What You Don’t Know About Motivational Interviewing, But Should: Interview with Lynn Carlisle
Q: Can you give our readers a brief synopsis of Motivational Interviewing?
A: Motivational Interviewing was originated by William Miller, Ph.D. in the early 1980’s. Miller was a psychologist whose 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. He found it was very effective.
He later was joined by Steven Rollnick, a British Ph.D. psychologist. They did extensive, evidence-based research and found that MI was also effective in many health care settings such as medicine, nursing, corrections, health educators, substance abuse, therapists, and coaches (but not dentistry – see below). They wrote the first edition of Motivational Interviewing in 1991.
Miller and Rollnick 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. They 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.
With Bill Miller’s encouragement, I said yes, in 2012, to write a book on Motivational Interviewing for dentistry. I had been a long time student of Bob Barkley, Carl Rogers, and Art Combs. Barkley was a dentist and preventive dentistry pioneer who died in a plane accident in 1977. He was a student of Rogers and Combs who were two of the developers of person or client-centered psychology. I had applied this person-centered approach in my preventive/restorative dental practice in Ft. Collins, Colorado since the 1970’s. After reading Miller and Rollnick’s book on MI and talking with Bill, I knew MI was a perfect fit for dentistry.
Here is my definition of Motivational Interviewing in Dentistry, from my book Motivational Interviewing in Dentistry, Helping People Become Healthier, Adjuvant New Media, 2014:
Motivational Interviewing in Dentistry helps dental professionals close the dental communication gap by improving their helping or counseling skills. Instead of the show, tell, then do approach that is so prevalent in dentistry, Motivational Interviewing focuses on awakening the client’s own reasons to change their inadequate dental care habits and to say yes to the dentist’s treatment recommendations.
Q: What is Motivational Interviewing in Dentistry?
Motivational Interviewing (MI) is a person-centered way of interviewing and counseling clients to help them discover their own motivations and strengths to change detrimental dental health behaviors. “It is a conversation about change.”
For example, it can be used with: lifestyle-related diseases such as periodontal disease and dental caries, home care habits, nutrition, stress management, interviewing patients, dental examinations, the Barkley co-diagnosis process, dental wellness, the oral/systemic disease connection, the complete dentistry movement that is emerging in dentistry, and any patient/client encounter that requires excellent communication and/or counseling skills.
Q: It seems to me that most dentists are familiar with MI, is that true?
A: I don’t agree. Three years ago, I did extensive research on this before writing my book Motivational Interviewing in Dentistry, Helping People Become Healthier.
I found that there was infrequent use or awareness of MI in dentistry. It is only used in a few dental hygiene programs such as the University of Missouri at Kansas City dental hygiene program. I found no evidence of its use to train dentists in dental schools or postgraduate programs. There is sparse use of it by dentists in their dental practices. (Hopefully, this is changing.)
There was scant research on the efficacy of using MI in dentistry – although since I first started researching MI and then writing my book, there have been several research articles on the efficacy of using MI in dentistry. These were mostly on using MI in tobacco cessation and oral hygiene. I list the current research at the time of writing my book in my book Motivational Interviewing in Dentistry.
Q: Why is MI infrequently used in dentistry?
A: As mentioned above, there is little awareness of MI in dentistry. Also, there is a long-standing blind spot in dentistry about the importance of being as proficient in the human dimensions of dentistry as dentists are in the techniques of dentistry.
It begins in dental school and persists throughout dental professional’s careers with dentistry’s overriding emphasis on technique and treatment. I have written extensively about the importance of being a “Triathlon Dentist” – being proficient in three areas: the techniques of dentistry, the human dimensions of dentistry and the business systems of dentistry. Proficiency in the human dimensions – effective caring, compassion, kindness, active listening, communicating, interviewing, motivation, and helping skills – is rare in dentistry.
The exception to this is the area known as Relationship-based Dentistry that was developed by Bob Barkley and others in the 1960’s and 70’s. A small group of dentists (by my estimate 5% or less) has developed this way of practicing since the 1960’s. They are “Triathlon Dentists.”
Here is my definition of relationship-based dentistry:
Relationship-based Dentistry is a health and wellness-centered way of practicing dentistry. This approach believes that the relationship between a dental professional and their patients or clients is as – or more – important than the technical treatment they provide. This relationship is a person or patient-centered one that views patients or clients as collaborators who have the resources and interest to make wise choices for their dental care — if a facilitative climate of respect, trust and caring are established. Its intent is to build a helping relationship with the patient or client that results in excellent compassionate care for the patient or client and results in helping them achieve personally chosen dental comfort, function, esthetics, health, and wellness. It is also rewarding for the dental professional personally, professionally, financially and spiritually
Q: Where would you recommend someone learn how to utilize the MI philosophy/technique?
A: To learn about MI, I recommend reading my book first: Motivational Interviewing in Dentistry, Helping People Become Healthier, Adjuvant New Media, 2014. (You can order it from Amazon – www.amazon.com – using the title) Then you can take an MI in Dentistry workshop that I offer.
I also have written extensively on MI and the human dimensions of dentistry on my website In a Spirit of Caring. You can find information on my books –including Motivational Interviewing in Dentistry, workshops and MI at the In a Spirit of Caring website – www.spiritofcaring.com
Another option is to take a general course in MI from a MINT trainer in your area. You can find information HERE
Bill Miller and Steve Rollnick, the developers of MI, have written several books on MI. Two that I recommend are Motivational Interviewing, 3rd Edition and Motivational Interviewing in Healthcare.
Q: Can you share an instance where (you believe) using MI was the difference between a patient saying ‘yes’ and moving forward with a treatment and likely saying no?
A: Here is an example of facilitating a patient’s acceptance of a comprehensive examination from my MI book:
MI honors the person’s autonomy and provides a climate in which they can self-discover their own best ways to change or act in congruence with their stated dental health values.
Here is an example of how to evoke their core values and goals:
Helper: “Would you say your dental health is a high priority for you?”
Client: “Well, I haven’t thought about it much, but yeah I guess it is.”
Helper: “You haven’t given it much thought?”
Client: “Well no.”
Helper: “Do you mind if I ask you some questions that might help?”
Helper: “Do you believe that the health of your mouth contributes to your self-esteem and sense of well-being?”
Client: “You’ve got me again, I haven’t thought about this.”
Helper: “Would you like some examples?”
Helper: “Self-esteem could be how your teeth look. Are there any stains or are your teeth too dark? Are they crooked or worn? Well-being could be, do you have any pain? Have you noticed any bleeding with your gums or are their teeth that are sensitive?”
Client: “Oh, I see what you mean. Now that you mention it, I do think my teeth are too dark, and they are a little crowded. And my gums do bleed, and there is some sensitivity when I drink cold water.”
Helper: “Keeping these things in mind, how would you rate your dental health now on a scale of 1-10, with 10 being excellent?”
Client: “Well I guess about a 5.”
Helper: “And where would you want to be?”
Client: “An 8.”
Helper: “What keeps you from being an 8?”
Client: “Well, I guess those things that I mentioned earlier and maybe some other things I don’t know about.”
Helper: “Can we finish this interview by asking some more questions that will help you and me discover where you are now with your dental health and where you want to be?”
Client: “You are making me think about things I have never thought about my dental health. Yeah, let’s finish this so we can find out what is wrong and how to fix it.”
This scenario is a compilation of typical interviews that I did in my dental practice. Bob Barkley called this “Helping patients think.” It was my favorite part of practicing dentistry. It is an excellent example of MI in action. (Don’t try this until you have read my book!)
Q: Are there any ‘short cuts’ or easy phrases you can share that will help an office with their next patient?
A: Not really. Dentists should first read my book. It is the personhood (Carl Rogers called this “genuineness or congruence”) of the person using MI that is the key to becoming proficient in MI. This takes time to develop. In the book, I go over how to develop this. There is something called “Brief MI.” Brief MI is a good place to start.
Q: Last, what do you say to dental professionals that think MI isn’t practical (takes too much time, too hard to learn, etc.)
A: Baloney! As mentioned in my reference above to being a “Triathlon Dentist,” MI is one of the three most practical things you can do in your dental practice. Why? Most dentists have never been trained in communicating with their patients. MI gives a systematic, evidence-based way to communicate with patients.
Once you have read the book and taken the MI training, you can start using MI immediately. MI can be used in every encounter you and your team members have with patients from the first phone call to case presentations.
As you use it, you will become more proficient – just like when you learned to ride a bike or do a crown preparation. One excellent thing about using MI is that you can be wrong and correct yourself immediately.
The few dentists that have become proficient in the use of MI invariably say “Why didn’t I learn how to do this before? It has transformed how I practice dentistry.”