In the next several weeks, I'll be posting short articles related to improving patient behavior and following their provider's plan of care.

Over the past half century, starting with Dr. Ivar Lovass and his study of children on the autism spectrum, researchers have been aware that behaviors will always return to baseline when they are not reinforced. A well done United Kingdom pharmacy study showed that the behavior of patients who were highly reinforced returned to their baseline once their reinforcement programs were withdrawn. In fact, the behaviors began to approach the same levels as patients who had received no training or reinforcement. Motivational Interviewing has shown similar results. These findings strongly support that schedules of reinforcement must be continued on "at-risk" patients even after 8 to 12 months of treatment.


The Lovass Loop is shown below in Figure A. In 1965, Lovass worked with children on the autism spectrum. When his funding ran out, these children were all returned to their previous facilities. While he made excellent progress, you can see that all of them returned to baseline.

The UK Pharmaceutical study in 2012 (Figure B), presented patients with different opportunities to learn. The red lined group receive the greatest amount of training and reinforcement. After more than eight months, the enhanced reinforcement was removed and they began to return to baseline.

Figure C was a study done in Australia with business workers. No intentional reinforcers were used in the Masero-Lee study. This was simply a study of workplace behavior and productivity. There are two points of interest, however:

1. New employees were highly motivated early in their employment and then their productivity started a long decline to match other employee’s baselines. (Conclusion: when behavior is not reinforced, it moves to the mean.)

2. Equally important, as shown in the graph, is that the next three decreases in performance demonstrated that punishment or the threat of punishment returned below average behavior to baseline. This improvement was not long lived and it gravitated to the mean until punishment was again threatened.

Threats to “punish patients” (e.g., take your medicine or else) will prove just as ineffective. Dr. Aubrey Daniels suggests that we, “Change the baseline!” The only way to effectively do that is through the power of positive reinforcement. At a minimum, we need to provide some level of intermittent reinforcement, even when our patients have been on medication for an extended period of time.

The question is who is going to do that work? A second question is, "Which of my patients are the most at risk of non-adherence?" In our next post we will continue the journey into Adherence Management (AdM) Coaching... A Better Approach to Improving Patient Adherence when the Motivational Interview is over.

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