psychology of prophylaxis | particularly when people experience a lack of support for their basic psychological needs.” Motivational interviewing— An alternative approach To motivate their patients to be proactive in their be- haviour, healthcare professionals must adopt the per- spective of the patient, Niemiec recommended. “The idea, if you want to support autonomy, is to elicit and acknowledge the feelings of your patients with regard to health behaviour,” he clarified. “Really try to understand what health behaviour means for the patient—what are the challenges and what are the potential benefits to living in a healthy way?” Promoting compliance Engendering compliance in dental patients with regard to good oral health habits can be difficult, however. A wealth of literature on the subject clearly demonstrates that, for patients with chronic but non-life-threatening, often asymptomatic conditions, such as periodontitis, there is generally a low level of compliance with sug- gested oral hygiene regimens. This is due to a myriad of factors, though high on the list is a lack of patient understanding. A 2009 nationally representative study by Yin et al., published in Pediatrics, on the health liter- acy of parents in the US found that 28.7 per cent of the sample had basic or below-basic health literacy, which has been linked to negative health outcomes. Though this may imply that using clear, easy-to-understand lan- guage when conversing with patients might lead to im- proved health habits, the way in which this information is conveyed can have a determining effect on patient com- pliance. “Healthcare professionals can minimise their use of con- trolling language in order to give their patients a sense of autonomy,” Niemiec advised. “Control is all around us— people tend to tell us that we should floss more often, and when I hear that as a patient, I begin to feel as though the dentist or dental hygienist has a particular agenda or goal for me, and I don’t feel as though it’s really my goal. Be encouraging, use phrases like ‘you may want to’ instead of ‘you must do this’, and the patient will feel much more like an agent than a pawn.” Gardner echoes Niemiec’s endorsement of autonomy- inducing language and emphasises a cooperative, sup- portive dentist–patient relationship. “With regard to in- trinsic motivation, it has been shown that people may be more receptive to behavioural change where the person giving the behaviour change advice uses au- tonomy-supportive language, i.e. language that makes the person feel like he or she is in control of his or her own decisions,” Gardner explained. “So then, a medi- cal professional should not tell a patient ‘you must do X’; instead, he or she should say ‘have you considered doing X?’” Dr Johan Wölber is based in Germany, where he practises as a dentist and is a researcher at the University of Freiburg’s Depart- ment of Operative Dentistry and Periodontology. He is a practitioner of the motivational interviewing (MI) approach, a concept developed by psy- chologists Bill Miller and Stephen Rollnick. MI is based on the client-centred therapy first described by psychologist Carl Rogers. “Research has shown that instructional communica- tion has mostly induced contradictive behaviour,” said Wölber. “This is the point that the first MI researchers communicated—they were coming from having worked with patients with alcohol problems, and they had seen that the more they told their patients not to drink alcohol, the more their patients tended to drink. From this, we can see that there was a paradox between instructional inter- vention and the actual health outcome.” Wölber’s deep knowledge of this topic has been solid- ified through his own research. A 2017 systematic re- view by a team including Wölber, published in Frontiers in Psychology, measured the effects of MI as an adjunct to periodontal therapy. They found that its use in this re- gard might have a positive impact on clinical parameters like gingival inflammation and plaque values, as well as provide a boost to patients’ confidence in their ability to execute healthy oral hygiene practices. He emphasised that, though MI does not depend on instructional communication, the dental professional, nevertheless, needs to be able to guide the patient to- wards a place of self-empowerment. “MI is a directive method—I’m not telling the patient what to do, but I am directing the flow of the conversation by providing him or her with certain questions about his or her thoughts on oral hygiene and so on, whether the patient thinks he or she can improve it,” said Wölber. Is there a solution? In the end, no single approach will prove to be satisfactory for each and every patient, as motivating factors can differ drastically from person to person—for example, older pa- tients, particularly those older than 60, are used to a more instructional doctor–patient relationship and, therefore, may prefer being told what to do (instead of forming ideas themselves), according to Wölber. Regardless, a willing- ness to listen, communicate openly and provide patients with a true sense of autonomy is essential to ensuring their adoption of a positive approach to their oral care. prevention 1 2019 09