and their caregivers. At the 2-year follow-up, the group receiving MI had a significantly higher proportion of children brushing seven nights a week at bedtime, compared to the traditional health education group at 35.45% to 25.33% respectively.

Even though a higher proportion of the MI group (61.2%) assured children were brushing twice a day compared to 56% in the health education group, the result was not statistically significant. Harrison (2012) and Weinstein (2006) showed a 46% and 35% decrease respectively, in early childhood caries among children whose mothers received MI.

In a clinical trial of MI applied to adult chronic periodontal patients, Jönsson and colleagues randomised 113 patients to either standard oral hygiene education or a multi-session, MI-enhanced oral hygiene programme. Plaque, proximal gingival index, global gingival index, and bleeding on probing were evaluated at baseline, 3-month and 12-month follow-up visits. Results showed the MI-enhanced education resulted in a significant improvement in all oral health measures. Plaque and GI scores for this trial are displayed in Table 2.

PRINCIPLES OF MOTIVATIONAL INTERVIEWING

Miller found the likelihood for positive change occurred more readily when the clinician connected the change with what was valued by the patient. He also found confrontational styles or direct persuasion are likely to be met with increased resistance and should be avoided.

MI is based on a theory that motivation is necessary for change to occur; that it resides within the individual and is achievable by eliciting personal values and desires, and the ability to change. It is based on allowing the patient to interpret and integrate health and behaviour change information, if it’s perceived as relevant to his/her situation. It also acknowledges the patient is the expert in their own life.

MI appears to be most effective for patients with low motivation for behaviour change, as it encourages trust between clinician and patient, and enables the clinician to focus on gauging how ready the patient is to change their behaviour.

The four key principles for using MI in healthcare are: resisting the righting reflex, understanding your patient’s motivation, listening to your patient, and empowering your patient. (RULE)

Four General Principles of MI (RULE)
  1. Resisting the righting reflex. Avoid a prescriptive, provider-centered style of solving the patient’s problems for them. Guide them in eliciting their own solutions.
  2. Understanding your patient’s motivation between current behaviour and important goals or values. The second key principle is understanding your patient’s motivations. Any perceived inconsistency between the patient’s current health status, behaviours and values, creates an internal tension that may provide a rationale for change. If time is limited, the best alternative is asking patients why they might desire a change and how they might accomplish it, instead of relying on telling the patient what they should do.
  3. Listening to your patient through acceptance, affirmation, open-ended questions and reflective listening. A third key principle is listening to your patient. When the clinician actively listens to the patient’s response, they express empathy and acceptance. Active or Reflective listening goes beyond just keeping quiet while the patient responds. Reflecting back what the clinician perceives the patient has communicated allows the clinician to ‘get it right’. Good listening and reflection is a complex skill explored further in MI strategies.
  4. Empower your patient with support, optimism and inspiring self-efficacy. It should be obvious the clinicians’ behaviour and engagement strategies are aimed at empowering your patient. In doing so, the clinician is showing the patient they believe he/she is capable of change. Since it is the patient, not the clinician, who must initiate behaviour change, supporting self-efficacy effectively shifts ‘ownership’ of the solution to the patient. In the language of Self Determination Theory, supporting self-efficacy can increase the person’s sense of competence and increase the likelihood of successful change.
MOTIVATIONAL INTERVIEWING TOOLS

The key components of brief MI that can be applied to delivering oral health information and advice are: Ask Permission, Elicit-Provide-Elicit (using OARS), Explore Options, and Affirm Commitment.

Ask Permission

Soliciting the patient’s permission to share information sets the collaborative spirit of MI right from the start, while giving the patient the autonomy to accept or decline the offer. Get Permission: “May I ask you a few questions about your current oral hygiene habits so I can better understand your situation?”

Elicit-Provide-Elicit (Asking, Listening, Informing)

Using the three communication skills discussed above (open-ended questions, reflection and affirmation) allows the patient to begin talking about and hearing their own intrinsic motivation for change. This also creates the opportunity to use the Elicit-Provide-Elicit strategy, to guide the patient towards real solutions. The Elicit-Provide-Elicit approach continues using evocative questions, affirmations, complex reflections and summaries (Table 2).

Elicit Provide Elicit
The patient's readiness/interest in hearing the informatiion/instruction. Solicited information or advice in as neutral fashion as possible. Patients reaction to the information/instruction provided.
What do you know about how long you should brush? The data show us that the patients do have a natural tendency to overestimate their brushing time. Could this be true in your case?
There is another option that might help you increase your actual brushing time. Would you be interested in hearing about it? Some electric toothbrushes have a timing device to help ensure you brush for two minutes. Is that something you think you might like to use at home?
SUMMARY

Extensive literature clearly demonstrates the important factors in motivation: values/beliefs, perceived susceptibility, social and family norms, cultural differences, lifestyle values and current perceived needs. When clinicians attempt to motivate (e.g. through direct persuasion or advice given from an expert source), patients often respond with a guilt-induced transient change or by simply sustaining their current behaviour. MI is a well-accepted strategy for behaviour change that’s consistent with contemporary theories of behaviour change. The spirit of MI is defined by partnership, evocation, compassion and acceptance exhibited through specific techniques and strategies.

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