|Year : 2013 | Volume
| Issue : 3 | Page : 165-168
Reframing in dentistry: Revisited
Sivakumar Nuvvula1, Rekalakshmi Kamatham1, Ramasubbareddy Challa1, Sharath Asokan2
1 Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, K.S.R. Institute of Dental Science & Research, Tiruchengode, Tamil Nadu, India
|Date of Web Publication||11-Sep-2013|
Department of Pedodontics and Preventive Dentistry, Narayana Dental College, Nellore - 524 003, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The successful practice of dentistry involves a good combination of technical skills and soft skills. Soft skills or communication skills are not taught extensively in dental schools and it can be challenging to learn and at times in treating dental patients. Guiding the child's behavior in the dental operatory is one of the preliminary steps to be taken by the pediatric dentist and one who can successfully modify the behavior can definitely pave the way for a life time comprehensive oral care. This article is an attempt to revisit a simple behavior guidance technique, reframing and explain the possible psychological perspectives behind it for better use in the clinical practice.
Keywords: Behavior guidance, psychodynamic perceptive, reframing
|How to cite this article:|
Nuvvula S, Kamatham R, Challa R, Asokan S. Reframing in dentistry: Revisited. J Indian Soc Pedod Prev Dent 2013;31:165-8
| 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. Growing up is a complex process, as children learn to come to terms with the world around them. A lot of things can be frightening to them until they develop the cognitive skills to deal with the new experiences around them. The perception about dentistry, oral habits and hygiene maintenance can differ from a child-to-child. Before treating any child it is important to analyze his/her behavior and the psychological approach is the key for behavior shaping them whenever there is a need to modify it. An old behavioral approach- reframing, can be effectively used to change the perception on dentistry.
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."  This communication technique is in fact a part of neuro-linguistic programming that helps in strengthening the relationship. 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 can be applied to everyday life situations. A mother who starts to worry about the cost of expensive glassware her child has just broken while playing, stops to worry when her husband says that "we are very lucky that our child didn't get hurt." She now hugs the baby with happiness that the child is safe. In the above example, the situation has remained the same (glassware is broken), but the meaning of the situation has changed for the mother, making her happy. On the other hand, a mother is worried that her child is very active, naughty and does not stay quiet for a minute, however, when a neighbor says, "children being active, keeps them healthy and prevents problems like obesity from occurring in the future," the mother feels good about her child's activity. In this example, the situation is again the same, but the context in which the behavior is applied has changed, thus making the mother happy.
Reframing has been considered and proven to be one of the behavior guidance techniques in pediatric dentistry with wide applications. , Hence, this article has attempted to revisit reframing and explain the possible psychological perspectives of reframing for better use in practicing successful pediatric dentistry.
| Psychological Perspectives|| |
Reframing can be explained using principles of transactional analysis by Eric Berne, Freud's psychoanalytical theory and Pavlov's associative learning.
Transactional Analysis: Personalities are made up of three parts or ego states: the Parent (P), the Adult (A) and the Child (C) ego states. The "parent" ego state is a set of thoughts, feelings and behaviors that are learned or "borrowed" from parents or caretakers during the first 5 years of life. It is also known as "taught the concept" of life. The parent ego state can be either "nurturing parent," that is the soft, loving, or permission giving type or the "critical parent," comprising the pre-judged thoughts, feelings and beliefs that is learned from parents. The "adult" ego state is the data processing center. It is part of the personality that can process data accurately, that sees, hears, thinks and can come up with solutions to problems based on the facts and not solely on our pre-judged thoughts or childlike emotions. The "child" ego state is part of the personality that is the seat of emotions, thoughts, memories and feelings that is present from childhood. The child ego state can also be of two types: the "free child" (natural child) and the "adapted child" (rebellious child). The free child ego state can be playful, authentic, expressive and emotional. The adapted child is part of the personality that has learned to comply with the parental messages received while growing up. When the parental messages are restricting, instead of complying with them, we rebel against them. This shows the rebellious child ego state. ,, The communication between two people involves six ego states, three for each person.
According to Freud's psychoanalytical theory, regression is one of the ego defense mechanisms. In stressful situations, instead of handling the unacceptable situation with an adult approach, we to tend reverse our ego to an earlier stage of development, either temporarily or in long-term.  This adaptive regression in the service of the ego, can be either beneficial or harmful. If we regress to the happy events of our childhood, it could be beneficial because we derive pleasure out of it. If we regress to the unhappy childhood, it could be more detrimental.
In Pavlov's associative learning a stimulus acquires the capacity to evoke a response that was originally evoked by another stimulus with which it was paired.  Many unconditioned stimulus-response (S-R) pairs exist in our mind and the response to a new stimulus depends upon the unconditioned S-R pair, we associate this new stimulus to.
Relating all the hitherto mentioned theories together, we can state that, in stressful situations we change our ego state from adult to either child or parent state; which changes the thinking, in turn affecting the process of association with S-R pairs. Reframing is the technique of changing the association from an undesirable S-R pair to a desirable one by changing the thinking pattern and that is possible by reverting back the person to an adult ego state. Summarizing the theories, it can be concluded that, theory of transactional analysis helps in answering the basic ego states a person can have; and psychoanalytical theory helps in answering the change in ego state during stressful situations; and associative learning in answering how reframing works.
Consider the everyday life examples of reframing mentioned in the introduction section. There were some pre-existing unconditioned stimuli (UCS) - unconditioned response (UCR) pairs for the mother like:
1 st S-R pair: Breaking the glassware (UCS) - Unhappy (UCR).
2 nd S-R pair: Child, happy and safe (UCS) - Happy (UCR).
3 rd S-R pair: Child messing up the house (UCS) - Worried (UCR).
4 th S-R pair: Good for the child's health (UCS) - Happy (UCR).
The mother was in stress and displayed her critical parent ego state. In the first example, the mother initially associated the new stimulus, i.e., breaking expensive glassware, to the 1 st S-R pair and hence she was unhappy. After her husband's she reframed to the adult ego state, her thinking process changed and associated the new stimulus to the 2 nd S-R pair and was happy. In the second example, the mother initially associated naughtiness of her child to the 3 rd S-R pair and hence was worried. However, after reframing she became happy as she was associated with 4 th S-R pair. Thus, reframing is changing the thinking pattern by changing the ego state and relieving the stress of the situation.
| Reframing in Dentistry|| |
The dental operatory can be a stressful situation for adult and especially for a child. There can be a change in the ego state and thinking pattern [Figure 1]. For appointment to be successful, the patients should be in the adult ego state and communicate with the adult ego state of the dentist. Patient should associate his thinking process with a desirable S-R pair. Hence, the aim of dentist in general and the pediatric dentist in particular is to bring him/her back to the rational problem solving adult ego state by employing effective means [Figure 2]. This makes a complementary or reciprocal transaction between the child and dentist (ego state addressed is the one that is responding).
|Figure 1: Ego states in the dental operatory (Stressful) (P: Parent ego state; A: Adult ego state; C: Child ego state; S-R pair: Unconditioned stimulus response pair)|
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|Figure 2: Change in the ego state by employing appropriate methods (P: Parent ego state; A: Adult ego state; C: Child ego state; S-R pair: Unconditioned stimulus response pair)|
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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. Then to bring about the change in ego state, it is essential to use adequate facial expression, voice intonation and supporting non-verbal communication. The clarity of the message and the use of euphemisms can help pediatric dentists in making the child understand the situation better.  Effective communication comprising of skills such as active/reflective listening, self-disclosing assertiveness and reinforcing the correct behavior through praise,  leads to the development of trust in the child and this can relieve him/her of the dental stress. Behavior modification techniques like tell-show-do, modeling and contingency management can also help in reframing. The child's ability to accept reframing relates to the ability of the child to communicate easily and reframing will be a failure with children under age three and the examples or language used by the dentist is too high and beyond the comprehension of the child. 
| Case Discussion|| |
A 10-year-old boy was brought to the Department of Pedodontics by his mother with the chief complaint of lip biting habit. Past dental history revealed a visit to the private practitioner 2 months ago and the boy was given a lip bumper for the habit. The dentist had to repair the appliance thrice in a time span of 2 months. It reflected the reluctance of the child to discontinue the habit and to wear the appliance. The child made it clear to us that he would break the appliance even if it was fixed again. Assessing the situation, we assured the child that the appliance will not be fixed again. We also informed him that he can continue the habit and even increase the frequency of biting his lip. However, every time he bit his lip he was asked to make a note of it. The parents were assured about the management strategy and the child was recalled after 1 week. The child was shown photographs of children with proclined teeth and was informed that if he continued the habit, his teeth would also look the same. As the child showed willingness to discontinue the habit, he was given a calendar to note the frequency of lip biting. In 1 month, the frequency of lip biting significantly reduced. Based on his interest in painting, he was given drawing books and crayons as rewards. The parents were instructed to praise the child when he was not indulging in the habit and to ignore him whenever he indulged in it. Within 3 months, the child completely discontinued the habit and the child was given a certificate of appreciation as the best patient, in his last recall appointment.
The lip bumper inserted by the first dentist to stop the habit was considered as a punishment by the child and he became more adamant because of the punishment. In the 1 st 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. In 1 week, the habit had become a duty for the child and it was no longer enjoyable for him. 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 changed the child's thinking/reasoning. He was able to stop the habit easily in a month's time as the positive reinforcers encouraged him to do so. Before reframing, the habit was associated with pleasure and with symptom prescription, it was associated with duty and later with second step of reframing it was associated with displeasure.
| Conclusion|| |
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, associations and to make him/her communicate with proper ego states. Reframing relates our words, thoughts and behavior to our goal of bringing the best out of our patients. 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.
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[Figure 1], [Figure 2]
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