Elicit-Provide-Elicit (Asking, Listening, Informing)

Using the three communication skills discussed previously (open-ended questions, reflection and affirmation) allows the patient to begin talking about and hearing their own intrinsic motivation for change. This also sets up the opportunity to use the Elicit-Provide-Elicit strategy to guide the patient towards real solutions. As demonstrated in this video segment, begin by asking the patient what they already know or are interested in learning about a specific oral health topic. "What do you know about the risks associated with diabetes and gum disease?" This simple opening respects the patient’s autonomy and knowledge, not to mention avoids re-telling them something they already know. The practitioner then provides only the information the patient desires, and does so after the patient selects from a list of options only the information they are interested in learning about.

The Elicit-Provide-Elicit approach continues through the use of evocative questions, affirmations, complex reflections and summaries (Table 2). Open-ended questions requiring more than a yes or no answer stimulates the patient to do most of the talking. A pivotal aspect of MI is an active reflective listening process. The clinician assumes the role of an active listener reflecting back what the patient has said. Reflective listening is an important and challenging skill to develop. Skillful reflections extend the dialog or make an attempt at deciphering the unspoken meaning. They also serve as an ongoing chance to express empathy.

The ruler is an MI strategy often used to further explore an understanding of patient motivation, importance and readiness for a behavior change. "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 importance as well as confidence in engaging in a new behavior.

Healthcare providers often have a strong desire to share information or prescribe a solution to solve the patient’s problem. Advice giving is common among the helping professions and is referred to, as mentioned previously, as the "righting reflex." Information given in a unidirectional fashion is to be avoided as it often increases resistance, thereby decreasing the probability of behavior change. With MI, information is provided when requested by the patient or with the patient’s approval. In this process, the patient "hears themselves" talking about and reflecting on their own behaviors and motivation for change. Hearing themselves discuss the importance and/or confidence often results in a previously unexplored self-awareness and is referred to as 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.

Directed 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?

Response to change talk provides the opportunity to explore options and affirm a commitment to change. When patients express positive reasons for changing health behaviors and realistically evaluate their likelihood of success, this can make the change seem or appear achievable and worthwhile. Finally, the patients’ change talk can be reflected back to assist the patient in generating options and goal setting.

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