We know counseling patients can be challenging. Today we offer a few reasons why it can be so hard, and a few strategies that work to help patients really make change.
One of the greatest forces working against us (and our patients) is called proactive interference. Old habits are a significant force keeping us from forming new habits. In essence you don’t just have to learn something new, you have to also unlearn old habits.
Proper tooth brushing is a seemingly simple motor activity that can promote oral health. Applying health theories, such as the Information-Motivation-Behavioral Skills (IMB) model, Motivational Interviewing (MI) and Integrated Health Coaching (IHC), may help optimize tooth brushing technique in those with suboptimal skills. Some motor activities, including tooth brushing, may over time become rote and unconscious actions, such that an existing habit can inhibit new learning, i.e., exert proactive interference on learning the new skill. Proactive interference may impede the acquisition of new tooth brushing skills; thus, in this report, we: (1) Review how the habit of tooth brushing is formed; (2) Postulate how proactive interference could impede the establishment of proper tooth brushing retraining; (3) Discuss the merits of this hypothesis; and (4) Provide guidance for future work in this topic within the context of an approach to behavior change that integrates IMB, MI and IHC methodology.
“Some motor activities, including tooth brushing, may over time become rote and unconscious actions, such that an existing habit can inhibit new learning, i.e., exert proactive interference on learning the new skill. Proactive interference may impede the acquisition of new tooth brushing skills.”(Thavarajah R, Kumar M, Mohandoss AA, Vernon LT. Drilling Deeper into tooth brushing skills: Is proactive interference an under-recognized factor in oral hygiene behavior change? Curr Oral Health Rep. 2015 Sep;2(3):123-128)
One consistent message we convey to all doctors is that changing someone’s behavior surrounding sugar consumption is harder than changing their behaviors surrounding alcohol. This is a significant challenge. If alcohol treatment requires a 12 step program, changing sugar habits may be a 13-14 step process. We mention this to hammer home just how difficult behavior change around diet can be.
The Cochrane Oral Health Group Trials Register CENTRAL, Medline, Embase, PsycINFO, CINAHL, Web of Science conference proceedings (IADR and ORCA), reference lists and Dissertations Abstracts were searched.
Randomised controlled trials assessing the effectiveness of 1:1 dietary interventions in a dental care setting were included. This could be brief advice, skills training, self help materials, counselling or lifestyle strategies delivered by any member of the dental team.
DATA EXTRACTION AND SYNTHESIS:
Two reviewers independently screened and abstracted data with disagreements resolved by discussion and a third review author. The Cochrane risk of bias assessment tool was used.
Five studies were included; two were at high risk of bias, three were at unclear risk of bias. Two were multi-intervention studies where the dietary intervention was one component of a wider programme of prevention, but where data on dietary behaviour change were reported. One of the single intervention studies concerned caries prevention. The others concerned general health outcomes. No studies were aimed at preventing tooth erosion. Four out of five studies found a significant change in dietary behaviour in at least one of the primary outcomes.
“There is some evidence that one-to-one dietary interventions in the dental setting can change behavior, although the evidence is greater for interventions aiming to change fruit/vegetable and alcohol consumption than for those aiming to change dietary sugar consumption.”(Evans D. Some evidence that one-to-one dietary interventions in the dental setting can change behaviour. Evid Based Dent. 2012 Jun;13(2):42. Sys Rev. 5 trials.)
Ask open ended questions
So what do we do? One of the greatest strategies I have learned to implement is asking open ended questions. These are questions that cannot be answered ‘yes’ or ‘no’.
Instead of asking: Do you floss? How many times per day?
What would you like to focus on?
How has this affected your life?
One of the best non-judgmental statements is:
Tell me more about…
Telling (selling) vs. Asking
Another trap we fall in is telling patients what they need instead of asking what they want.
Are we telling them what they “should” do?
Or are we asking them what they want?
Are we selling or are they purchasing?
These are just a few of the strategies I find helpful in counseling my patients. What strategies do you find helpful?