Counselling Style through Motivational Interviewing - A Tool for Clinicians: A Review
Citation: Alqarni MA. Counselling Style through Motivational Interviewing: A Tool for Clinicians: A Mini-Review. Ann Med Health Sci Res. 2019;9:550-552
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Motivational interviewing is a well-known, scientifically tested method of counseling clients developed by Miller and Rollnick and viewed as a useful intervention strategy in the treatment of lifestyle problems and disease. This increases the patients’ motivation and helps them to commit to the process of change. MI is an empathic and directive, it is more than a doing, and it is a way of being. In relation to dentistry, MI has been effectively used to: promote oral health behavior. After one has adopting healthier behaviors, it can increase or decrease the likelihood for sustained behavior change.
Counseling; Motivational interviewing; Oral change
What is oral health and why do we say an oral disease is a serious public health problem? Oral diseases directly affect a certain area of the human body, but their results and impacts affect the whole body. The World Health Organization (WHO) defines oral health as ‘a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal disease, tooth decay, tooth loss, disorders that stop an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing . However, oral diseases are not inescapable, but can be prevented through productive measures at all stages of the life, both at the individual and population levels. 
Avoiding unhealthy lifestyle behaviors combined with performing adequate home care have been shown to be effective in disease prevention.  Counseling patients using methods of persuasion and confrontation have been shown to be ineffective in promoting lifestyle behavior change.  On comparing the multiple health theories it suggests that humans have three psychological needs: the need to feel skilled and self-efficacious; the need for autonomy where they have control over themselves rather than controlled by others expectations; and, the need to feel connected with others in meaningful social relationships.  Even though people need autonomy, they need close relationships in which their thoughts, feelings and beliefs are respected. After one has adopting healthier behaviors, it can increase or decrease the likelihood for sustained behavior change. 
According to Di Matteo et al., customary clinician recommendations on health behavior are generally not followed and can lead to regret for the clinician and a hitch for the patient.  In 1983 research began on the use of Motivational Interviewing (MI).  MI is an evidence-based approach used to impart health behavior change counseling. Motivational interviewing is defined as a “patient–centered, directive method for boosting intrinsic motivation to change by travelling over and resolving ambivalence”.  The aim of motivational interviewing is to guide the patient toward a firm decision on ambivalence and inconsistencies in their behaviors so that they build motivation for change, usually in a particular direction.
Literature Review in Relation to Dentistry
MI developed from working with addiction counseling and more recently expanded to other healthcare areas such as chronic illness, eating disorders pain management and behavior change. Behavior change and health promotion are very much related for dental clinicians. MI approach in dentistry has included the general area of avoidance behavior with a focus on prevention of dental caries.  MI also encourages behavioral change like cessation of smoking which in turn improves the outcome of periodontal therapy and reduces risk of oral cancer.  Therefore it is important for dental clinicians to have clinical competencies to deal with these behavioral risk factors and thus promote good oral health.
What is MI?
Use of MI began in 1983by Miller and Rollnick.  MI is an empathic, directive and patient-centered counseling approach that helps people to change by resolving ambivalence, amplify intrinsic motivation and build confidence to change.  This approach fits well with health stimulation, which encourages people to increase control over their health. Miller and Rollnick found using a non-authoritative approach focusing on intrapersonal communication which enables patients to break through uncertain thoughts, feelings, beliefs and attitudes.  MI is a skillful, easy, directive clinical method and is not mere techniques: it is more than a doing, it is a way of being. 
Elements of Motivational Interviewing
An understanding of the core beliefs of MI, it is essential for healthcare clinicians to follow the MI approach’s [Figure 1].
Spirit of MI
This was influenced by clients-intrinsic motivation to change rather than the change being imposed, as proposed by Carl Rogers in 1953.  Therefore, the clinicians task is to support the client in renaming and resolving conflicting ideas, emotions and attitudes, whereas the clients task is to resolve his /her ambivalence. Spirit involves the integration of core principles of collaboration, evocation and autonomous.  Collaboration between clinician and patient permits a positive relation, allowing for change to occur.  MI elicit patients personal motivation. Patient directs their own views, good reasons and resort to make lifestyle changes. It is an urge in which the practitioner does more listening than talking. Another component is autonomy; this means the patient decision in the direction of change is upto him or her. 
Spirit is the heart for training clinicians in MI. This is an correct time to improve students and clinicians with their communication skills by integrating them with MI practice and will brace behavioral change. These processes will help clinicians beyond the skills and advice and refer. 
Principles of MI
MI is the foundation for effective interventions and has been practical in focus. The motivational interviewing must proceed with a strong sense of purpose, clear strategies and skills for carrying on that purpose and intervene in particular ways at astute moments.  The clinician practices MI with 4 keys of principle. With the help of these principles the patient expresses his or her view of benefits and drawbacks. Finally the decision resides within the patient, not the clinician.  There are four key principles in MI which are expressing Empathy, Developing a discrepancy, Rolling with resistance and Supporting selfefficacy.
• In expressing empathy the clinician should show concern and understand what patient says.  This allows the patient to feel acknowledged and enables them to open up with their feeling. The patient patient can openly express him/herself and began to resolve their doubt and provide support throughout the recovery process. Listen rather than tell.
• Another MI principal is to develop a discrepancy between where the patient is now and where they would like to be. Allow patient to make own argument for change.  It helps the patient identify own goals/values. Focus on those that are feasible and healthy.
• The third principal is rolling with resistance. This is done by avoiding tension between the clinician and the patient relationship. The clinicians need to avoid confronting and arguing with the patient. 
• The fourth major MI principal is to support self-efficacy. It expresses optimism that change is possible. Unless a client believes change is possible, the perceived discrepancy between the desire for change and feeling of hopelessness about accomplishing change is likely to result in rationalizations or denial in order to reduce discomfort. Because self-efficacy is a critical component of behavior change, it is must you as the clinician should believe in client’s capacity to reach their goals. 
Elicit Change Talk
Change talk is the patient’s expression of desire, reason, ability or need to make a change in their oral health behavior. Expressions may come naturally as a result of open-ended questions or can be further elicited through use of direct questions. Response to change talk provides the opportunity to explore options and affirm a commitment to change. 
MI strategies help achieve desired behavior change. OARS are 4 strategies of motivational interviewing in the early stage of treatment. Change consist of asking open-ended questions, providing affirmations, reflective listening and summarize.
• Open-ended questions (OARS): elicit descriptive information. It required more of a response than a simple yes or no. When asking open-ended questions, you must be willing to listen to the person’s response. Often start with words like how or what or tell me about or describe. In this client does most of the talking help you avoid making premature judgments and keep communications moving forward .
• Affirmations (OARS): Are statements and gestures that helps patient recognize its strength and acknowledge behaviors that lead to positive change, no matter how big or small.  e.g. you handled this situation real well. To be effective, affirmations must be genuine and congruent.
• Reflective listening (OARS): is a way of checking rather than assuming that you know what is meant. It demonstrates that you have accurately heard and understood a patient’s communication. It strengthens the empathic relationship between the clinicians and the patient. Also encourages further exploration of problems and feelings.
• Summarize (OARS): Reinforces what has been said. Most clinicians find it useful to periodically summarize what has occurred in counseling sessions.  Summarizing helps to ensure that there is clear communication between the speaker and listener. Also, can be a stepping stone towards change. 
• Through the spirit, principles and strategies of MI, the patient is brought in as an active participant.
Clinicians need to recognize that they are not the best judge of what is important to patient in order to become effective behavior change advocates in the dental environment. Fundamentally, MI training has been implemented for dental clinicians at a post graduate or professional level. The MI approach has a lot to offer the dental clinician, in terms of addressing both dental behavior change and health promotion.
Conflict of Interest
The authors disclose that they have no conflicts of interest.
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