|Year : 2014 | Volume
| Issue : 1 | Page : 22-24
Use a thorn to draw thorn: Reframing and symptom prescription for habit cessation
TD Yogesh Kumar, Sharath Asokan, Baby John John
Department of Pedodontics and Preventive Dentistry, KSR Institute of Dental Science and Research, Tiruchengode, Tamil Nadu, India
|Date of Web Publication||26-Jun-2014|
Department of Pedodontics and Preventive Dentistry, KSR Institute of Dental Science and Research, Tiruchengode, Namakkal - 637 215, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Successful pediatric practice involves a combination of good hand skills and proper behavior guidance of children. Reframing can be used effectively to alter children's thought processes. Reframing can be explained using principles of transactional analysis by Eric Berne, Freud's psychoanalytical theory, and Pavlov's associative learning. The art of reframing lies in learning the skill of knowing the ego state of the child, modifying it (reframing) by changing the thought process and associations, and to make him/her communicate with proper ego states. The role of reframing in the treatment of habits such as thumb sucking and lip biting has been observed. Without psychological management for habits, if other methods of treatment are used, the child pairs the treatment with punishment and may become adamant. Hence, dentists can use reframing in the case of habits, such as symptom prescription or reverse psychology, a component of reframing as the first step wherein the patient is asked to increase the frequency of the habit. Children could no longer enjoy the habit and they became more receptive for communication and by showing photographs of children engaged in the habit that lead to disfigurement, we can further alter the children's thinking. Thus, the change in our approach can bring about a change in mind and attitude of our patients, in turn changing their health behavior and quality of life. This poster attempts to explain the concept of reframing and its application in a clinical situation.
Keywords: Behaviour shaping, habits, reframing, symptom prescription
|How to cite this article:|
Yogesh Kumar T D, Asokan S, John BJ. Use a thorn to draw thorn: Reframing and symptom prescription for habit cessation. J Indian Acad Dent Spec Res 2014;1:22-4
|How to cite this URL:|
Yogesh Kumar T D, Asokan S, John BJ. Use a thorn to draw thorn: Reframing and symptom prescription for habit cessation. J Indian Acad Dent Spec Res [serial online] 2014 [cited 2019 Mar 18];1:22-4. Available from: http://www.jiadsr.org/text.asp?2014/1/1/22/135437
| Introduction|| |
Health psychology is the field within psychology, which is concerned with all psychological aspects of health and illness across the life span. It has an important role to play in dentistry, especially pediatric dentistry. Before treating any child, it is important to analyze his/her behavior, which is the key for behavior shaping/modification. The treating dentist should show a positive approach and be truthful and flexible while listening and communicating with the child. The process of establishing communication is delicate and is based on the child's age and should start with complementary comments. Effective communication comprises skills such as active/reflective listening, self-disclosing assertiveness, and reinforcing the correct behavior through praise.  The communication should gradually change the thought process of the child, which in turn would bring in the desired behavior. Reframing is a routinely used technique that helps in altering the thought perception of an individual.
Reframing is defined as "taking a situation outside the frame that up to that moment contained the individual in different conditions and visualize (reframe) it in a way acceptable to the person involved, and with this reframing, both the original threat and the threatened "solution" can be safely abandoned."  It is based on the principle that the content of any event depends upon the frame, in which one perceives it. When there is a change in the frame, it changes the content, which in turn changes the response and behavior of the person. It can be achieved either by changing the meaning or sense of the situation or by changing the context. 
Reframing has been considered and proven to be one of the behavior guidance techniques in pediatric dentistry with wide applications.  This article attempts to explain the concept of reframing and its application in form of symptom prescription in a clinical situation.
Reframing and its application in dentistry
Reframing can be explained using principles of transactional analysis  , Freud's psychoanalytical theory,  and Pavlov's associative learning.  The article by Nuvvula et al., has explained the psychological perspectives involved in reframing. 
The dental operatory can be a stressful situation for any individual, especially for a child. The behavioral guidance techniques that we routinely use in day-to-day practice indirectly help in reframing. The dentist should first make the child relax either by creating a non-hospital-like child friendly environment or make the child imagine an environment other than the dental office using suggestions. The child's ability to accept reframing is based on his/her level of understanding and how they respond back. Reframing will be a failure in children under the age of three and if the examples or language used by the dentist is too high and beyond the comprehension of the child. 
| Case Report|| |
A 9-year-old girl was brought to the Department of Pedodontics by her mother with the chief complaint of thumb-sucking habit [Figure 1]a. After ruling out relevant medical history, a fixed habit-breaking appliance with cribs (reminder appliance) was fabricated and cemented with glass ionomer cement (GC type I, Tokyo, Japan) on 16 and 26. The child continued the habit even with the appliance in place for 3 months. The appliance was then modified as spikes (punishment appliance). In the recall visits after 4 months, the child's mother reported that there was no reduction in the frequency of the habit. The dentist had to repair the appliance twice during this time span. This reflected the reluctance of the child to discontinue the habit and to wear the appliance. Assessing the situation, we assured the child that the appliance will not be fixed again. We also informed her that she can continue the habit and even increase the frequency of sucking the thumb (symptom prescription). The child was told to continue the habit with the other digits also. However, every time she sucked the digits she was asked to make a note of it [Figure 1]d. The parents were assured about the management strategy and the child was recalled after 2 weeks. The child was made to sit in front of a mirror and continue her thumb-sucking habit (Dunlop beta hypothesis) [Figure 1]c. The child was then shown photographs of children with proclined teeth and was informed that if she continued the habit, her teeth would also look the same. Whereas if she discontinued the habit her appearance would improve (a photograph of a child of similar age without any disfigurement was shown). The parents were given both the sets of photographs and instructed to place in her room so that it could act as an additional reminder. In 1 month, the frequency of thumb sucking significantly reduced. Based on her interest in painting, she was given poster colors as rewards (material reinforcement). The parents were instructed to praise the child (social reinforcement) when she was not indulging in the habit and to ignore her whenever she indulged in it. Within 3 months, the child completely discontinued the habit and the child was given a certificate of appreciation as the best child patient, in her last recall appointment [Figure 1]b.
|Figure 1: (a) Preoperative photo, (b) Postoperative photo — 2 months, (c) Dunlop's Beta hypothesis, (d) Calendar for frequency notification|
Click here to view
| Discussion|| |
Transactional analysis states that personalities are made up of three parts or ego states: The parent (P), the adult (A), and the child (C) ego states. A communication between two people involves six ego states, three for each person. 
The child belonged to concrete operational period according to Jean Piaget's cognitive theory. The child of this age group belonged to second stage of moral development, i.e. moral realism. Children at this stage understand the concept of rules but still see them as external and rigid. They recognize the sanctity of rules and that they have to play by them and cannot make up new ones to a game.  The instructions given by us initially proved too rigid for the child and appliances cemented to stop the habit was considered as a punishment and she became more adamant because of it. The patient after placement of appliance (stressful situation) changed her ego state from adult to child (regression) either temporarily or for a long term.  The patient in this state tends to show lot of emotions, whereas the dentist communicates in an adult ego state trying to find solutions to the problem. This results in destructive crossed transaction where both the parties are making judgements and decisions for each other.
Symptom prescription involves an explicit directive by the therapist encouraging clients to maintain their problematic behavior or symptom. At times clients may be requested to exaggerate the symptom.  In the first week, we used symptom prescription or reverse psychology  by asking the child to increase the frequency of the habit. This was the first step of reframing in which a behavior that is considered undesirable but pleasurable is made to appear as a duty. The pleasure (response) derived by thumb sucking (stimulus) was desirable during the initial stages. In 2 weeks, the habit had become a duty for the child and it was no longer enjoyable for her. So the response to already existing stimuli had become undesirable and she was ready to stop the habit. The ego states of both the dentist and child were in adult state during this conversation. This type of conversation is called complementary conversation. The child had become more receptive at this stage and the second step in reframing was introduced. Showing photographs of other children with dental disfigurement and the constant reminders (hanging the photographs in the child's room) changed the child's thinking/reasoning. She began associating the thumb-sucking habit to dental disfigurement due to which she was able to stop the habit easily in a month's time. The positive reinforcements too encouraged her to do so.
Thus, the theory of transactional analysis helps in knowing the ego state a individual can have, and psychoanalytical theory helps in answering the change in ego state during stressful situations, and associative learning theory answers how reframing works.
The art of reframing lies in learning the skill of knowing the ego state of the child, modifying it (reframing) by changing the thought process and associations, and making him/her communicate with proper ego states. Thus, the change in our approach can bring about a change in mind and attitude of our patients, in turn changing their health behavior and quality of life.
| Conclusion|| |
Definite role of reframing in the treatment of habits such as thumb sucking and lip biting has been observed. Without psychological management for habits, if other methods of treatment are used, the child pairs the treatment with punishment and may become adamant. Application of reframing in the treatment of oral habits before resorting to extensive appliance therapy has been suggested here. Reframing can also be applied in patient education and diet counseling. Reframing on adolescents, especially girls, can be achieved by associating non-cariogenic diet with a slim body and esthetics.
| References|| |
|1.||Nash DA. Engaging children′s cooperation in the dental environment through effective communication. Pediatr Dent 2006;28:455-9. |
|2.||Peretz B, Gluck GM. Reframing - reappraising an old behavioral technique. J Clin Pediatr Dent 1999;23:103-5. |
|3.||Bandler R, Grinder J. Content reframing: Meaning and context. In: Andreas S, Andreas C, editors. Reframing Neuro-Linguistic Programming TM and the Transformation of Meaning. Moab, Utah: Real People Press; 1982. p. 5-43. |
|4.||Nuvvula S, Kamatham R. A strategic behaviour guidance tool in paediatric dentistry: ′Reframing′ - an experience. J Coll Physicians Surg Pak 2013;23:238. |
|5.||Solomon C. Transactional analysis theory: The basics. Trans Anal J 2003;33:15-22. |
|6.||Freud S. A General Introduction to Psychoanalysis. New York: Washington Square Press; 1917. |
|7.||Pavlov IP. In: Anrep GV, editor (Trans). Conditioned Reflexes. London: Oxford University Press; 1927. |
|8.||Nuvvula S, Kamatham R, Challa R, Asokan S. Reframing in dentistry: Revisited. J Indian Soc Pedod Prev Dent 2013;31:165-8. |
|9.||Piaget J. The language and thought of the child. New York, Harcourt; 1926. |
|10.||Katz J. Symptom prescription: A review of the clinical outcome literature. Clin Psychol Rev 1984;4:703-17. |
|11.||Rinchuse DJ, Rinchuse DJ. The use of educational-psychological principles in orthodontic practice. Am J Orthod Dentofacial Orthop 2001;119:660-3. |