Motivational Interviewing in Dentistry: Helping People Become Healthier

2014

Introduction

What Is It?

Recently, I heard about Motivational Interviewing from a couple of sources. Because of the title, I didn’t pay much attention. My experience in 40 years of practicing dentistry and experience with the client/person-centered approach developed by Carl Rogers, PhD, his colleagues, and Arthur Combs, PhD, convinced me that only the individual motivates him/herself. Other people can help and can be adjuvants or healing catalysts that can provide information and create conditions that help the person motivate him or herself, but they don’t motivate others. I assumed that MI was one of those selling approaches sales people use to manipulate people into buying what they are selling.

So I ignored Motivational Interviewing. Then I heard about it a couple of other times and decided to check it out on Google. This quote popped up on an early page I visited:

What is Motivational Interviewing? Motivational Interviewing is a form of collaborative conversation for strengthening a person’s own motivation and commitment to change.

It is a person-centered counseling style for addressing the common problem of ambivalence about change by paying particular attention to the language of change.

It is designed to strengthen an individual’s motivation for and movement toward a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.

This quote took care of my cynicism about what the term Motivational Interviewing (MI)¹ was about. It was exactly what I believe about motivation.

So I read further on Google.

I read about the originator of Motivational Interviewing, William Miller, PhD. His early training was in client-centered therapy and cognitive-behavioral approaches. He used this training as a professor at the University of New Mexico Department of Psychology and Psychiatry in working with people with addictions. Through this experience, he found that the person-centered approach was much more effective in improving outcomes than the traditional approaches that were highly authoritarian, confrontational, even demeaning, relying on a heavily directing style of counseling. I read about his discovery of a way to counsel that mirrored Rogers’ and Combs’ work in that it relied on the person’s own motivation for change instead of confronting them and making them defensive. This is an approach that trusts the client to discover their own reasons for change.

I was hooked, so I read further and found a book, Motivational Interviewing in Healthcare by Dr. Miller, Steven Rollnick, PhD, and Christopher Butler, MD. I ordered it. The first sentence in the Preface hooked me even more: This book is for any health care practitioner who spends time encouraging patients to consider behavior change.

The authors believe that many of the health care encounters between practitioner and patient or client involve resolving health problems that are caused by patient/client lifestyle choices. Often the practitioner’s counseling style (or lack thereof) results in the patient resisting their best efforts. The authors believe that an atmosphere of trust, respect and caring can help facilitate health behavior change in patients or clients. They apply the words elicit and evoke to describe the counselor approach to help the patient/client make choices that are best for themselves. They believe that the Motivational Interviewing (MI) method provides a way to have these person-centered conversations with patients/clients about changing their health behavior. This is dentistry in spades.

I kept reading and with each passing chapter a question pressed more and more insistently: "How in the world did I miss this? I have been using and advocating person-centered approaches for almost 40 years and I was not aware of this. Its philosophy is very similar to mine and what I wrote about in In a Spirit of Caring in the early 1990’s."

After I read the last chapter, I went back to the internet to find information on Dr. Miller and his e-mail address. When I found his address, I sent an e-mail asking him how he developed MI and how or if Carl Rogers’ work had influenced him. He replied quickly and related his experience of counseling people with addictions that I quoted above. He said that a major part of his counseling training was in the client-centered approach. He added that one of his big regrets was never meeting Carl Rogers or being in a workshop with him. I relayed to him the work I had done in applying the person-centered approach to dentistry and my experience with Carl Rogers and his colleagues and Art Combs. I told him I was flabbergasted that I had missed MI. I asked him what he knew about the use of MI in dentistry, but he said that he wasn’t aware of much. With further research, I have found this to be mostly true, but reports about and interest in MI in Dentistry are increasing (Gao, et al., 2013).

Since this conversation, Dr. Miller has been very helpful in answering my questions about MI. I have read extensively, including the third edition of Motivational Interviewing by Miller and Rollnick, watched videos on MI and I have attended both a 2-day introductory and advanced MI workshops. I am also giving workshops on Motivational Interviewing in Dentistry.

Dr. Miller first wrote about Motivational Interviewing in 1983 in the journal Behavioral Psychotherapy. As of the writing of the third edition of Motivational Interviewing, published in 2013, there are more than 1,200 publications on this method and 200 randomized clinical trials. There are more than 2,500 MI trainers teaching in 45 different languages. A Google Scholar search turned up 30,000 articles on MI – 5,000 new articles in 2011 – and 40 books on MI. MI is evidence-based.

You can see why I am flabbergasted that dentistry, except in sporadic cases, has missed this way of helping people change. Why do I like MI? It fills a long standing helping relationship gap in dentistry and health care by giving a behaviorally sound structure on how to interview patients and help them change unhealthy behaviors.

If you are familiar with my writing, you know that I have a strong belief in the importance and effectiveness of person or patient-centered approaches. MI is person-centered. And, while Carl Rogers and his colleagues have had a profound effect on counseling and the helping professions (and me), their strong belief in using a non-directive approach is difficult for dental professionals to understand and use. It is like a foreign culture and language to them. MI’s emphasis on guiding and a more structured approach is more dental-professional–friendly. Also, it is more readily available through its network of MI trainers. My Rogerian, person-centered friends quibble about this guided, more structured approach, but I think it is a perfect fit for dental professionals. MI also gives structure and skills to the person-centered approach I wrote about in my book In a Spirit of Caring.

Properly applied, using MI and the person-centered approach can significantly enhance your dental practice – especially relationship-based dental practices. Veteran relationship-based dental professionals already use many of these skills and approaches in their dental practices. For them, MI and the person-centered approach will give them a spirit and a structure for what they have intuitively learned to do.

All of these experiences have strengthened my commitment to write this book: Motivational Interviewing in Dentistry: Helping people become healthier. The subtitle comes from the subtitle of my dental practice newsletter, Adjuvant: Helping people become healthier. The word adjuvant refers to one that helps or facilitates (Mish, 2002). My definition of adjuvant is a healing catalyst; someone or something that helps people become healthier.

As you read this book, you will discover why I chose this subtitle. To me it well describes the people in dentistry who are adjuvants, and are becoming healing catalysts for their patients and clients. They are committed to helping people become healthier.

This subtitle closely parallels Miller and Rollnick’s subtitle for the third edition of their Motivational Interviewing: Helping people change.

Here is what I plan to cover in this book:

the history of person-centered approaches in dentistry,

an overview of MI,

why its use is transformative for dentistry,

the communication styles of guiding, directing, and following,

how to use reflective listening,

how to recognize change talk,

how to respond to discord and conflict,

the three core skills of asking, informing and listening,

how to recognize when to use the guiding and following style of MI instead of directing,

how to use the skill of eliciting/providing/eliciting (E/P/E) information,

how to avoid the righting reflex and the expert/savior trap,

the role of ambivalence in patient’s behavior

and other aspects of MI

I will write about how MI can be used in dentistry and a dental practice. For example, it can be used in dental schools to help students learn how to relate to and interview patients and counsel patients, how hygienists can use MI to help their patients change destructive oral hygiene habits, how dentists can use MI in their initial interviews of patients and to help their patients change health behaviors for the better, and how dentists can help patients resolve their ambivalence about having dental treatment.

Of increasing importance, MI can be used to facilitate dental patients’ understanding and implementation of the knowledge in the rapidly emerging oral/systemic field that is finding a connection between the oral environment and overall health and the relationships between oral infections and systemic diseases and conditions such as diabetes, cancer, osteoporosis, heart disease, pulmonary disease, inflammation, obesity, and complications of pregnancy (Glick, 2014).

In my two previous books, In a Spirit of Caring and In a Spirit of Caring Revisited, I explored the spirit of caring and understanding and finding meaning in the doctor/patient relationship. It was a broad discussion about my journey in discovering and applying the person-centered approach in my life and dental practice and my development of a relationship-based dental practice. It was also a philosophical, psychological, historical and personal account of how dentists could implement the person-centered/relationship-based approach in their dental practice.

Repetitive? In this book, I explore the skills or methods of Motivational Interviewing and how to have conversations with patients or clients about changing destructive health behaviors. While this book has things in common with my two previous books, it is much more skill or method focused about how to listen to, interview, guide, and engage patients and help them focus, evoke, plan and implement health behavior change in their lives. It will include how to implement MI in your dental practice.

This specific skill or method approach was not used in my two previous books because I was not aware of MI. It fills a gap that was present in these books and in dentistry. (The In a Spirit of Caring web site (www.spiritofcaring.com) has gone into detail about how to implement the person-centered approach in a relationship-based practice.)

For some, learning Motivational Interviewing is like learning a new language with its new concepts and vocabulary. Unlike dental procedures, it is okay in Motivational Interviewing to make guesses and mistakes. Take this book in doses that work for you and enjoy the journey.

I will use some quotes from my books and web site in these articles to expand and clarify my writing about MI.

I recommend that you read the book Motivational Interviewing in Healthcare and the third edition of Motivational Interviewing for more information on MI.

¹ In the following, ‘MI’ will be used as an abbreviation for Motivational Interviewing.

Part I

Preventive Dentistry’s Legacy and Motivational Interviewing

Before I present the person-centered approach of Motivational Interviewing (MI), I want to give a background to the development of the person-centered approach in dentistry. It was first introduced to dentistry by Bob Barkley, DDS, in the 1960s. Barkley introduced the discoveries of Sumpter Arnim, PhD, DDS, C.C., Bass, MD, and Harald Löe, DDS, and their preventive approaches to dentistry during this time. Barkley was called the Abraham Lincoln of dentistry for his story telling ability. He was dentistry’s equivalent of a rock star as he lectured to thousands of dental professionals about introducing the concepts of preventive dentistry in their dental practices.

Dental Professionals were born again as they began to see themselves as more than tooth carpenters endlessly filling cavities, removing or fixing teeth and scraping teeth and gums. They could help their patients prevent the scourge of dental disease.

However, Barkley quickly became frustrated with dental professional’s understanding and use of the concepts he so eloquently presented from the podium. He sought the help of a PhD psychologist – Nathan K. Kohn, Jr. - who helped him understand that the approaches that dental professionals used in case presentations and educating their patients about preventive dentistry are not behaviorally or educationally sound, and they try to force people to learn too rapidly. They try and get people to accept you on the basis of your recommended dentistry. Successful relationships cannot be built this way.

Barkley found Kohn’s quote to be true for most dental professionals. Barkley, through Kohn’s influence and his frustration, became a student of Carl Rogers, Arthur Combs (an early student of Rogers) and other humanistic psychologists. He also credits L.D. Pankey, DDS, and Sumpter Arnim, as his other main influences along with Kohn.

Fast forward to now. Why use the person-centered approach of Motivational Interviewing in Dentistry? Motivational Interviewing amplifies the gifts that these pioneers gave to dentistry. MI helps dental professionals provide their best care, skill and judgment by having more effective conversations about change. These MI conversations can help their patients activate their own reasons for changing their health behaviors for the better.

Part I introduces the history of the person-centered approach in preventive dentistry. Then, it begins to explore the concepts and processes of how Motivational Interviewing can help dental professionals accomplish this.

Chapter I

The History of the Person-centered Approach in Dentistry

When a patient leaves your office able to explain to his friends his relationship with you and how it benefits him immediately and in the years ahead, you have established a relationship with that patient that is the only sound basis for the growth of your practice and the development of your profession.

Do you enjoy this kind of relationship with your patients?

Chances are that your honest answer to the question would be an unqualified yes. If you were to appraise your practice, however, you’d probably find a large number of patients who should be doing a better job of prevention; some who need improvement in appearance, comfort and function; and some who come in for checkups only after repeated follow ups by your auxiliaries.

These are symptoms of patients’ attitudes toward dentists. They indicate that dentists are failing to help people see dental care in terms of a good dentist-patient relationship – a cooperative, long-term effort of prevention and correction aimed at providing the patient with a lifetime of attractive appearance, comfortable chewing and lowered dental repair costs.

Psychologists have discovered, as a matter of fact, that the inability of individual dentists, or the dental profession, to establish this relationship with patients is a major contributing factor to the problem of why more people do not avail themselves of adequate dental care. (Nathan K. Kohn, Jr. PhD,)²

Kohn's prescient quote is still true and missed in most of dentistry today -- 50 years later. It is an example of the deep roots that relationship-based dentistry has in the person-centered approach.

Before I present the person-centered approach of MI, I want to give a background to the development of the person-centered approach in dentistry. It was first introduced to dentistry by Bob Barkley, DDS, in the 1960s. Barkley introduced the discoveries of Sumpter Arnim, PhD, DDS, C.C., Bass, MD, and Harald Löe, DDS, and preventive dentistry to dentistry during this time. Barkley was called the Abraham Lincoln of dentistry for his story telling ability. He was dentistry’s equivalent of a rock star as he lectured to thousands of dental professionals about introducing the concepts of preventive dentistry in their dental practices.

Barkley quickly found Kohn’s quote to be true for most dentists. Barkley, through Kohn’s influence and Barkley’s frustration in introducing preventive dentistry to dental professionals (especially dentists), became a student of Carl Rogers, Arthur Combs (an early student of Rogers) and other humanistic psychologists. He also credits L.D. Pankey, DDS, and Sumpter Arnim, as his other main influences along with Kohn.

Rogers and Combs did groundbreaking research in the 1940s and 1950s that expanded psychologists’ findings on what conditions or beliefs were found in the most effective psychotherapists. Further and more expanded research (Combs, 1986) found that these research findings applied to any profession that worked with people, such as nurses, pastors, physicians, social workers, teachers, and mental health workers. This list of professionals influenced keeps expanding. Combs and Rogers called these people helpers, which is a very simple term for professionals who help their patients and clients improve their physical and mental health. They called the relationships these helpers formed with their patients and clients helping relationships (Rogers, 1961).

We will use these terms – helper and helping relationship – frequently in this book to refer to the dental professionals that help and the relationships they form with their clients and patients. (Also, in this book, I will refer to dentists and dental professionals interchangeably. I will trust you the reader to make the distinction.) The term client will be used throughout the book. Client generally refers to someone with whom you have an equal relationship. Patient is someone with whom you don’t.

With this research, psychology became much more accessible and applicable to lay people and available for general use by professionals of any ilk. Instead of just focusing on people’s external behavior and how to change this behavior, humanistic psychology looked at the internal meanings of people’s perceptions and how this influenced their behavior and the problems of their experience of being human.

The focus of psychology, before humanistic psychologists’ research, focused only the study of the mind and behavior. Humanistic psychology expanded this definition to psychology becoming the art and science of understanding and helping people. Miller and Rollnick’s later research in the 1980s, until now, validated and expanded on the humanistic pioneers’ findings.

Carl Rogers’ pioneering work in humanistic psychology provided the foundational research on the conditions present in effective helping relationships. This is his central hypothesis: Individuals have within themselves vast resources for self-understanding and for altering their self-concepts, basic attitudes, and self-directed behavior; these resources can be tapped if a definable climate of facilitative psychological attitudes can be provided (Rogers, 1980). This research showed that it was the relationship between the therapist and client, and the presence in the therapeutic relationship of the three conditions genuineness (or congruence), unconditional positive regard and empathy, which facilitated a growth-promoting climate for clients.

Rogers’ three conditions to facilitate a growth promoting climate

His research over the years showed that these facilitative conditions applied in any relationship where the development of the person was a goal. Examples he gave are relationships between therapist and client, teacher and student, parent and child, doctor and patient, leader and group, manager and employee. Most recently, these conditions have been used between adversaries in conflicts ranging from the most personal to the global.

Combs’ research on good and poor helpers went one step further to seek the dynamics of helping processes in the perceptions or belief systems of helper and helpee (Combs, 2006).

Rogers initially called his counseling approach client-centered and later referred to it as person-centered to reflect its widening application in many fields. In addition to Rogers and Combs, Robert R. Carkhuff, C.B. Truax, Gerard Egan, Jack R. Gibb, Alfred Benjamin, Thomas Gordon and others wrote extensively about helping relationships. Several of these people were early students of Rogers.

Their work, as suggested by the earlier Kohn quote, helped dentists, and especially Barkley, bridge the gap of why more people do not avail themselves of adequate dental care.

As mentioned earlier in this chapter, even though Barkley was a star on the lecture circuit, he was frustrated by his spotty success at helping dentists implement preventive approaches in their dental practices. He searched for an answer, or a group of answers, to this dilemma. This search led him to the field of humanistic psychology and the above pioneers in this emerging third force" in psychology. (Behavioristic and psychoanalysis are the other two.) Barkley defined a humanistic person as:

Someone whose relationships with others are highly interdependent, a person whose purpose is to help others to get into touch with their own strengths and develop their own capacities in order to become more effective human beings. It draws on the spiritual (not merely the mortal) resources which are available to all of us. (Barkley, 1977)

Arnim, Bass, and Löe’s discoveries of the importance of dental plaque removal in controlling dental disease laid the foundation for the field of preventive dentistry.

Barkley’s introduction of this work in the 1960’s to practicing dentists led to the phenomenon of preventive dentistry and plaque control sweeping the dental profession like wild fire. Dentists were born again. Dentistry now knew how to prevent two of the three most common diseases, dental caries and periodontal disease (the common cold was the third). These discoveries changed dentists’ perceptions of themselves from being tooth carpenters using the drill, fill and bill techniques of constantly patching holes in teeth and fighting the red tide of gum disease to being true healthcare professionals.

The public’s perception changed also, as this quote from an article by Daniel S. Greenberg in the Boston Globe in 1987 shows:

Front page homage and reverence are heaped on organ transplants and other medical high wire acts. Meanwhile dentistry goes unnoted, except as the butt of harebrained television humor. But, it is one of the few health technologies that almost invariably succeed, both in prevention and in treatment. There is little else in the health care arsenal that can share that claim.

Dentistry is one of the great success stories of our time. Viewed against the economic turmoil and limited achievements that generally afflict medical care, dentistry is especially notable for its advocacy of health education and public preventive measures.

But, dentists quickly became frustrated because many patients would not implement the simple oral hygiene procedures necessary to control dental disease. They blamed Barkley for being a false purveyor of hope. He became known as the pied piper of plaque because of his 5-day disease control program. Dentists had misinterpreted Barkley’s message and had just implemented the technique of plaque control without understanding the underlying philosophical shift it introduced to their relationships with their patients. This shift included an understanding of the dynamics of educating patients, creating effective doctor/patient relationships, a shift from being disease-centered to health-centered, and helping patients change destructive health behaviors.

Barkley accepted responsibility for the role he had played in dentists’ frustrations