Motivational Interviewing – A Primer

You care about your patients. But helping them change and get on the right path to dental health can be one of the most challenging parts of your job. Chris Moriarity, PDA’s VP of Business Development, sits down to give you some strategies you can employ now to help identify those patients who are ready to change.

By Chris Moriarity, BA, MA, FA, Vice President of Business Development

Before you read any further, you should know something. I’m psychic. Let me prove it. You want patients to do more than what insurance will cover, to do more of the work that they need. But you’re struggling to get them to buy into what you’re telling them they need.

When a new patient sits in your chair I’m going to guess that you:

1. Attempt to demonstrate or prove that the patient has a problem (if they do).
2. Educate the patient on the benefit of change or treatment.
3. Tell the patient how to change so these problems don’t recur.
4. Warn them of the consequences if they don’t change.
5. Get frustrated when they don’t change and begin to question your career.
6. Repeat.

We need new tools. Desperately. People’s behaviors are destroying their mouths and you want to help them break that cycle, get the help they need, and live healthier lives. You can be an effective vehicle of change for encouraging your patients to change their unhealthy behaviors and get the care they need with Motivational Interviewing.

Motivational Interviewing

Motivational interviewing (MI) has been around for years and has become increasingly popular in the fields of psychology and health. While motivational interviewing is certainly no panacea, the techniques MI provides can help keep you from fighting the wrong fights and help you recognize the signals given by patients who are ready to change.

Imagine you run a tire shop. Every morning your clients wake up, throw a fresh box of nails into their driveway, and drive over them. They then come into your tire shop every six months complaining about the rough ride and the poor quality of the tires you are selling them. Repairing or replacing the tires isn’t going to help in the long run until they’re willing to stop throwing nails.

Much of the issue with getting patients to say yes comes down to the fact that people generally resist change, and many dental problems have a behavioral component to them. The average dental patient doesn’t usually view the behavior change as necessary or even possible. They won’t quit smoking, they won’t wear a night guard, and some won’t even use the bristly-end of a tooth brush.

D-A-R-N

So, before we waste time on strategies, we need to identify the patients who are ready for a change in the first place. One of the MI thought leaders, David Rosengren, uses a simple acronym – DARN – which stands for Desire, Ability, Reasons, and Need.

Desire. This is the key to the kingdom; no real change will occur without it. It doesn’t matter how good a communicator or doctor you are if the patient doesn’t see a problem or want to change. Just because they have bad breath, gum disease, or copious cavities doesn’t necessarily mean it bothers them. They must want something better to make a change.

Ability. Ability relates to the barriers a patient has put up that prevent change from happening. Do they think they can eliminate the soda from their diet, brush and floss regularly, or come in for their regular six-month appointments? Encourage these behaviors when you see them. As everyone knows, change is hard. So if a patient believes they have the ability to change their habits, you want to help encourage them to take the small steps they can start making within the context of their current lifestyle.

Financial ability is the most limiting factor. It’s no secret that if dentistry was free, people would do a lot more of it. But budgets are real, and often impossible to alter (fixed-income), but there are always behaviors and commitments that demonstrate ability.

You want to help people who show the ability to change their behaviors, even if they don’t have the financial ability. For those scenarios, document, document, document. Keep track of those patients who are willing to dump the soda, take care of their oral hygiene, and stay regular with an evidence-based re-care schedule. While their financial options may be limited, they have shown the desire and ability to make changes to improve their dental health. If possible, these are the patients you want to help with alternative financial options.

Reasons. Change rarely happens in a vacuum. Ask questions until you’ve found the trigger. Often something simple can be just enough to get the ball in play. A hurtful-truth from a child, an upcoming reunion or divorce. Why change now? Learning the patient’s motivation will align the goals of the office with the goals of the patients.

Need. Simply put, the solutions proposed should meet the needs of the patient. Doctors often fall into what MI practitioners refer to as the ‘righting-reflex.’ If a doctor sees something broken, then the patient needs to get that fixed. Well, if we are brutally honest, the patients don’t “need” any of their teeth, but we assume most would certainly prefer them. There are some patients who only “need” to be out of pain. If it doesn’t hurt, then they’ll wait. Even if you know a patient should have all four of their cavities fixed, if all they need is to be out of pain because one is bothering them, that’s all they will be willing to have done.

Ready for a Change

Once you’ve identified who’s ready for change, start with three simple steps: Ask an Open-Ended Question, Affirm, Summarize & Seal the Deal.

1. Ask an Open-Ended Question

Open-ended questions encourage a patient to use their own knowledge and feelings. A good rule of thumb, is the 70/30 rule. The patient should be doing 70% of the talking. Asking open-ended questions invites the patients to share how motivated or willing they are to change.

For example, instead of asking, “Did your teeth break down because of how much soda you drink?” you can ask “Why do you think your teeth broke down like this?”

Very rarely will a patient have no idea. The trick here is to not let the patient go on long enough that they convince themselves they’re a lost cause.

2. Affirm

Once the patient has told you what the problem is, simply state back to the patient what they told you, but framed as the solution to the problem. This is a very simple and very effective strategy: “So, Mrs. Jones, it sounds like if we got you fixed up and found a way to cut back on the soda, wear your night-guard, and stay regular with your cleanings, we’d have a good chance of this lasting the rest of your life. Did I understand that right?”

Self-realization is big part of change. The patient has to truly believe that they’re capable of the change. In the example above, you have proven to the patients that they know exactly what do to, and if they do that, the rewards are attainable and virtually assured.

Now, the wisdom behind this method is that it is no longer the doctor’s responsibility to tell the patient what they need to do. The patient self-educates and, in doing so, volunteers themselves to be the only person truly responsible for the outcome.

3. Summary and seal the deal.

“Seal the deal” simply refers to an agreed upon course of action, not necessarily a buy-in to treatment. As a dentist, your goal is to be an effective agent of change and help the patient get started on work that need to be done. They may not yet be ready to accept your full treatment plan but getting them on the right path is a perfectly acceptable place to begin.

When summarizing and sealing the deal, never ask the patient where or how they’d like to start. Instead, give them options. Patients are more likely to agree to a treatment plan when offered two options. Here’s an example of how to seal the deal:

“Mrs. Jones it sounds like we know exactly what we need to do and I truly believe you’re going keep up your end of the deal. Knowing that, I recommend we start with X or Y. However, considering [Reasons from above], I believe you’d be happier with X.”

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Was this information helpful? Could you benefit from more patient relations training and buy-in, reserve your seat at a PDA Productivity Workshop now. Contact Chris at chris@productivedentist.com.