Organismic
Just finished
exercising, so unusually warm
An antecedent is an environmental or
physiological stimulus that precedes a behavior (also called a discriminative
stimulus). For example, a red light is a stimulus for putting on the brakes,
and a growling stomach is a stimulus for eating.
A behavior (also called a response) is
the target behavior, or phenomenon of interest. A behavior is anything the
whole person does. For example, eating is a behavior while digesting food is
not; speaking is a behavior while vibration of the vocal chords is not; looking
at something is a behavior while a visual image striking the retina of the eye
is not.
A consequence is an event that follows the
behavior. A consequence will increase or decrease the probability of the
behavior occurring again in the presence of the same antecedent. Reinforcing
consequences increase the probability of the behavior occurring again, and
punishing consequences decrease the probability.
Organismic variables represent biological and cognitive factors that
affect the target behavior. For example, the effect of caffeine on trying to
fall asleep, or the effect of a delusional belief on attending a doctor’s
appointment, are both organismic variables. Contingencies
A contingency is a relationship between a behavior and a consequence, in
which the consequence is presented if and only if the response occurs. For example, getting a paycheck is contingent
on going to work. Contingencies can be
described in the form of if: then statements. For example, if you go to
work, then you will get your paycheck. Five types of contingencies
affect learning a behavior. (see Figure 2) A contingency might either be a
desirable stimulus (e.g., praise, money) or an aversive stimulus (e.g., being
yelled at or being fined). These stimuli
might either be applied to a person after a behavior, or taken away. A consequence that leads to an increase in
behavior is a reinforcer. A consequence
that leads to a decrease in behavior is a punisher. Reinforcement is generally
more effective than punishment for changing behavior. The reasons for this will
be elaborated below.
The procedure in which desired stimuli are presented to a person after a
behavior is called positive reinforcement.
Positive reinforcement increases behavior. That is, people are more likely to repeat a
behavior that has been positively reinforced.
Examples might include praising a consumer for showing up on time for an
appointment, or awarding points that can be exchanged for goods to reward
participation in a therapy group, or getting paid to come to work. Positive
reinforcement is positive in the sense that something is added to the
environment.
The procedure in which aversive, or
unpleasant stimuli are removed or withheld from a person after a behavior is
called negative reinforcement. Negative
reinforcement also increases behavior. That is, people are more likely to
repeat a behavior that is negatively reinforced.
Examples might include a parent who stops nagging after his
daughter cleans her room, or the beeper stopping after you buckle your seat
belt. Negative reinforcement is negative,
in the sense that something is subtracted, or removed from the environment.
The procedure in which unpleasant stimuli are presented to a person
after a behavior is called positive punishment. Positive punishment decreases
behavior. That is, people are less
likely to repeat a behavior that has been punished. Examples might include spanking a misbehaving
child, or reprimanding a staff person who did not finish charting his group
notes on time. Positive punishment is positive in the sense that something
is added to the environment.
The procedure in which desired stimuli are withheld or removed from
persons after a behavior is called a response cost, or negative
punishment. Response costs decrease behavior.
That is, people are less likely to repeat a behavior that is followed by a
response cost. Examples might include
fining a person (taking money from them) for speeding or taking dessert away
from a child for having a tantrum at the dinner table. Response cost is a form of negative punishment
in the sense that something is subtracted or removed from the environment.
Extinction is the procedure in which a behavior that has previously been
reinforced is no longer reinforced.
Extinction decreases (extinguishes) the frequency of behavior. For example, suppose that we establish that a
child’s temper tantrums at the grocery store are reinforced by her mother
buying her a candy bar. This behavior
would be extinguished by no longer buying candy when the child has a
tantrum. Another example might be
ignoring a consumer who shouts to get attention from treatment team staff, if
it has been established that the consumer’s shouting has been reinforced
by staff attention. When an extinction
procedure is introduced the target behavior often briefly increases in
frequency before it decreases. This
increase in the target behavior’s frequency is called an extinction
burst. For example, the tantruming child
and shouting consumer might briefly increase the intensity or frequency of
their tantrums and shouting before these behaviors decrease. It is important
for the clinician to recognize that this extinction burst will occur. Many an extinction procedure has been
abandoned because staff observed the extinction burst, concluded that the
intervention was not working, and prematurely terminated it.
We can only know whether a consequence is a reinforcer or punisher after
we observe an increase or decrease in the behavior that produces that
consequence. That is, one can only call
something a punisher or reinforcer based on the effect it has on behavior. A reinforcer increases the probability
that the behavior that precedes it will be repeated, and a punishment decreases
the probability that the behavior that precedes it will be repeated. For
example, it is easy to assume that candy is always a reinforcer, or that being
yelled at is always a punishment.
However, candy may not function as a reinforcer for someone who doesn’t
like candy, is allergic to sugar, or has just eaten a large meal. Similarly, if someone doesn’t mind
being yelled at, or if being yelled at is the only time one is acknowledged,
being yelled at will not function as a punisher. If we apply a consequence, and the behavior
doesn’t change, that consequence is not a reinforcer regardless of what
our intention was when we applied the consequence. We might erroneously conclude that positive
reinforcement does not work. However,
before reaching such a conclusion, we should first find out what is reinforcing
to the individual and try a new consequence.
While some contingencies are almost universal, e.g., money as a
reinforcer or pain as a punisher, we can only define reinforcers and punishers
in relation to the effect they have on the behavior of an individual. Figure 2 below outlines the types of
contingencies and their effects on behavior.
Figure 2: Types of
contingencies and their effects on behavior
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Effect on Behavior
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Behavior produces event
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Behavior removes or postpones event
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Contingencies terminated
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Increased rate or
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Positive
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Negative
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likelihood of recurring
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Reinforcement
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Reinforcement
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Decreased rate or
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Punishment
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Time Out, Response
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Extinction
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likelihood of recurring
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Cost
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Considerations for selecting reinforcers When considering
possible reinforcers the clinician should select reinforcers that can be
presented immediately following the behavior, can be presented repeatedly with
minimum satiation, and are in reasonable supply. For example, using a movie as
a reinforcer may not work well because it is unlikely that the individual will
be able to view the movie immediately following the behavior. One might instead award points that can be
exchanged for goods and privileges. Points
can be given immediately, and the individual might later choose to buy a movie
ticket with the points. Food may not work as well as some other reinforcers
because people get full (become satiated).
Where possible the clinician should use a
variety of reinforcers to minimize satiation.
The clinician should use natural reinforcers, that is, those likely to
be encountered in the community such as praise and attention. For example, natural consequences of using
social skills are that one can ask for what they want, talk about what
interests them, or expand their social network, all of which increase
opportunities for positive reinforcement.
Possible reinforcers are listed in Table 1: Possible Reinforcers
Social Reinforcers
Informative Feedback
Activities and Privileges Tangibles and Edibles Generalized Reinforcers (e.g.,
money, tokens, or points) Self-Reinforcement______________________________
Social reinforcers, include, for example, praise and attention,
status in the program (e.g., an opportunity to lead the community meeting).
Informative feedback is identifying progress made toward accomplishing a
goal. It is most effective when combined
with goal setting. Informative feedback is usually combined with praise or
self-reinforcement (e.g., “Good job!
You completed your homework and are half way toward meeting your
goal.”). Activities and privileges
can also be reinforcing, for example, an opportunity to go on an outing, use a
computer, make a phone call, or obtain a special pass. The Premack principle states that one can use
a high frequency behavior to reinforce, and thus increase the frequency of, a
lower frequency behavior. For example,
an individual who reads the newspaper every morning might be assigned to walk
three blocks to get a newspaper instead of having it delivered to increase the
frequency of exercising.
Tangibles and edibles, for example candy, coffee, personal care
products, stamps, etc. may also be used as reinforcers. However, edibles in particular may be subject
to satiation. Generalized reinforcers (e.g., money or tokens) are usually more
versatile. These are reinforcers that
can be exchanged for other items that are desirable to the consumer. An advantage of generalized reinforcers is
that consumers can exchange them for different things or activities, and they
are resistant to satiation (we have yet to encounter anyone who has said,
“No thanks, I have too much money.”). Tokens should always be given along with social
reinforcement, (e.g.,
“Good job. You arrived on time and participated in the
group, so you earn 25 points.”). In self-reinforcement, the consumer
might use any of the above reinforcers, but delivers them herself (e.g.,
“I completed my conversation skills homework by calling a friend so I am
going to watch my favorite television program.”).
Of course, the clinician must first find out what is reinforcing to the
consumer(s). This can be accomplished in
a variety of ways. Most simply, the
clinician can ask the individual, “What do you like to do for
fun?” “If I gave you five
dollars, what would you spend it on?”
“What are your hobbies?”
These questions can be asked in a verbal interview or in a written
questionnaire. (A sample questionnaire is included in the resource section of
this guideline.) The clinician may also ask people who know the client well,
such as family members or other treatment providers. The clinician can observe
the individual, noting what she does frequently, what she asks for, what she
complains about, etc. Variations of identified
reinforcers can also be used, for example, if the consumer says he likes
playing Nintendo games the clinician might use access to a different computer
game as a reinforcer. Problems with punishment
There are several features of punishment that make it problematic as a
behavior change strategy. Punishment
does not teach the person what to do, only what not to do. For example, if a staff person is punished
for turning in an assignment late, she has not learned anything about how to
manage her time better, improve her report writing skills, set priorities, or
change any behaviors that may have contributed to her tardiness.
It can be difficult to ensure that the
target behavior will be suppressed after punishment is applied. For example,
suppose a group leader scolds John for speaking out of turn during group by
reprimanding him. John responds by no
longer speaking at all in the group. The
group leader thought the punishment would decrease the inappropriate behavior
of speaking out of turn. However she actually punished (decreased) speaking in
groups at any time. Punishment teaches
sneakiness; that is, the person learns not to do the behavior when others are
observing. For example, a staff person
was punished when his supervisor observed him taking office supplies. Now he
continues to take office supplies, but makes certain his supervisor is not
looking. Punishment may lead to emotional states that interfere with
learning. For example, Marco is told he will
lose his afternoon walk privilege after he arrives to group late. He is so upset about losing the walk that he
ruminates about it and does not pay attention for the duration of the
group. The mood of the person delivering
the punishment often influences when and how it is delivered. Suppose there is
a rule against swearing. A consumer
stubs his toe and shouts “damn!”. In one instance you have just
been reprimanded by your supervisor for being late, because you were caught in
a traffic jam and got a late start after having to change a flat tire, and were
told you couldn’t take your preferred vacation day because someone else
asked for the day off first. In another instance, you have just returned from a
two-week vacation to Hawaii and were informed you will be getting a raise. In which instance would you be more likely to
punish the behavior, and in which would you be more likely to ignore it?
Punishment is likely to increase anger and aggression. For example, Mark is shouting because he is
angry and wants to go to the courtyard and smoke and has not yet earned this
privilege. He is told that not only can
he not go outside and smoke, he cannot go to the vending machine this evening
as punishment for yelling. Is his anger now likely to increase or decrease? Reinforcement is preferred over
punishment whenever possible as a strategy for influencing behavior.
Differential reinforcement
Differential reinforcement strategies are
often effective alternatives to punishment for decreasing undesirable
behavior. There are three common forms
of differential reinforcement: differential reinforcement of other behavior
(DRO), of alternative behavior (DRA), and of incompatible behavior (DRI).
When reinforcing other behavior a consumer is reinforced for engaging in
any behavior other than the behavior targeted for decrease. For example, if decreasing shouting were the
target behavior, the consumer might be reinforced each hour he does not
shout. One drawback to DRO interventions
is that the focus is on what the consumer is NOT doing, so it does not teach
new behaviors. For this reason, DRO interventions have been humorously referred
to as “The Dead Man’s Program”, as a dead person could follow
the program by not being aggressive, disruptive, etc. In contrast, DRA and DRI
programs are focused on what the consumer is doing as well as what he or she is
not doing.
In differential reinforcement of
alternative behavior (DRA), the consumer is reinforced each time they use an
alternative to the behavior targeted for decrease. For example, continuing with
the target behavior of shouting, the consumer might be reinforced for leaving
the room when angry instead of shouting.
This type of intervention is more specific than a DRO intervention in
that the consumer would only be reinforced for other behavior in situations
when they are likely to engage in the target behavior. Thus the consumer is reinforced for what he
or she does, not merely for what he or she does not do.
Differential reinforcement of incompatible behavior (DRI) is even more
specific in its focus on the target behavior.
When a DRI intervention is used the consumer would be reinforced only
for engaging in behaviors incompatible with the target behavior. For example, the consumer who tends to shout
would be reinforced for making a request in a soft tone of voice. This is an incompatible behavior, as one
cannot shout and speak softly the same time.
Differential reinforcement can be used to decrease undesirable behavior
by focusing on what the consumer does instead of engaging in maladaptive
behavior, and does not have the disadvantages associated with punishing
interventions. Schedules of reinforcement
Schedules of reinforcement are the rules that specify how often to
provide a reinforcer in return for performing a targeted behavior. If behavior is reinforced often, people learn
more quickly. Once a behavior is learned
and is performed consistently in the appropriate situation, reducing (but not
eliminating) the frequency of reinforcement may increase the likelihood that
the behavior will be maintained. If
reinforcement stops completely, people may stop performing the behavior. For example, employees will stop coming to
work if they stop getting a paycheck. Extinction occurs when a person stops
performing a behavior because it is no longer reinforced.
Reinforcers may be delivered to a consumer according to different schedules. Different schedules of reinforcement may
affect the speed of learning, increase the likelihood that a newly learned
behavior will be maintained, or increase the resistance of a behavior to
extinction. Continuous reinforcement schedule (CRF) One of the fastest
ways to teach a new behavior is to use a continuous reinforcement schedule
(CRF), which provides a reinforcer every time a behavior is performed. A student who is praised each time he
correctly spells a word is on a CRF schedule.
Some behaviors, such as social behaviors, may remain on a CRF schedule
even after they are learned. For
example, every time one says “hello” to a friend, the friend says
“hello” back. However, one
problem with a CRF schedule is that the behavior tends to extinguish quickly
when it is no longer reinforced.
Also, the person may become satiated on some reinforcers. For example, if a consumer was reinforced
with a candy bar every time she initiated a conversation, she might not want
anymore candy bars and may stop initiating conversations after three or four
times. Finally, CRF schedules are
demanding on staff time and resources, unless the reinforcer is natural or is
quickly switched to a natural reinforcer.
For example, one might start by awarding points for initiating a
conversation, but we would want the natural social consequences of conversation
to take over so that points are no longer needed to maintain conversation. Fixed
reinforcement schedule (Fixed Ratio [FR] or Fixed Interval [FI])
One way to address problems with the CRF schedule is to provide the
reinforcer after the behavior has been performed a specified number of times (a
fixed ratio), or after a specified interval of time has passed (a fixed
interval). Getting a frequent flier ticket every time 10 flights have been
completed is an example of a fixed ratio schedule. Getting a paycheck every two
weeks is an example of a fixed interval schedule. Clinically, a reinforcer may be given every
third time a behavior, such as initiating a conversation, is performed. This would be an FR-3 schedule (Fixed Ratio
of three). Notice that continuous
reinforcement is a fixed ratio schedule in which the behavior is reinforced
every one time it occurs (FR-1).
Alternatively, the behavior might be reinforced after a fixed time
interval. For example, a consumer might
be reinforced every ten minutes during which she initiates at least one
conversation. This would be an FI-10
schedule (Fixed Interval of ten minutes).
Increasing the number of times the
behavior is performed before getting a reinforcer is called fading. That is, requiring the behavior five times
(FR-5), then ten times (FR-10), or increasing a time interval from 10 minutes
(FI-10) to 20 minutes (FI-20) would fade the reinforcer. Fixed ratio schedules are more resilient to
extinction than are CRF schedules.
However, the behavior is likely to extinguish if the reinforcer is
completely removed. Variable reinforcement schedule Moving from a fixed
schedule to a variable (VR or VI) schedule reduces the likelihood of
extinction. VR schedules use an average
number of target behaviors for reinforcement, e.g. on an average of X times the
behavior is performed, a reinforcer is given.
Slot machines operate on a variable ratio schedule, paying a jackpot
after some average number of lever pulls.
On a VR-5 schedule, reinforcers could be given after 2, 8, 4, and 6
times a behavior is performed - an average of 5 behaviors per reinforcer. On a VI schedule, reinforcers are given after
an average amount of time has passed. For example, one might arrive at a bus
stop knowing that the bus arrives an average of once every fifteen
minutes. On some occasions the wait
might be 5 minutes and on other occasions 25 minutes. On a VI-8 schedule, a reinforcer might be
delivery after 6, 10, and 8 minutes, for an average of once every eight
minutes. Under variable schedules,
people cannot figure out exactly when they are going to receive a
reinforcer. For this reason, behaviors
learned on variable schedules are very resilient to extinction. Moving from continuous reinforcement (FR1) to
a greater fixed ratio, and then to a variable schedule makes the behavior occur
more quickly and extinguishes less frequently. For example, the gambler playing
a slot machine does not know exactly when the jackpot will hit. The large amount of time and money an
individual might spend at a slot machine illustrates just how resistant to
extinction a variable ratio schedule is.
Contingencies of reinforcement are the
foundation for all behavioral interventions.
Some of the behavioral interventions that will be discussed further
include token economies, behavioral contracting, and skills training, including
planning for generalization. However,
the clinician must first conduct a thorough assessment before identifying the
most suitable intervention.
Assessment The goals of a behavioral assessment are to
identify target behaviors, identify controlling variables and potential
reinforcers (contingencies), select appropriate treatment strategies, and determine
useful outcome measures for evaluating the effectiveness of treatment. There are several appropriate assessment
strategies. Qualitative assessment Qualitative assessment provides a
comprehensive description of specific problem behaviors in an organized
format. The focus is on the form
(topography) rather than the function of the behavior, and how the consumer
experiences it. Qualitative assessment
answers the question, “Exactly what would I see if I observed you
performing the behavior?”. The
chief advantage of qualitative assessment is its efficiency; a single staff
member can complete the assessment, and much information can be obtained from a
single, relatively brief interview. It
also requires people to be specific about exactly what they are doing.
The disadvantage of qualitative assessment
is that it does not provide information about variables controlling behavior
other than individual self-report, which is notoriously unreliable. Functional
assessment
The goal of functional assessment is to identify the relationships
between a target behavior, and events that precede and follow it. The emphasis is on
antecedent-behavior-consequence relationships. Functional assessment answers
the question, “What is the effect of the behavior on the environment (the
consequence) in a particular situation (the antecedent or discriminative
stimulus)?”. It is a functional
approach in that the assessor focuses on variables controlling behavior, e.g.,
discriminative stimuli, consequences to determine the function of a target
behavior. For examine, yelling obscenities (target behavior) during quiet time
(antecedent) functions as a means of getting attention (consequence).
One advantage of functional assessment is that it has high precision as
compared to qualitative assessment, because it relies on the direct observation
of behavior, rather than self-report.
The clinician directly observes the behavior and the variables
controlling it, or relies on the report of the consumer or a collateral who
might monitor the behavior via a diary or recording form. (An example of a
functional assessment tool, the Specific Event Log, is included in the resource
section of this guideline.) The major
disadvantage of functional assessment is that it can be time consuming to
observe a large enough sample of behavior from which to make valid inferences. Quantitative
assessment
In quantitative
assessment behavior is described in measurable terms in order to assess the
impact of a behavioral intervention on a target behavior. Behavior is usually measured in terms of its
frequency, duration or intensity.
Quantitative assessment answers the question, “How frequently (or
intensely, or long) does this behavior occur?”. For example, in describing the alcohol use of
a consumer we might say that she drinks six days a week (frequency) or from
noon until she passes out (duration), or that she has 10 drinks on each
drinking occasion (intensity). Behaviors
described in measurable terms can be easily monitored, recorded, and visually
graphed. Thus changes in behavior
frequency, duration and intensity are easily observed. For example, we might
note that after MISA treatment the consumer’s drinking decreased from six
days a week to twice a month, or that the ‘intensity’ decreased to one
drink per drinking occasion. The major
advantage of qualitative assessment is that changes in behavior are easily
monitored, and the efficacy of interventions is quickly determined. The primary disadvantage is that sufficient
pre-intervention, or baseline, data must be gathered before the intervention is
begun. Assessment and the selection of target behaviors Information
gathered from both qualitative and quantitative assessments is important when
planning intervention strategies.
Functional and quantitative assessment help the clinician gain a
functional understanding of behaviors that aids in selecting interventions for
each target behavior. Qualitative
assessment helps the clinician understand how the consumer experiences his or
her problems and can provide useful information for selecting appropriate
target behaviors and contingencies. An
adequate qualitative assessment must address client strengths, interests, and
goals as well as client problems.
Information gathered during the assessment is used to select appropriate
target behaviors. Consumers with a
severe and persistent mental illness often have multiple problem
behaviors. It is not always possible to
target all behaviors for intervention at once, so they must be
prioritized. Target behaviors should be
selected by client and treatment provider together. While there is no one way to select
appropriate target behaviors, behaviors that might be considered appropriate
targets for immediate intervention are described in Table 2.
Table 2 Possible targets of
intervention_________________________ The behavior of most concern to the
client The easiest behavior to change The behavior most likely to affect other
problem behaviors The behavior most likely to generalize to other behaviors The
earliest behavior in a behavior chain The behavior that, if changed, leads to
the most opportunities for new behaviors and more reinforcement Suicide and
life threatening behaviors Treatment interfering
behaviors_________________________
The clinician can determine the behavior of most concern to the client
by asking what they would most like to change, or what they find most
distressing. For example, a consumer may
report that they are most interested in learning how to cope with anxiety. Alternatively, the clinician and consumer may
select the easiest behavior to change so that the consumer begins treatment
with confidence-building success. For
example, a consumer with a diagnosis of social phobia may opt to learn relatively
straightforward medication management skills before working on potentially
anxiety provoking social skills.
Selecting the behavior most likely to affect other problem behaviors or
that generalize to other behaviors may provide the consumer with the most
‘bang for their buck’. For
example, starting treatment with substance abuse treatment may lead to changes
in the consumer’s attendance in treatment and on the job and improve
their medication compliance as well as leading to decreased substance use. An example of a new behavior generalizing to
other behaviors is a consumer who participates in a skills training group and
learns a single set of skills to cope with anxiety, symptoms of psychosis, and
inappropriate anger.
Substance abuse treatment can also provide an example of changing the
earliest behavior in a behavior chain.
For example, suppose when the consumer uses cocaine, he then steals
money from his parents, then gets into arguments with them when they find out,
leading to his getting kicked out of the home and becoming homeless. Targeting cocaine use might be more
productive than targeting arguing with his parents.
The clinician and consumer might also
select the behavior that, if changed, leads to the most opportunities for new
behaviors and more reinforcement. For
example, a consumer who does not have basic conversation skills or does not
know how to use public transportation will have very limited opportunities for
social and occupational reinforcement.
Marsha Linehan, in Dialectical Behavior Therapy (1993), recommends that
suicide and life threatening behaviors always be the first target for
intervention, and that treatment interfering behaviors be targeted second, as
other behaviors cannot be adequately addressed in treatment until the consumer
is not a danger to herself, and consistently participates in treatment. Finally, she recommends that quality of life
interfering behaviors be taught third.
After identifying target behaviors the clinician will want to consider
possible interventions.
The Process Model and
Selecting Interventions
Psychiatric disability is made up in large
part of certain skills deficits. The
Process Model (Corrigan and Jakus, 1994) considers four psychological processes
associated with skills (Figure 3) and how people with severe mental illness are
impacted by them.
Figure 3. The Process Model
Process
Model
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C O
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Acquisition
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G
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N I T I
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Performance
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O
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Generalization and Maintenance
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N
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Acquisition Before one can perform a skill, one must learn,
or acquire it. During adolescence and
early adulthood most people learn basic social and coping skills by watching
what others around them say and do in both common and difficult
situations. This information is stored
away in memory for later use; we are able to discriminate which new situations
are similar to what we have seen before, and retrieve the corresponding skill
from memory. However, people with severe
mental illnesses are frequently unable to acquire skills if they are struggling
with early symptoms of their illness.
Example: Carl, is a 42 year old,
single, Caucasian male, diagnosed with Schizophrenia. He has poor social skills. When he is with a group of people, he
alternates between withdrawn silence, and interrupting others with irrelevant
remarks. The onset of his illness occurred at the age of 16. He had begun to withdraw from others, and
behave somewhat oddly a year prior to his first psychotic episode. An assessment suggested that he never learned
appropriate adult social behavior because he was withdrawn or ill during the
adolescent years when he would have been learning important social skills
through peer interactions. This is an
acquisition problem, since he has never learned the skills.
Performance The second step in skill development is
performance. People generally perform
skills that are reinforced; i.e., when there are good reasons, or incentives,
to do so, and when there are no barriers preventing one from performing them. For example, most people would not go to work
without the reinforcer of a paycheck.
Similarly, people with severe mental illnesses may not perceive
reinforcers to use skills they may have acquired. Conversely, they might perceive reinforcers
for performing a skill, but an individual or environmental barrier may prevent
them from performing the behavior in question.
Individual barriers might include factors like anxiety, a learning
disability, or thought disorder that interfere with concentrating in a skills
training group. Environmental barriers
include such things as lacking transportation or access to childcare that
result in one being unable to participate in treatment.
Example: Juanita
lives in a large board and care home.
The staff at the home
complain that she rarely showers and
wears soiled clothing. As a result of
her poor
hygiene practices she has offensive body
odor. Juanita spends most of her day
sitting on
the porch of the home, smoking
cigarettes and drinking coffee. She
rarely goes anywhere
other than to mental health
appointments. Several of her fellow residents also have poor
hygiene skills. Juanita reports that she knows how to bathe
and wash clothing, and says
she “just doesn’t feel like
it”. She reports that she does not
care if she is dirty since there
is no reason for her to wash. “Who cares whether I wash and wear
clean clothes? I never
see anyone I want to impress.”
Most people maintain hygiene because being clean feels good to them, or
they want the social approval of others that accompanies appropriate
hygiene. Others may be offered a
reinforcer for completing hygiene tasks (e.g., you can have a cup of coffee
after you shower). The above example
illustrates a problem of performance, because, Juanita has acquired the
skill, but does not perform the skill. Generalization Once a
skill has been acquired and performed, the next step is to apply the skill in
ordinary life situations. Distinguishing
which skills are useful in a particular setting or situation and then
performing the skill is called generalization.
This, too, is a point at which people with severe mental illnesses may
have difficulty. They may not have
learned to identify and match appropriate skills learned in the rehabilitation
program with real world situations they encounter every day.
Example: In an assertiveness
training group Mary practiced assertion by completing
a homework task of returning a dress to
the store where she purchased it after she
discovered it was missing a button. She
was successful in completing the task and
exchanging the dress for a new one. She was pleased with herself, was praised by
the
group leader, and happy that she had a
new dress with all its buttons. A few
days later,
she was having dinner at a restaurant
and was given the wrong order. Instead
of
returning it, she ate the food she was
given. She did not realize that this
situation was
similar to the dress with the missing
button and that she could use the same skills to get
the food she actually ordered.
Mary has a problem with generalization, because she has acquired
the skill (knows how to do it), has incentive to perform the skill
(feels good about herself, gets what she wants), but was not able to generalize
the skill from the situation of returning a dress at a store to returning an
incorrect food order at a restaurant. Cognition
Finally, cognitive, or thinking, skills
play a part throughout the skill development process. Cognitive skills include
mental activities such as planning, remembering, sorting, problem solving and
making decisions. One must have the
ability to process and sort social information to learn social skills. Because
schizophrenia and other mental illnesses are primarily cognitive illnesses,
people with severe mental illnesses may have cognitive processing problems that
interfere with their ability to acquire, perform, and/or generalize a skill.
The Process
Model can facilitate the selection of appropriate interventions. Different kinds of interventions may have
more or less utility depending on which process best accounts for the problem
behavior. Problems with skill
acquisition are best treated by participation in skills training. Problems with performance may be addressed
with various incentive therapies, motivational enhancement strategies (See
Motivational Enhancement Techniques guideline), or by addressing the barriers
that might interfere with participating in treatment. There are many techniques for increasing
skill generalization, which will be discussed further below. Problems with cognition can often be
remediated through cognitive rehabilitation or medication.
After considering the process model and narrowing the field of potential
interventions there are still many options for addressing the target
behavior. The considerations in
selecting an intervention are similar to those used in considering which target
behavior to select. The clinician should
consider the following questions in selecting an initial intervention: (The
questions are addressed in more detail in the attached behavioral consultation
form in the resources section.) What are
possible options for addressing the individual's problem(s)? For example, could the problem be treated
with individual treatment, residential treatment, or group therapy? Whose behavior should be targeted for
change—the consumer, staff, or others? Are there combinations of
interventions that might address the problem?
How should you prioritize and sequence interventions should a
combination of interventions be determined most appropriate? What are the pros and cons for each
alternative? Is the intervention feasible to implement? Does the intervention exceed limitations of
number of available staff, staff time, or other resources? What is the consumer's preference? What are the consumer’s priorities for
target behaviors and interventions?
Are there potential barriers to the intervention? What
are potential barriers to either the implementation or effectiveness of the
intervention? Consider staff, program,
consumer, and organizational barriers.
Examples of staff barriers are that staff do not agree with the choice
of the intervention; staff lack skills to implement the intervention; staff are
so angry with the consumer that they can't use positive reinforcement. Common program barriers include settings where
no appropriate skills training groups are being offered at the agency; there
are no staff to transport the individual to a treatment locale; there are so
many people in a group that it would be difficult to provide the consumer with
sufficient coaching. Consumer barriers
may include that a consumer has a learning disability; a consumer has failed in
previous attempts to learn a particular skill and is discouraged about being
able to do so now; a consumer does not evaluate a particular behavior as
problematic. Examples of organizational
barriers are that the agency will not allow the use of a selected reinforcer;
professional boundaries make it difficult to provide direct supervision to
milieu staff who need to implement the program; staff shortages make it
difficult to closely monitor and record a frequent behavior.
After an intervention or interventions are
selected the clinician must determine when, where, and who will implement the
intervention. Who will implement each component of the intervention? When does
the intervention occur, under what conditions, in response to which
behaviors? Where will the intervention
occur? Who will implement it, e.g., all
staff, group leaders, or primary therapist?
The clinician must then devise a
monitoring plan. How will implementation
and outcome of the intervention be monitored?
For example, will there be a special sheet for staff to record the
intervention or to graph the behavior?
Will the consumer keep a self-report log? Will the behavior be listed on
a token card? Consideration of these questions
will help the clinician address potential pitfalls before the intervention is
begun, or might lead the clinician to select an alternative intervention.
Behavioral Interventions A variety of behavioral
interventions may be used to influence consumer behavior, e.g., to increase or
decrease the frequency of target behaviors; to increase contact with components
of a larger treatment program; to facilitate the acquisition and generalization
of new skills. The variety and number of
possible interventions is limited only by the creativity of the practitioner.
The general use of reinforcement, punishment, and extinction procedures
has been discussed above. Specific interventions to be addressed in this
section include: token economies, which provide a single reinforcement system
to be used for consumers in an entire program; behavioral contracts which
specify contingencies at the level of the individual; and behavioral
interventions for increasing skill generalization at the level of the
individual or group. Token economies Token economies, or incentive
therapies, are reinforcement systems in which positive reinforcers, in the form
of tokens or points, that participants can exchange for desired objects and/or
privileges, (e.g., use of a video game, access to a telephone) are given for
specified desirable behaviors. Token
economies can provide program-wide contingencies, i.e. a set of rules for an
entire program. Three significant
benefits of a token economy are that it greatly decreases the chaos that tends
to lead to aggression in a program; it increases incentives for adhering to
treatment; and it requires staff to provide opportunities for the desired
behaviors to occur and to attend to them when they occur. Token economies can be set up by following
three simple steps: target behaviors are identified; contingencies are
specified; and exchange rules are determined.
First,
consumers and staff identify the targets of the token economy; i.e. what
specific behaviors the consumers should perform. For outpatient programs, this may include
attending all scheduled activities, being on time, participating in groups, and
completing homework activities. An
important consideration in selecting behavioral targets is to focus on the
do’s (i.e. what consumers and staff want participants to do, such as
attend skills training classes and complete homework assignments) rather than
don’ts (e.g., don’t swear, don’t smoke in the wrong place).
Programs dominated by don’ts have a negative atmosphere and are associated
with increased aggression. Both
program-wide and individual behaviors should be identified for the incentive
program.
Second, staff specify contingencies for
performing each target behavior.
Contingencies are simply “if...then” rules. “If you attend group, then you get 10
tokens.” Each behavior targeted in
the first step is paired with a specific number of points or tokens. The number of points should reflect the
priority of the behavior (more points, greater priority).
Finally, staff (with input from consumers) specify the exchange
rules. These rules tell consumers how
they may exchange their accumulated points or tokens, thus giving the points/tokens
value. The exchange rules include what the consumer receives in exchange for
tokens, such as privileges like telephone or computer time, or commodities like
food or toiletries; when they may exchange points; and who does the point
exchange. For example, consumers may
exchange points for reinforcers at the main office with the lead case manager
every afternoon at 3:00; consumers may exchange 25 points for a stamped
envelope and greeting card, 30 points for a free phone call, etc.
Behavioral Contracting
Behavioral contracting, like a token economy, is an incentive therapy
that provides individual contingencies rather than group contingencies. Behavioral contracts use
“if-then” rules. “If
you do X, then I will do Y.” For
example, “If you show up for group, then I will give you a bus
ticket.” Successful behavioral
contracts specify what will happen if the behavior is not performed. For
example, “If you attend group, then I will drive you to the store. If you do not attend group, you will have to
find your own transportation to the store.” Successful behavioral contracts target
behaviors that are not too difficult for the individual, and provide
reinforcers that are not easily satiated.
For example, a person may get too full if they are always reinforced
with food, but if reinforced with money they probably won’t be satiated,
or feel that they have enough and do not want any more.
When preparing a behavioral contract it is important that the clinician
negotiate the terms of the contract with the consumer. The clinician should bargain with the consumer
if necessary, by suggesting possible deals or compromises, or by making
counterproposals. The clinician should
find out how the consumer feels about the contract, and empathize with him or
her. One of the most important benefits
of contracting, in addition to increasing desired behavior, is teaching
negotiating skills.
Once the terms of the contract are agreed
upon the clinician must make certain that the description of the required
behavior is clear and detailed and that the consumer understands the terms. The
clinician should then establish when and how the consumer will be informed of
his or her progress. Reinforcers should
be delivered so that they follow the desired behavior(s) as quickly as
possible. Where possible, bonus clauses
for exceeding the terms of the contract may be offered.
While new behaviors are being learned in the treatment setting the
clinician should make certain that the consumer has opportunities to practice
behaviors in the community as well. Generalization strategies are essential to
ensuring the transfer of skills training over time and across settings. Generalization
Generalization occurs when a newly learned
behavior is performed in different forms, and in different settings, across
time. Problems in skill generalization
are common in mental health treatment settings.
Consumers often learn to perform skills in a treatment setting then fail
to transfer the newly learned skills and practice them in their home, on the
job, and in the community. For example,
a consumer may learn assertiveness skills and perform them adequately in the
skills training group, but fail to use them in the community. Or a consumer may learn cooking skills, but
fail to cook for himself in his home.
Generalization is promoted through transfer training; i.e. finding and
structuring opportunities to use skills in everyday community experiences. It was once thought that generalization is a
naturally occurring process, and therefore that once a behavior was learned it
would naturally generalize to other settings as well as to a broader set of
skills. However, the Process Model
suggests that generalization is not a naturally occurring process and
that generalization must be planned and implemented just like other parts of
the skills training process. There are
three types of generalization: stimulus generalization, response generalization
and maintenance.
Stimulus generalization occurs when behaviors learned in one setting
generalize to other settings. For
example, a reddish light on a small traffic signal in a cross walk means
‘don’t walk’. This stimulus is generalized when the person
can respond by stopping whether the light is orange or red, and whether it
flashes the words ‘don’t walk’ or a figure of a person
walking.
Someone saying “hello” is a
stimulus for responding with a greeting. In a treatment setting, an example of
stimulus generalization might be a person who has learned to respond
“hello”, when his caseworker says, “hello”. The stimulus is generalized when the person
responds “hello” when a nurse, a peer, or his psychiatrist says
“hello”.
Response generalization occurs when specific behaviors learned in the
rehabilitation program generalize to a broader set of behaviors.
Behavior
Consequence Feel too warm Turn down
thermostat Feel cooler