CHAPTER 5

BRIEF INTERVENTIONS IN PROMOTING HEALTH BEHAVIOR CHANGE

Anne Koerber

INTRODUCTION

As clinicians experience more pressure to use time effectively and maximize productivity, they seek briefer and more efficient techniques to influence behavior change in patients. While complex behavior changes cannot be expected to happen quickly, there are techniques that have been shown to facilitate change even when only a short amount of time is available. The focus of this chapter is on forming brief, effective interventions that may help patients along their continuum to change.

The following content relies mainly on Motivational Interviewing principles described by Miller and Rollnick and others, which have been adapted to dental situations (Miller and Rollnick 2002; Rollnick et al. 1999; Rollnick 2002). For the purpose of this chapter, brief interventions are defined as those that could be effective while taking up 5–15 minutes of a dental appointment with a patient.

The over-arching structure of how the clinician can facilitate health behavior change with a patient is the same for brief interventions as for longer interventions: first, if the patient doesn’t recognize the importance of a change, the clinician focuses on helping the patient see the importance; second, if the patient recognizes the importance of a change but doesn’t feel able to make the change, the clinician focuses on helping the patient discover how to make the change. In summary, brief interventions address three possible issues: (1) assessing motives, (2) raising awareness, and (3) supporting change. As mentioned and discussed in the previous chapters of this book, the clinician must take care to avoid argumentation and maintain rapport while addressing these issues (Rollnick 2002).

USING A PATIENT-CENTERED APPROACH

A patient-centered approach requires addressing change from the patient’s point of view. The clinician has a set of goals to offer the patient, but in order to be effective the clinician partners with the patient, rather than taking an authoritative, directive stance. With the limited amount of time available to repair breaches of empathy, avoiding or rolling with resistance may be even more essential in brief interventions than longer interventions. Although it isn’t intuitively obvious, using a patient-centered Motivational Interviewing approach saves time over more traditional educational or persuasive approaches because it is less likely to create resistance.

As discussed in chapter 4, Motivational Interviewing techniques are focused on understanding patient motives and ambivalences rather than imparting information or persuading a patient. As soon as the focus is set on the patient’ s motives, or on what the patient wants in life, rather than on what the clinician thinks the patient ought to do, the sooner the patient will engage in change (Miller and Rollnick 2002).

Righting reflex

Brief interventions require self-control from the clinician. When time is limited, the concerned clinician may be tempted to pressure the patient to commit to a change. As introduced in chapters 3 and 4, Miller and Rollnick refer to this as the “righting reflex” (Miller and Rollnick 2002). In brief interventions, the clinicians tend to “put things right” by pushing the patient in the desired direction. Unfortunately, this risks eliciting resistance from the patient. It is only human nature to push back when being pushed. If a clinician tries to force the patient to commit to change before being ready, the patient is likely to feel resentful and misunderstood. Furthermore, if clinicians respond to time pressures by talking more than listening, their ability to understand the patient’s point of view is reduced. To be effective, brief interventions require clinicians to control their instinct or desire to push. Even during a brief intervention, clinicians accept that the patient is in control of any change that is made.

Fortunately, dental visits often occur frequently over time, allowing dental clinicians to build on past appointments and allowing behavior change to emerge on its own timeline. Research suggests that frequency of contact increases the likelihood that health counseling interventions will be effective (Rigotti et al. 2007).

Goals of brief interventions

Brief interventions are usually able to be short because the goals of one appointment are limited, but not because patient talk is limited. Behavior change itself may not be the best goal for one single brief intervention. Only relatively simple steps toward behavioral changes will be accomplished in one brief intervention. Additionally, clinicians who understand how to limit the goals of each brief appointment feel less need to push the patient, are more aware of what they can accomplish in a brief amount of time, and therefore feel less frustration with patients.

ASSESSING MOTIVES

Assessment of the patient’s readiness to change involves learning about the importance of change for the patient and how confident the patient feels to make the change (Miller and Rollnick 2002). When time is limited, the first of these two is most important to uncover: why might a patient feel it is important to make a change?

The clinician can’t expect that a patient is motivated by some abstract wish for good health (Rollnick et al. 1999). As noted in previous chapters, something important to one patient may not be important to another. Likewise, that which is important to the clinician may not be important to the patient. When assessing importance, the clinician seeks to discover the patient’s specific motivators and values, in order to link them to the desired behavior change. We describe here three ways to assess motives expeditiously. The first is through the health history form. The second is through open-ended questions, and the third is by using the readiness scale.

Health history form

The health history form is an excellent method to obtain information on patient motivation by asking about the chief complaint and motives for oral health. The question could be phrased as:

or:

The clinician can then apply that information to the desired behavior. For example, if it was noted on the health history form that the patient wants pretty teeth and sweet breath, the clinician can use that information to target better attention to oral hygiene or to target smoking cessation. Sometimes, the information obtained from the health history form is sufficient to understand a patient’s motivation, and the clinician may immediately move to the next step of supporting change.

Open-ended questions

The second method of obtaining information about motives and thus importance is by using open-ended questions about the patient’s goals, feelings, and desires. Rollnick and co-authors suggest that skillful asking involves short, simply worded questions that feel part of normal conversation to the patient (Rollnick et al. 2007).

Here are a few examples:

The use of open-ended questions was thoroughly described in chapter 3. It may come as a surprise to the reader that asking open-ended questions is suggested as a technique for brief interventions. Contrary to common thinking, open-ended questions are most efficient for obtaining complex narrative information about patient views and opinions, knowledge of which are essential for helping a client change (Rollnick et al. 2007). The clinicians can use their listening skills to uncover and then clarify the patient’s goals.

Clinicians may avoid using open-ended questions out of fear of patients talking on and on, sometimes about unrelated elements. However, the vast majority of patients will respond to an open-ended question by providing considerable information about their motivation. In addition, allowing patients to tell the story in their own words develops rapport. For patients who are too talkative, chatty, or rambling, clinicians can gently ask permission to interrupt when they have heard enough to clarify the motives. By summarizing what they have heard and redirecting the patient, they will be able to keep the intervention focused and brief.

Readiness scales

The third method of obtaining information about motivation to change is to use the readiness scales consisting of (1) the importance scale, and (2) the confidence scale as described by Rollnick, Mason, and Butler (Rollnick et al. 1999).

First, the importance scale consists of three questions. For example:

Note that question 2 reveals the patient’s motives, and question 3 reveals the patient’s ambivalence.

Second, the confidence scale consists of the following questions:

Note here that question 2 reveals a patient’s strengths to make the change, and question 3 reveals the barriers. Using this series of questions, the clinician can form a rather complete picture of a patient’s position regarding change within a short amount of time.

Three methods of assessing motives have been discussed so far: questions on the health history, open-ended questions, and use of the readiness scales. The use of the readiness scales may be all that can be accomplished in one brief intervention. At this point, therefore, the clinician may end the intervention by summarizing the patient’ s goals and motives, mentioning any possible next steps, and taking notes to facilitate another brief intervention at a subsequent appointment.

RAISING AWARENESS

Once motives are known, the clinician can use that information to motivate a patient to make a change. However, in some cases, the clinician will need to raise the patient’s awareness of the problem. Periodontal disease, oral mucosal lesions, tobacco use, diabetes, and infant nursing practices are examples of issues that patients may not spontaneously identify as important in a dental office. In addition, patients may be aware of issues such as tobacco use that they know are considered “bad” by health professionals, but about which they hav/>