Motivational Interviewing: An alternative to the Marshall Art of Tongue Fu

What happens between a dentist (or any auxiliary) and a patient is shaped by many curious and confounding forces. Confusion between beliefs, actions or words and intent can sometimes be far from what we mean to convey. The slightest adjustment can change the way we are perceived and ultimately impact how we are valued, trusted and most important of all; impact the health of patients.

Many people think “I should” but they don’t. It’s a considerable challenge for dental practices where the “no pain – no problem” syndrome seems pandemic. In a way it is captured in the words, “you would think…”

  •   You would think a person at risk to lose teeth to periodontal disease would be diligent with home care as recommended by the hygienist or doctor;
  •   you would think when a person has experienced pain they would be interested in being proactive and follow recommendations before signs turn to symptoms;
  •   you would think with education, rather than risking more involved treatment or losing teeth prematurely, people would choose to invest in other than patch-o-metrics.

Motivational interviewing (MI) facilitates a natural process of change. Developed in part by clinical psychologists Professor William R Miller, Ph.D. and Professor Stephen Rollnick, Ph.D., this client centric method, which deals with the phenomenon of change, came from their work with addictive behaviours including alcoholism and smoking.

Emerging in 1983, 10 to 15 years later, this variant of client-centred counselling became one of the most popular approaches to the treatment of alcohol problems. The method was subsequently revised and enlarged (Miller & Rollnick, 1991), a research base emerged, and attempts were made to adapt the method to other client groups and settings. MI is now supported by more than 80 randomized clinical control trials across a range of target populations and behaviours, including substance abuse, health-promotion behaviours, medical adherence, mental health issues and dentistry.

To effect change, the model is to teach people, put something in to them, motivate them, convince or confront them. Although well intended, the Marshall Art of Tongue Fu often prevails; over-teaching, evangelizing, or over-questioning which can easily become manipulative or border on strong-arming.

In contrast, Motivational Interviewing (MI) draws out a person’s own thinking and valuing. It coincides with the ideas that “people don’t care how much you know until they know how much you care.”

The Trouble with Questions

Some promote the use of questions in dentistry; much of it coming from selling models. To continually formulate questions is not only difficult, it risks putting people on guard as the probing occurs. The created “reactance” can take on many forms including false agreement just to stop the uncomfortable feelings associated with interrogation.

The requirement to formulate questions puts a lot of pressure on professionals; to continually come up with the next “smart” question. Fearing or sensing reactance, anticipating misunderstanding or being unsure as to how to respond, the fall back for professionals is often to withdraw in silence and “wait”.

Where Education Fails

Education often embodies negative future forecasts which risks the patient perceiving threat; thus feeling strong-armed. By teaching; using “perfect” logic a person can feel painted into a corner or exposed for poor choice or pressured to action; thus leaving them feeling somewhat manipulated and sometimes defensiveness becomes the coping mechanism.

Give them choices and wait

Many professionals are clearly uncomfortable with “Tongue Fu” and believe the only right thing to do is provide all the options, consequence of options and leave the patient to choose. Unfortunately, leaving the patient at sea with a boat-load of choices also helps people get stuck.

Beyond EQ

EQ (The measuring of EI; Emotional Intelligence) has value and gained popularity. More than enhance the ability to follow emotions, which is appropriate with intense emotional experiences, MI goes further having concrete objectives; triggering change and facilitating movement of people to action.

Learning from Aesop

Aesop’s fable of the wind and the sun illustrates the distinction of MI.

The wind and sun observing a traveller challenged each other as to which of them could be most effective in having the traveller remove his coat. (Change behaviour)

The wind blew (an outside-in approach). The traveller clung tightly to his coat. Try as he might, the more the wind gusted, the more steadfastly the traveller held to his coat.

The sun asked for his turn. Beaming brightly the traveller was quickly warmed (an inside-out approach) and removed his coat. (changed the behaviour). Obviously, if neither the wind nor sun made effort, nothing would happen.

Fruitless Insurance Paperwork & Reluctant Teams


Most auxiliaries do want to be helpful. What they seek is safety; a way that respects the patient’s autonomy and avoids feeling like they are being pushy. (The spirit of MI)

Giving their best effort some may, for example, show a disturbing image hoping it will trigger change. This rather confrontational style often doesn’t. If “it doesn’t bother me” isn’t the defensive response, if the image is disturbing enough a patient will ask what needs to be done, quickly followed by “how much does it cost?” or “will my insurance cover it?”. Both are essentially objections and are no fun to handle.

What’s happened is that guiding has been replaced by telling or confronting via the image, thus triggering objections and defensiveness. By being forced to jump to remedies too soon by only showing a confrontational image without an appropriate conversational framework, effectiveness for change is difficult if not impossible to recover.

By telling or confronting with reality, neither does anything to uncover the meaning of the problem as could be expressed or felt by the patient were guiding conversational skills employed. Worse, it can trigger a debate, give way to cognitive dissonance, or seem to demand the need to ask the patient a lot of questions, or teach more; all of which strengthen resolve for the status quo.

“Lets see what insurance will do” often ends the interaction (said by the patient or team member) and not surprisingly leads to the next phase; “dialling for dollars”.

The conversational framework which can incorporate feedback like an image unfortunately requires much more explanation in order to be effective because the answer is part of a strategic process and not a “magic bullet” (tactic). This from Dr. Rollnick;

“Despite the positive outcome of controlled trials and the apparent popularity of motivational interviewing, the commitment of counsellors to developing and extending their empathic listening skills will be critical to its survival. Without this commitment, motivational interviewing could be mistakenly viewed or practised as a set of simple techniques applied on or to clients. This approach is unlikely to be of enduring benefit…., since it involves discarding the use of the one element of motivational interviewing, empathic listening, which has stood the test of numerous research efforts.” (Dr. Stephen Rollnick; The Essential Handbook of Treatment and Prevention of Alcohol Problems)

On the other hand, if a team member doesn’t believe your best and finest appropriate, it’s a whole other kettle of fish. It’s often more a matter of not understanding the service itself (as with joint based occlusion) than it is a values conflict with the practice.

In a recent survey of top rung dentists, less than one percent of all CE is devoted to behaviour
al competence. Most CE is devoted to putting “more products on the shelf” or perfecting what too many patients don’t seem to want. It’s understandable because it’s the most comfortable thing to do for many committed clinicians. Interesting that while change is fundamental to prevention, so little CE is devoted to it.

In the end, using Tongue Fu or doing nothing but wait, the status quo prevails. So much for prevention!

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 References1. Motivational Interviewing in Health Care: Helping Patients Change Behavior: Stephen Rollnick, William Miller and Christopher C. Butler (c) 2008 The Guilford Press.

2. Dr. William Miller, Distinguished Professor of Psychology and Psychiatry, University of New Mexico.

3. Dr. Stephen Rollnick, Department of General Practice, University of Wales College of Medicine.