Current Medical Diagnosis & Treatment in Psychiatry

Applications to Clinical Treatment

The practical utility of the operant apparatus and measurement approach was adopted quickly in ex-perimental psychology, physiology, neurochemistry, pharmacology, and toxicology laboratories throughout the world. The methodology provided the springboard for the field of behavioral pharmacology, the study of subcortical self-stimulation, animal models of addictive behavior, and the study of psychophysics and complex human social behavior in enclosed experimental spaces. Skinner’s pragmatic theory struck a popular chord with many young psychologists, special educators, and practitioners in training. In 1948, Sidney Bijou began an applied research program and experimental nursery school for children with mental retardation at the Rainier School in Washington, applying operant principles. Bijou was joined by Donald Baer, a recent graduate of the University of Chicago, and they conducted seminal research on early child operant behavior. In 1953, Ogden Lindsley and Skinner began applying operant methods to study the behavior of patients with schizophrenia at Metropolitan State Hospital in Waltham, Massachusetts.

Several major events brought the emerging field of behavior modification to the attention of psychiatry. First, Teodoro Ayllon and Nathan Azrin were granted limited funds in 1961 for an experimental program to motivate and improve the functioning of a group of severely mentally ill, mostly schizophrenic, women who were institutionalized in Illinois. The program used a token reinforcement system originally developed by Roger Kelleher, who had studied behavior of chimpanzees in laboratory settings. Tokens resembling poker chips were given to patients immediately after they completed agreed-upon therapeutic activities. Later the tokens could be exchanged for supplementary preferred activities or commodities. The changes in patient behavior were often dramatic and included markedly increased participation in therapeutic programs such as those aimed at employment, bathing, self-care, and related daily living skills.

Leonard Ullman headed a similar treatment unit in Palo Alto, California. Both programs operated on the principle that chronically mentally ill patients, primarily those with schizophrenia, had been largely unresponsive to conventional psychological therapeutic methods. Although older neuroleptic medications managed many of the florid symptoms of schizophrenia, they did little to increase the patients’ positive adjustment and often produced problematic side effects. These programs demonstrated that it was possible to use laboratory-based management methods to motivate patients with chronic schizophrenia, increasing their participation in hospital therapeutic programs and decreasing the amount of disturbed behavior. Although no one claimed these methods changed the underlying disorder, they were very effective tools for improving patient compliance and management.

A less frequently cited but still important study conducted during this era was Gordon Paul and coworkers’ comparison of the effectiveness of a social learning theory approach to a more traditional milieu therapy approach to managing the behavior of patients with chronic mental illnesses in an institutional setting. It is the single best study of its kind, demonstrating persuasively the effectiveness of a behavior therapy strategy for activating socially resistant patients who have schizophrenia. It also carefully documented reductions in schizophrenic disorganization and cognitive distortion; improvements in normal speech and social interactions; reductions in social isolation; and greatly reduced aggressive, assaultive, and other intolerable behavior.

The second major event was the demonstration in 1963 by Ivar Lovaas, a clinical psychologist working at UCLA, that positive reinforcement methods could be used to teach children with autism a variety of skills. Until that time, there were no known effective treatments for autism. Lovaas worked with children who were mute and with echolalic children who had autism (labeled “schizophrenic children” at that time). These children were severely mentally retarded, were self-injurious, displayed severe tantrums, and were extremely noncompliant. Lovaas used a combination of hugs and praise, edible reinforcers, and highly controversial aversive stimulation techniques to reduce self-destructive behavior. His rationale for the use of painful skin shock was that the alternative for some children was a lifetime in restraints to avoid severe self-injury. In some cases, children who, without restraints and without shock, banged their heads over 10,000 times per week, stopped head banging within 24 hours when skin shock was combined with positive reinforcement. In later years, Lovaas largely abandoned the use of aversive treatment methods, although for some researchers in the field, his name continues to be associated with this aspect of his method rather than the fact that he was the first person to develop an effective method for intervening to teach functional social, communicative, and other adaptive skills to autistic children.

The third major event that paved the way for modern behavior therapy methods was the work of Gerald Patterson and colleagues in developing a coercion model of the relationships between children with conduct disorder and their families. In the early and mid-1960s, Patterson began working with children of normal intelligence who displayed a wide array of predelinquent behavior. Some of the children displayed characteristics of attention-deficit/hyperactivity disorder, others seemed to have learning disabilities, and others were aggressive and noncompliant at home and school but exhibited no indications of other psychiatric or cognitive disability. Based on a series of laboratory and clinical studies, Patterson and his colleagues proposed that children who had conduct disorder and their families gradually learn a set of mutually coercive relationships based on interpersonal aversive stimulation and avoidance. Based on this model, he developed a behavioral treatment method drawing on basic operant methods (ie, positive social and tangible reinforcement and loss of reinforcement resulting from behavior problems, both of which were based on unambiguous and consistent contingencies). He combined these techniques with what would later be called cognitive-behavior therapy methods (ie, use of verbal self-instructions to mediate behavior changes).

Finally, in the late 1960s and early 1970s several large-scale programs were developed that applied operant behavioral principles in residential services for people with mental retardation. These early institution-based programs paved the way for subsequent community-based service and treatment programs for people with mental retardation, especially those with significant behavior problems.

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