“I really could give up smoking”

“You must stop smoking!” Patients often respond with antagonism to such demands, and many doctors become reluctant to address subjects like this because of frustrating experiences. So at the University of Freiburg dental students are learning motivational interview methods to guide patients’ cognitive processes and in this way encourage them to change their behavior.

Convinced non-smoker: if a patient reaches an understanding of the problem themselves, the odds are better that they will act accordingly. Photo: jetsadaphoto/stock.adobe.com

The ‘Motivational Interviewing’ method comes from the treatment of addiction. Researchers recognized that patients cannot be forced to change; motivation has to come from inside. This preventive method can be used whenever a change of behavior is necessary – for instance when giving up smoking, changing diet or encouraging exercise. “Using this method, we can also influence whether the patient returns, because they feel better as a result of respectful communication,” explains dentist Dr. Johan Wölber from the Department of Operative Dentistry and Periodontology at Freiburg University Medical Center.

For the eMI-med training program, which combines classroom lessons and e-learning, an interdisciplinary work group that he heads received the Kurt Kaltenbach Dental Education Award. The program, which students can use to learn this kind of dialog, can be accessed on the university’s continuing education server.

Asking the right questions leads to success

The idea behind the method is to stimulate and strengthen patients’ motivation to change. Simply ordering them to give up doesn’t work – they have to want to do it themselves. For instance, patients are often discouraged from trying to give up smoking because of previous failures. “Many of them would like to stop but don’t succeed, because – besides the addiction factor – there are many reasons for continuing to smoke. It’s relaxing, you wind down, and there’s a social aspect,” explains Dr. Götz Fabry from the Department of Medical Psychology and Medical Sociology at the University of Freiburg. Using the motivational interview method, doctors can guide patients to examine their problem.

Techniques such as open questions and active listening help the subject to become aware of the advantages and disadvantages of their behavior. “The expert isn’t trying to force knowledge on them,” adds psychologist Cornelia Schulz, head of the Cancer Prevention Management Team for Smoking Cessation, “The expert helps them to start the process of learning gradually and to change at their own pace. This allows the desire to stop smoking, which is there but is still overwhelmed with counterarguments, to grow and develop.”

One important motivational step for the patient is learning what functions smoking has for them. Once they know this, then the question is what measures they actually need to take in everyday life. The patient has to find out what it is that stops them from achieving their goal. “One typical situation is the work break, when they are asked if they want to go for a fag,” says Fabry. “If they’re unprepared for this, it’s difficult to respond the right way spontaneously.” If they have already developed an approach for dealing with this situation, it’s far easier.

Listening carefully and using the right questioning techniques: these are some of the skills students learn in ‘Motivational Interviewing’. Photo: lordn/stock.adobe.com

More effective learning

“It’s best to learn communication techniques in a practical framework,” says Milena Isailov-Schöchlin, teaching media coordinator for the Periodontology and Implant Therapy Master’s degree that the work group developed the training program for. Practical lessons, such as working with simulated patients, are resource-intensive. “We often have the problem that students aren’t well prepared for practical work,” explains Fabry. “Our digital tool means they can prepare themselves optimally and make first-class use of the hard-to-organize resources in practicals. It ensures more effective learning.”

Available online, the four-hour section of the training program conveys the principles of motivational interviews in short lecture modules. What is different about it are the additional interactive training modules: “The doctor has several possible responses to videos of typical patient interviews, in each case one conforms with the interview technique,” explains Isailov-Schöchlin. “Depending on which reaction is chosen the communications continue in another thread.” So the students can see how different dialogs can proceed – depending on how the learners act.

“The program has had an enthusiastic response from the students, because it’s interactive and can be used online,” reports Isailov-Schöchlin. The final stage of learning the communication technique takes place in a genuine interview: the students get to practise in a seminar where they speak to patients about behavioral measures. Analysis shows that they used the technique of the motivational interview taught on the training program and patients responded accordingly: “‘I was really able to think about giving up smoking’ – when we hear statements like this it’s very likely that the patient will also change their behavior,” says Wölber.

Link between diagnosis and therapy

The challenge to carrying this method out is the doctor’s self-image. “They’re used to telling the patients what they have to do – and are then frustrated when it doesn’t work,” reports Fabry. “It’s often hard for them to consider their point of view and understand that they can only achieve a goal that the patient wants themselves.” So the motivational interview is the link between diagnosis and therapy. “It’s our job to help the patient to think [about the problem] and guide them gently towards therapy,” stresses Schulz. “Recognizing that they are not yet far enough along with the process also helps us as experts to use our own resources better.”

Sarah Schwarzkopf

eMI-med online course