Encouraging behavioural change
It is well understood that patient education should be an integral part of dental treatment. It is also an essential role of the dental team not only to educate their patients but also to motivate them towards maintaining good oral health.
Motivation poses the more formidable challenge as it necessitates persuading patients to change their long held beliefs and behaviours. The most recent Cochrane Review of different strategies for promoting behavioural change identified the necessity for such techniques to be tailored to the individual needs of each patient.
This has been done successfully with motivational interviewing (MI), which is used extensively as an effective tool for enabling those with severe compulsion or addiction problems, such as drugs, alcohol and smoking, to change their behaviour.
Motivational interviewing is a form of talk therapy. When a patient says ‘I can’t…’ the aim is not to argue with the statement but through precise questioning challenge the thought processes that underlie the behaviour, thus changing the patient’s perspective.
Dental diseases are multi-factorial and affected by issues such as the patients’ lifestyle, behaviours and attitudes. The success of the treatment depends entirely upon the patients’ acceptance of, and participation in, the therapy we offer them.
And so we try to persuade our patients to follow home care regimes using recommended devices and techniques. However, patients have their own individual values, perceptions, resources and opinions, and they may not want to change their behaviour just because we tell them to.
Patients continue to offer the same excuses when they consider that they have failed us, and yet undaunted we continue to impart the same dental health message over to them with familiar results. The patient can feel discouraged, lectured, offended and disconnected. We feel disconnected too – as well as frustrated, ignored and bewildered.
It is important to assess the patient’s readiness to change. Sometimes patients are not at all sure that they want to change what they are doing and it is perfectly normal for patients to feel some ambivalence towards altering their behaviour. The feeling of ‘I need to but I don’t want to’ is a natural part of their dilemma.
Instead of regarding this indecisiveness as wilfulness on the part of the patient and labelling such individuals as ‘unmotivated’, dental professionals should see that ambivalence is actually at the heart of behaviour change. Once it is explored and resolved it will enhance the patient’s motivation to take action.
Motivational interviewing allows us to communicate with patients in a way that brings about behaviour change more effectively. MI can enhance communication and the relationship between patient and practitioner by decreasing the frustration for both. It improves clinical outcomes and patient satisfaction. It does, however, require collaboration with the patient, finding out their motivation to change and yet understanding that they have a right to decide whether or not they want to make any alterations to the way they behave.
The role of the practitioner is to facilitate a conversation about changing their oral health habits that will lead to talk about commitment, which, in turn, can lead to action.
Let the patient do most of the talking while you listen intently to what is being said. Ask simple yet insightful questions that will reveal the patient’s level of motivation. In searching for answers to your questions the patient will eventually come up with his own ideas for improving his oral health. By doing so the patient will open the door to a behaviour change because he will have recognised the problem for himself as opposed to listening passively while the hygienist ‘lectured’. The patient will have talked himself into changing. When conducting conversations about behaviour change:
• Be curious rather than intrusive
• Try to be impartial about the outcome
• Demonstrate accurate understanding, by summarising back to the patient what they have told you
• Use ‘open’ questions that provide elaboration
• Seek permission to ask questions and give advice
• Find the potential for change through understanding ambivalence.