• Get to know Motivational Interviewing in theory below.
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Patient-centered
Motivational Interviewing (MI) focuses on the patient with his care needs, wishes and possibilities. The patient is and remains responsible for his own choices and behavior with regard to his oral health. MI does not motivate by persuasion, but by increasing the patient's own motivation. This can indeed be steered by asking the right questions.

By asking motivational questions, the patient can clarify his own beliefs and opinions regarding his oral health and make personal choices. Choices that he fully supports and has commitment to. This commitment is necessary to realize the behavioral change. Learning new oral hygiene behaviors is a dynamic process that requires commitment from the patient over several weeks. Only when the new behavior has become a habit does the behavior come naturally to the patient without much effort.

What does Motivational Interviewing yield?

• MI is effective because it increases the patient's intrinsic motivation, increasing the likelihood of success;
• MI is efficient because each intervention is fully tailored to the patient's change process;
• MI makes the patient responsible for his own oral hygiene, which will improve the quality of his oral health;
• MI gives the patient a say in the treatment, which has a relationship-promoting effect.

In the courses of the Ivory Cross ample attention is paid to Gewoon Gaaf with Motivational Interviewing and motivational interviewing is practiced.

Stages in behavior change
Behavioral change only occurs when the new behavior has become a habit. If you want to motivate patients to change their behaviour, it is wise to join an existing habit. First find out what stage of behavioral change the patient is in. The model below shows the different phases of behavioral change.

Depending on the phase of behavioral change the patient is in, you apply a certain intervention. For example, for someone who is in the contemplation phase, it makes no sense to give a brushing instruction. It is much more useful to explore with the patient the advantages and disadvantages of his current and future behaviour.

If you apply an intervention that does not match the phase the patient is in, your intervention is pointless. That is a waste of time and effort.

The application of MI has a fixed sequence:

1. Inform the patient about the situation in his mouth → neutralize the facts
2. Investigate in which phase of behavioral change the patient is
3. Guiding the patient to the next phase(s) by applying the right intervention
4. Making a self-care appointment with the patient

During a conversation, put the chair upright

1. Introduction conversation
I just looked in your mouth / your son/daughter's mouth. I see (name what you see by plaque, holes). When you hear this, what do you think?
Explanation:

• as exact as possible
• neutral; without judgement

Then respond neutrally and without judgment to the patient's or parent's response.

Does the (parent of the) patient think that he/she, his/her child has a problem? If so? See which phase of behavioral change the patient is in.

If not? Keep in touch. Explicitly state: “At the moment you don't find the current situation in your mouth / in your child's mouth a problem.”

You may want to ask the question “What needs to be done to make you reconsider whether there is a problem?” add.

2. What stage is the patient in?
Ask open questions

• What do you think of the situation in your mouth/your son/daughter's mouth?
• How important is the health of your teeth to you?
• What do you want to achieve?
• When can you start the new behavior?
• How can you make your new behavior a habit?

Caregiver attitude
The way we address the patient when applying MI is fundamentally different from the attitude of traditional education. In the traditional way of providing information, the healthcare provider makes the diagnosis and then provides the solution to the problem. If the patient does not cooperate sufficiently or does not cooperate, the care provider will still try to convince the patient of the usefulness of his solution.

In MI, the healthcare provider makes the diagnosis and informs the patient in a neutral manner, asking the patient about his needs and wishes. What does the patient think of this problem? What does the patient want instead of this problem? How does the patient intend to achieve this? What effort will he make for this? And when does he think he will have reached his solution?

The attitude of the care provider is neutral, without judgment about the patient and his behaviour. The patient may be 'himself'. The healthcare provider has an attitude of 'not knowing' when asking his what, how and when questions. It is up to the patient to decide how and in what way he wants to improve his oral health. The basic principle here is that the patient is responsible for his own behaviour. As an information officer, the healthcare provider is more of a guide than an advisor. The care provider guides and motivates the patient to a healthy destination, as it were.

Points of attention for the correct posture in MI

• Relationship based on trust and equality
• Recognition and respect for patient autonomy
• Reinforcement and support of patient's positive ideas and initiatives

Active listening
When applying MI, active listening determines the result. Active listening is the most intensive form of listening. It is listening to the real message hidden somewhere between the lines, in gestures, in pauses, in the silences, in things that are not said. Practice in learning to listen, starts in silence. Because only when you lower your own chattering inner voice, are you able to listen to the other. This way you give real attention and the other person can tell his story.

A healthcare professional who actively listens, even for a short time, has only one thing on his agenda: to understand the patient's perspective and experience. It is essential to ask questions. The pitfalls here are that you think too quickly that you already know what the patient means. Half listening, already moving on in your mind or already working on the next question.

With MI you mainly ask motivational questions, questions that make the patient think. These are often open questions that give the patient plenty of room to say what he or she considers important. By probing and reflecting on the subject, the patient can go deeper into the subject and there will be more and more clarity. When the topic has been sufficiently explored, give a summary to check whether you have understood everything correctly and close the conversation.

With active listening you apply the basic skills below that ensure that the other person feels heard and understood. With active listening you do not think in advance what question you are going to ask. You keep your attention on the patient's story. You continue to ask, respond to the non-verbal communication and respond to what you do and do not hear the patient say. In active listening, the patient's answer feeds the next question.

To reflect is a question you ask when you want to elaborate on the other person's body language. This makes the conversation more complete. Now not only the content of the story becomes clear, but also what emotions and feelings the other person has. It is a response to what the patient says and communicates non-verbally. This gives the conversation more depth. Reflection is not reassurance, refutation or agreement with what the patient says, but a clear reflection of the patient's feelings and emotions. The subconscious message you communicate with a reflection is that you take the other person's contribution seriously.

You give a reflection when you:

• want to show the patient that you understand his feelings and that you can discuss them with you.
• takes the patient's ideas seriously, even when the feelings or concerns expressed are, in your view, incorrect or unjustified.
• you want to check whether you have correctly understood the patient's feelings (emotions).
• you want to respond supportively to the thoughts or feelings the patient expresses.

Summaries make it clear what exactly you have understood and what you think are the main and secondary issues. At the same time, you let the other person know that you have listened and the other person can supplement information if necessary. In addition, a summary forces you to organize your own thoughts and gives you the opportunity to direct the conversation.

Handle silences the conversation gives the other person the opportunity to think, to gain an overview and to make choices. However, dropping a silence in a conversation is not that easy for many people. Most people find a silence unpleasant and quickly ask another question or start a different topic, leaving the other person with no chance to respond.

Positive reinforcement
Giving compliments is the lubricant of communication. By giving a compliment you show that you see qualities in the patient. You pay attention to the other. Paying attention to the patient creates contact and contact forms the basis for good cooperation. By positively reinforcing the patient's own ideas, actions taken and possibilities, the healthcare provider promotes and strengthens the patient's self-confidence. Only genuinely given positive feedback is effective.

Giving positive feedback according to the www technique is as follows:

• who: by calling the recipient by name you address the other person personally
• indicate what you think is worth complimenting
• indicate why you think this is worthwhile.

The power of a compliment is in the sincerity with which it is made. A question at the end makes it easier for the recipient to respond. Giving a compliment not only does the other person good, it also gives you a good feeling!

Dealing with patient resistance or friction
As soon as you hear "BUT" with the patient, you know you are encountering resistance or friction. The better you notice the resistance, the faster you will have more information.

Resistance = information
Resistance provides information about one's own communication and indicates that something 'must' change. Don't get into the yes-no discussion. As soon as you notice that, as a therapist, you say 'yes, but..', you start a discussion.

For example: “At night you are really too tired and you don't feel like brushing anymore.” Then you look kindly at the patient and wait for the reaction. As long as you don't tell the patient what 'should' do, let him think and decide for himself how he wants to improve his oral health, you won't meet any resistance. This leaves the responsibility for oral health with the patient.

You provide all expert information and necessary explanations about the risks that the patient now runs if the situation remains unchanged. By asking motivational questions that make the patient think, you motivate him.

Keep coming back to the patient's goal. What does the patient want to achieve with his effort? What is feasible now? What is his long-term goal? What is his personal motivation (PM); his motive for making an effort to achieve his goal. It is essential that the care provider accepts the patient's opinion and decision, that the patient is given the space to be himself and to take responsibility.

Do not try to convince the patient, but give a reflection or summary of what you hear and see in the patient. This means that you may even lovingly "respect" a patient who (at that time) chooses not to change. The intervention you then make as a healthcare provider is to stay in touch with your patient so that he or she always 'dares' to come back.