Progress in Behavioral Social Work

Bruce A. Thyer, Walter W. Hudson, Bruce A. Thyer, Walter W. Hudson

• Publisher: Taylor & Francis
• Year: 2018
• eBook ISBN: 9780429830600
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Originally published in 1987, here are up-to-the-minute insights and perspectives on the application of the principles of behavioralism to social work practice. The foremost authorities in the field of behavioral social work provided important empirically based practice and qualitative research findings that effectively illustrated the validity of behavioral approaches to social work. This practical volume features original research findings that employ either conventional group research methods or single-subject approaches to practice evaluation; comprehensive reviews of the state of the art in behavioral social work; and treatment modalities, including individual, marital and family, and group interventions. All in all, this title has the information professionals needed to keep abreast of the developments in this field at the time.

Behavioral Treatment of Chronic Psychiatric Patients

Stephen E. Wong
James E. Woolsey
Estrella Gallegos

SUMMARY. Behavioral treatments for hallucinations and delusions, aggressive and destructive responses, inappropriate social behavior, poor self-care and grooming, and deficient recreational and vocational skills in chronic psychiatric patients are reviewed. Consideration is given to the short-term, long-term, and generalized effects of these interventions. Three case studies illustrate behavioral procedures of consumable reinforcement, response cost, graphic feedback, differential reinforcement of other behavior (DRO), and overcorrection. The potential contribution of clinical social workers in applying such programs on a psychiatric unit is discussed.

This article reviews learning-based treatments for functional disorders manifested by chronic psychiatric patients. The population presents a formidable challenge for clinical social workers with a bewildering array of problem behaviors that are unaffected by conventional therapies. The efficacy of behavioral interventions for ameliorating these disorders has been well documented (Liberman, Wallace, Teigen & Davis, 1974; Paul & Lentz, 1977: Wong, Massel, Mosk & Liberman, 1986); however, adoption of behavioral treatments in mental hospitals has not kept pace with research advances. This probably has been due to the medical establishment’s providence over these facilities (Hersen & Bellack, 1978), and an unawareness of what the behavioral approach has to offer in the management of psychiatric disorders (Brady, 1973).

A sizable proportion of social workers — more than one-fifth of the National Association of Social Workers (Morris, 1974) — are employed in psychiatric settings. Although the behavioral social work literature is steadily expanding (Thyer, 1985), little has been written about psychiatric social work from a behavioral perspective. Existing articles have briefly described ward programs (Aveni, 1974; Stone & Nelson, 1979) or family-centered interventions with less severely disturbed clients (Hudson, 1975, 1976, 1978). More comprehensive review of treatments suitable for chronic, institutionalized mental patients is lacking. Given the profession’s involvement in this field and the complex and refractory nature of psychiatric disorders, there is a need to become better acquainted with the full range of available behavioral techniques. This paper will examine learning-based interventions for a variety of dysfunctions in chronic psychiatric patients, and consider how social workers may aid in their implementation.

We will cover behavioral interventions to decrease hallucinatory and delusional speech, assaultive and destructive behavior, and bizarre stereotypies, as well as treatments to increase social skills, self-care and grooming, recreational activity, and vocational behavior. Case studies will exemplify some of the above therapeutic procedures. These case studies are drawn from the first author’s work at the Behavioral Rehabilitation Unit of the Las Vegas Medical Center, Las Vegas, New Mexico, and the Clinical Research Unit of the Camarillo State Hospital, Ca-marillo, California. Both state facilities are locked psychiatric units designated for the treatment and management of chronic mental patients. A section preceding the conclusion will discuss generalization of therapy effects across settings and time.

HALLUCINATIONS AND DELUSIONS

Hallucinatory behaviors are verbal self-reports of idiosyncratic sensory experiences (e.g., complaints about hearing voices), or vocal or motor responses indicating that the subject perceives something that doesn't exist (e.g., talking or gesturing into the empty air). Delusional behaviors are erroneous verbalizations or related actions (e.g., a patient claiming that he is Jesus Christ or that he is being persecuted) which persist in the face of overwhelming contradictory evidence. Hallucinatory and delusional behavior are considered to be principal symptoms of schizophrenia (American Psychiatric Association, 1980) and are often amenable to treatment by chemotherapy (Andreasen & Olsen, 1982; Davis & Gierl, 1984). Alternately, when viewed as maladaptive responses, these behaviors may also be treated by modifying the client’s environment.

Reinforcement of Incompatible Behavior

Psychotic speech has been modified in chronic mental patients by prompting and reinforcing desirable verbal behavior. In one study positive reinforcement consisted only of therapist attention which was given or withdrawn depending on whether or not the patient’s speech was appropriate (Moss & Liberman, 1975). In most of the research using this approach, however, social reinforcement for appropriate speech has been combined with some form of tangible reinforcement. Staff or therapist attention has been joined with contingent cigarettes (Ayllon & Haughton, 1964), coffee and snacks (Liberman, Teigen, Patterson & Baker, 1973), access to a preferred work activity (Anderson & Alpert, 1974), and token reinforcement (Patterson & Teigen, 1973; Wincze, Leitenberg & Agras, 1972) in programs correcting bizarre or inaccurate speech. A comparison of social versus token reinforcement has shown the latter to be more potent in reducing psychotic verbalizations (Meichenbaum, 1969). While tangible reinforcement has proven to be an effective procedure for changing psychotic verbal behavior, there are limitations to this approach. Certain patients do not consume and are unmotivated by the usual tangible reinforcers (cigarettes, coffee, snacks, etc.) and will not alter their speech to earn these rewards.

To illustrate a successful application of this technique, we now present a case study in which a patient’s delusional speech was treated using reinforcement procedures. This client’s verbalizations interfered with her placement planning, therefore, it was fitting that therapy be conducted by the unit social worker.

Case Study 1: Tammy K. Tammy was a 24-year old woman with a diagnosis of schizophrenia, paranoid type. Prior to her present commitment to the Las Vegas Medical Center, she had been hospitalized four times for mental breakdowns. Conduct in the community leading to rehospitalization included promiscuity, staying in bed all day, neglecting self-care and eating, and periodic aggression. With the exception of promiscuity, which was prevented by staff supervision, these problems continued in the hospital setting. Another of Tammy’s difficulties involved her claims that she did not belong in the hospital. Tammy would say that her admitting psychiatrist had promised that she would be hospitalized for only two weeks. Tammy would repeat this claim and demand to be released, even after being told that she had been legally committed for 6 months and that her admitting psychiatrist was no longer responsible for her care.

Behavioral treatment of delusional speech consisted of consumable reinforcement for accurate speech combined with response cost for inaccurate speech. Therapy sessions, each 10-15 minutes long, were conducted in the social worker’s office adjacent to the ward. Sessions were structured around a series of questions about the patient’s condition, her progress in the unit program, unit rules, and criteria for discharge from the hospital. In baseline, the social worker gave the patient negative feedback for delusional statements (e.g., “No, that’s wrong Tammy. You will not go home in two weeks.") and positive feedback For accurate statements (e.g., “Yes, that’s right. You must stay out of bed"). In the treatment phase, Tammy received the above feedback plus she earned one cigarette for every five accurate statements made - up to a maximum of two cigarettes per session. After being warned about her first delusional statement, she also lost one cigarette for every delusional statement emitted. Two weeks into training, the warning preceding cigarette loss was no longer given.

Results of this program are displayed in Figure 1. The upper graph depicts the number of delusional statements per session and the lower graph the number of accurate statements per session. During baseline, the number of delusional statements was highly variable and averaged 4.2; in the same period, a more consistent level of accurate statements was observed averaging 6.3. With the introduction of reinforcement and response cost procedures, the number of delusional statements gradually declined until by the 18th treatment session it fell to zero, where it stayed for all but one of the remaining sessions of the study. Concomitant changes were obtained in accurate speech, whose average level rose to 10.7 statements per session.

Figure 1. Data from Case Study 1. Upper graph shows the number of delusional statements and the lower graph the number of accurate statements emitted per session in baseline and treatment conditions.

The cessation of delusional statements permitted the social worker and other professional staff to discuss Tammy’s current ward behavior and placement plans with her in a rational manner. This was an important step in modifying Tammy’s behavior pattern by presenting a set of rules and by making her responsible for adhering to those rules. Staying in bed and poor grooming continued to be problems on the ward, and these were subsequently modified with an individual behavioral contract and an occupational therapy assignment. After a month of compliance with her behavioral contract and satisfactory performance on her job assignment, Tammy was discharged to live with a sister residing out-of-state.

Stimulus Interference

Besides being controlled by consequent stimuli, hallucinatory and delusional behavior can be affected by antecedent and concurrent environmental stimuli. Several studies have demonstrated that self-reported hallucinations (Anderson & Alpert, 1974; Alford & Turner, 1976; Turner, Hersen & Bellack, 1977; Alford, Fleece & Rothblum, 1982) and overt motor behavior indicative of hallucinations (Alford et al., 1982) can be nearly eliminated by engaging subjects in conversation unrelated to their delusional beliefs. One experiment has shown that non-social stimuli in the form of a ringing bell suppressed hallucinatory self-talk in a schizophrenic patient (Turner et al., 1977). Two uncontrolled case reports also suggested that listening to the radio (Feder, 1982) and watching television (Magen, 1983) could have similar therapeutic effects in interrupting hallucinatory behavior. Related research has demonstrated that involvement in independent recreational activities can supplant self-talk and per-severative motoric behaviors in long-term institutionalized patients (Wong et al., 1984).

Punishment

Consequent stimuli that lower the probability of behavior can be programmed to weaken psychotic speech. In an early case study using punishment, a schizophrenic man was taught to self-administer a mild electric shock whenever he heard hallucinatory voices (Bucher & Fabricatore, 1970). Faradic shock has also been applied in two single-subject experiments during therapy sessions whenever patients reported auditory hallucinations (Al-ford & Turner, 1976; Turner et ah, 1977). Observational data from one of the above experiments showed response suppression generalized to the ward environment, while anecdotal data from both investigations showed that auditory hallucinations remained at low levels on 6-month and 1-year follow-up assessments.

Timeout from reinforcement, in the form of confinement within a locked and barren room, has also been applied as an aversive consequence to decrease non-directed vocalizations occurring on the hospital ward. Self-talk and mumbling in a middle-aged chronic schizophrenic woman were reduced by one-half through the use of contingent locked timeout lasting 10 minutes (Haynes & Geddy, 1973). Hallucinatory and delusional verbalizations in another female schizophrenic were similarly suppressed when they were consequated with 15 minutes of locked timeout (Davis, Wallace, Liberman & Finch, 1976).

AGGRESSIVE AND DESTRUCTIVE BEHAVIOR

Most state civil commitment laws dictate that persons who are involuntarily confined in mental hospitals present a danger to themselves, or others, or be gravely disabled (American Bar Association, 1979). Because of these legal criteria, the most violent and low-functioning mentally disturbed persons are concentrated in the closed public institutions. Not surprisingly, aggressive and destructive acts are a frequent occurrence in these settings and pose a major clinical and administrative problem (Wong, Slama & Liberman, 1985). Viewing aggressive and destructive acts as behavioral excesses, learning-oriented treatments have attempted to reinforce alternate appropriate behavior as well as to directly weaken antagonistic responding.

Reinforcement of Incompatible Behavior

Aggressive and destructive behavior can be associated with inadequate social skills for satisfying one’s needs or for resolving interpersonal conflicts. Social skills training is an attractive method for treating antagonistic behavior, because it employs only positive procedures and involves no aversive stimuli. Despite these advantages, it rarely has been utilized with chronic psychiatric patients. In an early application of this technique, a highly aggressive, brain-damaged patient was successfully treated with contingency contracts and assertiveness training (Wallace, Teigen, Liberman & Baker, 1973). Assertiveness training consisted of instructions and roleplaying in how to deal with frustrating institutional situations. Introduction of the treatment package was associated with a near cessation of aggressive incidents on the ward; but, since this was an uncontrolled case study, results could not be directly attributed to training. A controlled multiple-baseline experiment teaching social skills to two aggressive male inpatients better demonstrated the potential impact of this technique (Frederiksen, Jenkins, Foy & Eisler, 1976). Training increased appropriate requesting behaviors and decreased hostile behaviors in role-played situations, and also improved performance in contrived on-ward interactions used to assess generalization.

Punishment

Punishment of mental patient’s aggressive and destructive behavior has generally been limited to the withdrawal of positive reinforcers or the application of mild aversive stimuli. While any sort of punishment of mental patients is entangled in legal and ethical controversy (Wexler, 1984), the empirical support for employing punishm...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Progress in Behavioral Social Work: An Introduction
• Behavioral Treatment of Chronic Psychiatric Patients
• Research in Behavioral Parent Training in Social Work: A Review
• Behavioral Social Work with Obsessive-Compulsive Disorder
• Life Skills Counseling for Preventing Problems in Adolescence
• Treatment Compliance in Social Work
• Clinical Research in Sexual Dysfunctions: Social Work Contributions
• Evaluating a Social Learning Approach to Teaching Adolescents About Alcohol and Driving; A Multiple Variable Evaluation
• Unilateral Family Therapy with the Spouses of Alcoholics
• The Empirical Evaluation of Clinical Practice: A Survey of Four Groups of Practitioners
• Medical Social Work Management of Urinary Incontinence in the Elderly: A Behavioral Approach