Components of MI

This review of MI principles will focus on how this approach might be used to elicit oral health behavior change within the dental counseling atmosphere. The foundation for MI rests not in the specific strategies of patient engagement but on a sincere “spirit” of mutual respect and collaboration. The clinician must abandon the impulse to solve the patient’s problems (often referred to as the “righting reflex”) and allow the patient to articulate his or her own solutions.

Image: MI Pyramid showing spirit at the base, principles in the middle and strategies at the top.

Using the guiding principles of MI, the clinician follows the patient’s cues and moves between listening, asking, listening and informing. This collaborative exploration is accomplished through 4 key principles of MI. Use of these principles enables the patient to express his or her view of benefits and drawbacks associated with a particular behavior pattern and determine what action, if any, to take. Ultimately the decision resides within the patient, not the clinician. In this sense, the clinician allows the patient to have complete autonomy in the decision making process.

The four key principles are: resisting the righting reflex, understanding your patient’s motivation, listening to your patient and empowering your patient.

Four General Principles of MI
  1. Resisting the righting reflex. Avoid a prescriptive provider-centered style of solving patient’s problems for them. Guide them in eliciting their own solutions.
  2. Understanding your patient’s motivation between current behavior and important goals or values.
  3. Listening to your patient through acceptance, affirmation, open-ended questions and reflective listening.
  4. Empower your patient by support, self-efficacy and optimism.

In the traditional clinician-patient encounter, the clinician assumes responsibility for providing information and coming up with a solution to the patient’s problems. Unfortunately, this prevents meaningful two-way communication. Research has shown the average health care provider interrupts a patient disclosure within 18 seconds, thus sending a non-verbal message that the patients’ input is neither respected nor relevant. When clinicians affirm the patient’s interest or efforts, a trusting relationship is supported. Once trust is established the patient can openly express him/herself and begin to resolve their ambivalence about change. When the patient expresses resistance to change or adopting a new behavior, the clinician acknowledges theresistance rather than continues to push forward. This is an ideal opportunity to explore the patient’s viewpoint and need for autonomy. Moreover, it non-verbally conveys that the patient is central to any behavior change. A simple comment of “Okay, it sounds like you aren’t quite ready to ________. Is it okay if we come back to this conversation at some point in the future?” demonstrates the clinician hears the patient and acknowledges their autonomy. Again, this collaborative approach allows for collaborative solutions consistent with where the patient is at, at that point in time.

The second key principal is understanding your patient’s motivations. Any perceived inconsistency between the patients’ current health status, behaviors and values creates an internal tension that may provide a rationale for change. The first step of using open-ended questioning and reflective listening gives the clinician information about values, attitudes and beliefs held by the patient. The clinician can then further clarify by asking the motivation ruler question: “On a scale of 1 to 10 with 10 being completely motivated and 1 having no motivation at all, how motivated are you to _____?” When the patient identifies their self-rated motivation, the clinician can further clarify by asking “What gives you this level of motivation” and “What would it take for you to increase your motivation 2 or 3 additional levels?” This approach can also be used to explore their level of interest as well as confidence in engaging in a new behavior.

A third key principal is listening to your patient. When the clinician asks open-ended questions and actively listens to the patient’s response, they infer an expression of empathy and acceptance. Reflective listening, or reflecting back what the clinician perceives the patient has communicated allows the clinician to “get it right”. This process of open-ended questioning and reflective listening shifts the encounter to a patient-centered engagement.

Lastly, it should be obvious the clinicians’ behavior and engagement strategies are aimed at empowering your patient. By doing so, the clinician is signaling to the patient the clinician believes he/she is capable of change. Since it is the patient, not the clinician, who must initiate behavior change; supporting self-efficacy effectively shifts “ownership” of the solution to the patient. In the language of Self-Determination Theory, supporting self-efficacy can increase the persons’ sense of competence and increase the likelihood of successful change.

Image: MI Pyramid showing spirit at the base, principles highlighted in yellow in the middle and strategies at the top.

Another important facet of listening in MI is listening for change talk. Change talk is the patients’ expressions of desire, reason, ability or need to make a change in their oral health behaviors. Expressions of change talk may come naturally as a result of open-ended questions and reflections or can be further elicited through the use of directed questions. Response to change talk provides the opportunity to explore options and affirm a commitment to change.

Evocative questions to elicit change talk
  • Why would you want to make this change?
  • If you did decide to make this change, how might you go about it in order to succeed?
  • What are the three best reasons for you to do it?
  • How important would you say it is for you to make this change, on a scale from 0 to 10,
    where 0 is not at all important, and 10 is extremely important?
  • [Follow-up question: And why are you at ____ rather than a lower number of 0?]
Summarize then ask one final question: So what do you think you’ll do?

The key components of brief MI which can be applied for the delivery of oral health information and advice are: Ask Permission, Elicit-Provide-Elicit (using OARS), Explore Options and Affirm Commitment.