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 (formerly 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 for use of MI in healthcare are: resisting the righting reflex, understanding your patient’s motivation, listening to your patient and empowering your patient.

Four General Principles of MI (RULE)

  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 the resistance 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 patient-centered 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. If time is limited, the best alternative is to asking patients why they might desire a change and how they might accomplish it instead of relying on telling the patient what they should do.

A third key principal is listening to your patient. When the clinician actively listens to the patient’s response, they infer an expression of empathy and acceptance. Active or Reflective listening, goes beyond just keeping quiet while the patient responds. Reflecting back what the clinician perceives the patient has communicated allows the clinician to "get it right." Good listening and reflection is a complex skill explored further in MI strategies.

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.

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.