A New Look at Motivation
Nothing so challenges a professional as to learn that a principle once accepted as absolute may no longer have relevance, practicality, or validity.
Twenty-five years ago, I felt behaviorism might hold the key for conditioning orthodontic patients to cooperate and for training orthodontic office personnel. I pursued this strategy zealously over the years and learned a great deal about human personality, behavior, and motivation. However, the more I've tried to arrange reinforcement schedules and organize the orthodontic office environment to maximize compliance, learning, and improvement of patients and personnel, the less enthusiasm and confidence I've retained for behavioristic programs.
I have no quarrel with the basic tenets of behaviorism. I still believe that consequences dictate behavior and that people will learn quicker if they receive immediate, positive reinforcements. People do learn mostly by modeling (imitating) others, and they learn best if the lessons are shaped into small, digestible bites. I also continue to believe that punished behavior will occur less often. What keeps me--and, I presume, others--confused is the difficulty in figuring out and implementing the reinforcements that effect changes in behaviors.
Unfortunately, many of our models for behavioristic learning have been experiments in which animals were starved and then fed when appropriate behaviors were performed. Negative reinforcement schedules that taught avoidance behaviors likewise relied on somewhat drastic techniques, such as electric shocks. Such severe measures obviously have limited use with orthodontic patients.
The problem with the conditioning of humans has been determining what reinforcers have meaning for them. With a neocortex superimposed on top of a primitive limbic system, humans offer more of a challenge to the behaviorist than pigeons or rats do. Dr. Gabriel Della-Piana of the University of Utah once told me, "I can always rely on the laboratory animals to perform as expected. I can't always rely on humans." The diversity in human personalities almost guarantees the impossibility of finding any universal reinforcer that works with everyone. And even if we're lucky enough to discover such a reinforcer for just one individual, there is no guarantee that the reinforcer will continue to remain effective for any length of time.
My practice for many years used a token economy that rewards patients for behaviors we feel important to successfully complete their treatments. It became clear to me, though, that compliance was unpredictable among the patients who needed it the most.1,2 Sometimes their mouths were clean, the permissive parts of their therapies were used, and they had not broken any brackets or bands. But quite frequently with these non-cooperating patients, we discovered broken appliances, chronic gingivitis, or poor compliance with the permissive appliances. The compliance problems were always with the same patients. There seemed to be some feature of their personalities beyond the influence of positive and negative reinforcers and, increasingly, it seemed related to their pain tolerances.
Some patients seemed to withstand discomfort better than others, and quite naturally brushed their teeth well with little or no instruction. The poor brushers, on the other hand, continued their poor oral hygiene, high breakage rate, and overall poor compliance, despite repeated instructions, reinforcements, and encouragement. Studies done in 1983 and 1984 established that good and poor brushers differ significantly in the amount of pressure they place against their teeth and gums.3,4 Although it hasn't been statistically documented, the poor brushers in my office always seemed to have more broken bands and brackets and poorer compliance with permissive appliances.
Efforts to change toothbrushing behavior behavioristically, using a sophisticated biofeedback, soft-bristled toothbrush, showed some promise in improving the oral hygiene of non-compliant patients. But after many years of working with this method, the most I can claim is that the results were equivocal; we seldom succeeded in permanently improving difficult patients' toothbrushing or other behaviors.
A book entitled Know Your Child, written in 1987 by the husband-and-wife team of Stella Chase and Alexander Thomas, suggested a genetic and perhaps immutable basis for our failure.5 The authors' study of 133 children from birth past 30 years of age established several genetic features of temperament that defy change. These include sensitivity threshold, activity level, regularity/irregularity, approach/withdrawal, distractibility, mood, adaptability, and persistence.
Coupled with my research, the work of Chase and Thomas counsels us not to expect too much from any behavioral change program that addresses these features of personality. Rather, we should adapt our expectations, responses, and treatment strategies to compensate for patients' peculiar and particular endowments. Expecting sensitive patients to use permissive appliances without breaking them and to maintain good oral hygiene may not be realistic. Still, we can develop some strategies that will lessen sensitive patients' discomfort and enable them to cooperate more, such as:
No one, to my knowledge, has ever accurately determined what percentage of these patients make up our orthodontic population. In my practice, it is at least 50%. In any case, it isn't an insignificant problem, and it demands that we find solutions that will enable us to deliver first-rate treatment despite patients' inabilities to help us.
Rather than seeing these patients as having character defects, we might be better served by viewing them as turtles without shells. Then we can be as clear-eyed, rational, and open-minded as possible as we seek pragmatic and useful strategies. Continuing with an approach that clearly is not working only meets author Rita Mae Brown's definition of insanity: doing the same thing again and again, but expecting different results.