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View from the Chairside: I use Motivational Interviewing, do you?

By Dr. Richard Anderson

Anderson-PicDr. Richard K. Anderson is a practicing general dentist in Ottawa, ON. He graduated from The Schulich School of Medicine and Dentistry at Western University in 2008. He is involved with the Ottawa Dental Society and volunteers with the Ottawa Mission Dental Clinic. He loves his family and his profession.

Motivational Interviewing and New Year’s Resolutions

Picture this: A patient walks into to your dental office, and before you even pick up the drill or carry out an injection, a conversation takes place that leads your patient to a lifetime of optimal oral health. What just happened? How could a simple conversation change your patient’s life so positively? I would like to introduce you to Motivational Interviewing (MI), its purpose, its techniques, and how you can elicit a positive behavioural change in your patients.

As a dentist, I want the best oral health for my patients. In other words, I want to prevent and eliminate oral disease. If I can encourage my patients to adopt positive behaviours, I can then consider myself successful in preventing and eliminating oral disease. As you are well aware, it is not that simple to motivate patients to change their habitual behaviours, even when they learn about the damage it causes to their health. Ambivalence to change is common. On the one hand, the patient knows that they need to change, but on the other hand, they are comfortable and set in their ways. Traditionally, this has led the counsellor or clinician to give direct advice as the authoritative expert in their field. And, most often, this type of advice lead to patient’s resistance and lack of change, because the patient would defend their ambivalence.

The stubbornness, evasiveness and/or anger that ensued was the opposite of the desired result. This has led clinicians into an area of research within psychology which has been shown to increase the likelihood of eliciting positive behavioural change. Motivational Interviewing addresses the common problem of ambivalence about behaviour change and honours people’s autonomy and self-determination to make their own choices. MI is a person-centered, goal-oriented, collaborative conversation intended to strengthen a person’s own motivation and commitment to change. This is the intent of MI: the clinician does not impose change, but supports change congruent with the patient’s own values and concerns.

The MI Approach

There is more to the practice of MI than simply understanding its intention. I personally like to use MI techniques in a particular way:

  • I use non-judgmental, open-ended questions which allow for further conversation, rather than a brief ‘yes or no’ answer.
  • I affirm the patient’s skills and strengths which builds rapport and helps the patient see themselves in a new and positive light.
  • I listen carefully and give reflective responses which demonstrate empathy and guide the patient towards talk of change.
  • I summarize the key points of the conversation which allow for structured, organized thinking, and summaries that promote some ideas and minimize other ideas.

The New Year’s Resolution Example

Edward is a 50-year-old male patient with a history of smoking a pack a day for the past 30 years. He does not have a family physician. The poor conditions of his gum and his teeth mean that Edward will be frequently returning for appointments. He presented for a new patient examination where the following conversation unfolded:

  1. Would you mind telling me about your tobacco use?
  2. People often smoke because there is a something that has benefited them in some way. How has smoking benefited you?
  3. What are some aspects of smoking you are not happy about?
  4. I’d like to let you know about some of the risks in smoking that you might not already be aware of, but I want to emphasize that it is your choice alone to decide to make a change.
  5. Could you rate, on a scale of 0-10, the importance of making this change relative to other priorities in your life?
  6. What would it take for you to go from a ‘5’ to a ‘7’?
  7. If things worked out in the best possible way for you, what would you be doing in a year from now?
  8. After this discussion, are you clearer about what you would like to do? What will be your next step?
  9. What else do you think you will need to support you in this plan for change?

Edward proceeded to set an intention to live a smoke-free life as his New Year’s Resolution. Supplemental information and helpful resources were supplied. Nicotine replacement therapy and smoking cessation medications were prescribed. I arranged for follow-up appointments (either in-person or in the form of a phone call) beginning with the first week after the quit/change date.

This initial conversation, grounded in MI techniques, may dramatically change Edward’s life and give him a lifetime of optimal oral health.

I hope that I have demonstrated howMI can be an effective approach to bring about positive lifestyle changes in patients. MI is a collaborative person-centered form of guidance, which elicits and strengthens one’s motivation to change.

Do you think that you could use the MI approach in your practice? Why or why not? Have you tried it before? I look forward to hearing about your experiences using the MI technique or any another successful approach you have been using.

 

 

5 comments

  1. Congratulations Richard for using Motivational Interviewing in your office and sharing your experience with us. You articulate well what Motivational Interviewing is: more than a powerful tool, it reflects a personal shift and a maturity of leadership that, when put in practice, can enhance any dental practice. MI moves prevention from the teaching and telling model to inspiring others to change by helping them uncover their own potential to do so. It appears to be more time consuming than the traditional teach and tell approach, but because it yields more lasting results, whether from patients quitting smoking or committed to flossing every day, long term, it is time saving and very rewarding for both the clinician and the patient. A win win philosophy of care.

  2. Nice article Richard. Summarizes what most clinicians are lacking in their approach to creating loyal patients.

  3. Dear Richard,

    Thank you for writing this inspirational piece. You remind me of a much younger version of myself when I too viewed oral health education as an eye-opening transactional relationship with my patients. I too viewed my position as that of one being at a non adversarial positional with my patients and that this would lead to change. I too employed boundary conversations with patients on subjects like smoking cessation. Sadly, many years of research after I soon realized that my flaw was not in the process but in the premises upon which I based my theory. You have to accept that “Change is an outcome variable” based upon the strategy that you employ and the the structures within which you employ them. This change occurs as a process over time in which the relationship involves a definition of meaning, understanding, a form of oral health solidarity and then collective action and follow-up. To publish motivational interviewing as a solitary means is an injustice to adult education. It is an artifact technique when employed by those with the tacit skills necessary to achieve success, but should not be published to be used in everyday practice unless there is a substantial referral to other programs that can provide long-term follow up and support. Nonetheless I personally applaud you for your piece and welcome you for dinner to talk about this some more whenever you are free.

    Yours fraternally,

    Waji Khan

  4. Richard,

    I am writing a book on Motivational Interviewing in Dentistry at Bill Miller’s suggestion. I have found very little reference to “MI” as I have been tracking it on Google Scholar and on other resources.

    I was very gratified to see your article appear on Google Scholar. I join the other responders to your article in saying “Congratulations!”. I am interested in finding out more about how you found MI and how you use it in your dental practice.

    For more information on me and my work with MI and person-centered approaches in dentistry, go to my “In a Spirit of Caring” web site at http://www.spiritofcaring.com.

    Lynn Carlisle, DDS
    http://www.spiritofcaring.com

  5. Hello Richard:
    Sorry for the late replay. I applaud your interest in MI and how you have respectfully integrated it into your practice.

    I use a similar approach in my practice that is supported by our practice core values and a core belief that there is an “inner dentist” inside of every patient. Our job is to create a safe place, judgement free where the inner dentist can be heard and understood rather than fixed and healed. We do this through kindness, humility and patience. This is our “why” we do what we do.

    Many years ago, I discovered this quote via Mary Osborne, from Margaret Wheatley and Myron Rogers’ book, A Simpler Way.

    “We encourage others to change only if we honour who they are now. We ourselves engage in change only as we discover that we might become more of who we are by becoming something different.”

    What makes process most effective is if we can be personally authentic. If we show up as “who” we really are – vulnerable, transparent and courageous. Think of times in your own life when you could truly be yourself in front of someone – you felt accepted and safe. No doubt , because the person you were with, was real and leading an undivided life.

    How does this show up in my practice? Personal leadership is essential – how I behave is critical – not only with patients but with team members too. And to facilitate the patient conversations we have developed a WISH list. It is a conversation with the patient that is all about the patient. It begins with the “H” question: “If we were having this conversation a year from now, what has to have happened over the year for you to feel happy about your progress both personal and professionally?”
    Then the “W” question: “What are you worried about? WHat keeps you up at night?”
    Then the “I” question: “What is less than ideal for you” If you could wave a magic wand, what would it look like?”
    Then the “S” question: “What is working for you now? What are your strengths?”

    All answers are recorded on the WISH form in the patient’s own words as quotes . These are then shared with the patient for editing. Together we work to eliminate the worries, capture the opportunities that are part of the patient’s ideal, protect the strengths and the H question or Happy question helps us prepare the agenda- first things first.

    It is very powerful to see how honoured people feel to be truly listened to and to actually hear their own voice speak their own truth in a safe place.

    This has become an integral part of what we do – for new patients, for emergency patients and routinely at hygiene appointments. Our patients come to expect the WISH list conversation.

    Equally important is our patient rights statement that honours the inner dentist: “We believe you have the right to know. So we promise to tell you what we see. However, we also believe you have the right to choose. What you feel is best for you and how and when to fit your choice into your lifestyle.” In my experience, it is rare for patients to choose poorly- their inner dentist is very intelligent. And I always preface this conversation saying that I will not let them do something I would’t let my Mom do!

    I’m not saying this is easy and yes it takes some time, however, it takes time to build trust. I know of no better way to build trust.

    For a dentist to show up as “who you are” is the most compelling attraction for a patient.

    A final quote from Parker Palmer, from The Healing Heart of Democracy

    “No reward could possibly be greater than the one we give ourselves by living our own truth “out loud” and in the light of day…….I cannot imagine a spiritual pain deeper than dying with the thought that during my sojourn on earth, I had rarely, if ever , shown up as my true self. And I cannot imagine a spiritual comfort deeper than dying with the knowledge that I had spent my brief time on this planet doing the best I could to be present as myself to my family, my friends, my community, and my world.”

    “Be yourself, everyone else is already taken”

    DJ

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