Leah Plummer, who has just graduated as a dentist, presents an overview of motivational interviewing and how it can be incorporated into conversations with patients.

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When we instruct patients on the correct oral hygiene routine it is the starting point of a behavioural change process that the patient needs to undertake. It is not simply a one-off task we are asking them to do; it will take time over several appointments and be a long-term process of change. The COM-B model of behaviour change1 suggests that in order for this to occur the following needs to be addressed: capability, opportunity and motivation (Table 1). Motivation is the most difficult component to address in the dental setting; it is therefore often the remaining barrier that prevents change. Motivational interviewing (MI) is a conversation style which has been explored by Miller and Rollnick2 to harness a patient's inner ambivalence, that is, the want to change versus the want to remain the same both simultaneously. It is patient-centred and relies on the professional acknowledging that change is difficult, and that the patient is an expert on themselves with the right to make their own decisions. This article aims to give an overview of the principles of MI and how they can be incorporated into everyday conversations with patients in the dental setting.

Table 1 COM-B Model of Behaviour Change with dental examples
Full size table

Express empathy

Real empathy goes beyond merely nodding in agreement with the patient's circumstances. Being empathetic involves taking an active interest in seeing the situation through the patient's eyes. Miller and Rollnick defined empathy as 'a specifiable and learnable skill for understanding another's meaning through the use of reflective listening. It requires sharp attention to each new client statement, and the continual generation of hypotheses as to the underlying meaning'.3 As dental professionals we are quick to criticise and tell patients what to do the moment we are aware they have bad oral hygiene. Instead we should hold back on our duty to educate the patient and avoid placing our own views on the situation. Asking open-ended questions will help to better understand the patient's perspective. Offering summary statements on what you believe the patient is trying to communicate to you will demonstrate that you actively care about their point of view. Being truly empathetic will provide the foundations for a trusting and mutually respectful relationship which is needed to welcome behaviour change.

Ask before you give

As dental professionals we have a duty to respect our patients' autonomy in every aspect of our work and this includes offering oral health information. By taking a moment to gain permission, 'I wonder if I could tell you some more about the effect sugar is having on your teeth?' will increase the patient's willingness to hear what we have to say. We are also less likely to receive a defensive response. Asking the patient what they already know shows respect for their current knowledge and may save time by stopping us repeating information they have already heard. When we share our knowledge, it is important to think about what the patient most wants/needs to know; the information should be prioritised to their needs, not our desires to offer a solution. After providing information check for the patient's understanding, by asking for example, 'have I been clear to you so far?' or 'can you tell me in your own words what I've said?'. This not only confirms that the patient understands but also gives us feedback on how clear we have been in our explanation.

Don't be a dictator

There is often an unequal power balance between the dental professional and patient, which stems from our common assumption that because a patient has bad oral hygiene they either don't care or don't know any better. It is our default response to tell the patient what to do in a dictator style way. However, people are much more likely to be persuaded by what they hear themselves say, rather than what is dictated to them. In response to being told to change most people will feel ashamed, overwhelmed or discouraged. Instead ask 'what are the positives of staying how you are?', this will tend to lead the patient to naturally move on to the positives of change and help to further cement this in their thoughts. We could also ask 'what are the three best reasons for you to improve your oral hygiene?'. This way we are guiding the patient to realise their own motivation for change.

Patients often already know what is good and bad for them. Avoid telling them what to do; instead express empathy and allow them to explore their own reasons for change.

Power of a ruler

If you are unsure how to move the conversation forward without dictating to the patient what they should do, try asking this, 'on a scale from 0-10 where 0 means 'not at all important' and 10 means 'the most important thing for you right now, how important would you say it is for you to look after your gums?'. The answer to this question is not important, what is important is the follow up question, 'why are you not (their score -1)?', or alternatively 'what would it take for you to go from a (current number) to say a higher number?'. This will give opportunity to the patient to explore their ambivalence towards change.

Affirmations

While the patient is talking, actively listen for what has been referred to as 'change talk'.2 This is when the patient expresses desires, reasons, or ability to change. In response to hearing these statements even if they are embedded within the negatives, we should highlight them to the patient. This can be done through affirmations to encourage, or open-ended questions to give them the opportunity to explore their inner thoughts further. For example, 'you mentioned you have bad breath, how does that affect you?'; this question explores the patient's reasons for change. Furthermore, one of the challenges that prevents change is the lack of confidence that the patient has in their ability to change. By highlighting the patient's positive characteristics and small achievements this will help empower the patient to realise they do have the ability to change.

Plan and set goals

If the patient has expressed willingness to change it is time to form a change plan and set SMART goals (specific, measurable, achievable, relevant, and timely). Goals work best if the patient can come up with their own plan. To explore what may work best for the patient we should ask them the following, 'what barriers do you think will stop you from changing?', and follow this by giving them the opportunity to come up with their own ways to overcome these barriers. If they are stuck, offer some options that may have worked for others, but we should reassure them that they know themselves best and will know what will work for them.

Summary

Aspects of MI can be included in everyday discussions with patients without a huge amount of effort. It is important to remember at the heart of MI is making the conversation patient focused and giving them the opportunity to explore their own reasons for and against change. One of the most important principles we should remember is that patients often already know what is good and bad for them. Avoid telling them what to do; instead express empathy and allow them to explore their own reasons for change.