Behavior Therapy in Psychiatric Practice. The Use of Behavioral Procedures by Psychiatrists

213 Pages·1976·12.216 MB·English

by  Joseph Wolpe and Leo J. Reyna (Eds.)

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BEHAVIOR THERAPY IN PSYCHIATRIC PRACTICE
The Use of Behavioral Procedures by Psychiatrists
Vol. 1 - Selections from
The Journal of
Behavior Therapy and Experimental Psychiatry
(1970-1975)
Editors
Joseph Wolpe, M.D.
Professor of Psychiatry,
Temple University School of Medicine
and Eastern Pennsylvania Psychiatric Institute
Philadelphia, Pennsylvania
and
Leo J. Reyna, Ph. D.
Professor of Psychology,
Boston University
Boston, Massachusetts
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PREFACE
In 1973, The American Psychiatric Association's Task Force on Behavior
Therapy issued its report on "Behavior Therapy in Psychiatry." The Task
Force concluded that:
". . . behavior therapy and behavioral principles employed in the
analysis of clinical phenomena have reached a stage of development
where they now unquestionably have much to offer informed
clinicians in the service of modern clinical and social psychiatry."
In this, the first of a series of volumes on "Behavior Therapy in
Psychiatric Practice," nearly forty articles authored or co-authored by
psychiatrists from 1970 to 1975 in the Journal of Behavior Therapy and
Experimental Psychiatry have been selected. A broader sample of the clinical
problems and procedures dealt with by psychiatrists, psychologists and social
workers are to be found in the full tables of contents of the volumes for
these years (see Appendix), and in the other journals devoted to behavior
therapy — Behavior Research and Therapy, Behavior Therapy and The
Journal of Applied Behavior Analysis.
Subsequent volumes in this series will provide further contributions of
the increasing involvement of psychiatrists in behavioral analysis and
procedures, culled from the total published literature, together with invited
original articles.
In the meantime, this sampler is testimony to the expanding range of
clinical problems for which behavioral methods are being used by the
psychiatric community.
Joseph Wolpe, M.D.
Leo J. Reyna, Ph.D.
ACKNOWLEDGMENTS
The Editors gratefully acknowledge the contributions of the following whose works
appear in this volume:
Abel, G.G. Goldstein, A.J. Pineda, M.R.
Appel, J.B. Gotestam, K.G. Rackensperger, W.
Balson, P.M. Heath, R.G. Rada, R.T.
Barlow, D.H. Lamontagne, Y. Ramirez, E.
Berman, P.A. Levis, D.J. Razani, J.
Bianco, F.J. Liberman, R.P. Rosen, G.M.
Birtles, C.J. MacCulloch, M.J. Roy, A
Boren, J.J. Mann, E.T. Rubin, R.R.
Boisvert, J.M. Melin, G.L. Sanders, N.
Brady, J.P. Mills, G.K. Schnurer, A.T.
Bryntwick, S. Moan, C.E. Scrignar, C.B.
Carr, J.E. Moss, G.R. Serber, M.
Clancy, J. Naud, J. Solyom, L.
Cooper, A. Nelson, P. Thomson, M.J.C.
Denholtz, M.S. Nicassio, F.J. Turner, B.B.
Edwards, N.B. Orenstein, E. Weathers, L.
Feinberg, A.M. Orenstein, H. Williams, C.
Furman, S. Patterson, R.L. Yamagami, T.
Fürst, J.B. Piaget, G.
A CONTINGENCY MANAGEMENT PROGRAM ON A DRUG-FREE
UNIT FOR INTRAVENOUS AMPHETAMINE ADDICTS*t
G. LENNART MELIN and K. GUNNAR GÖTESTAMJ
Psychiatric Research Center, University of Uppsala
Summary—In a contingency management program, high frequency behaviors were used as
reinforcers for low frequency behaviors on a ward for intravenous amphetamine addicts. The
stay on the ward was divided into three phases: detoxification (Phase I); access to some privileges
(Phase II); and all privileges (Phase III). After 5 months the program was changed to a point
system (a kind of token economy), with higher points on lower frequency behaviors, which
made quantification of a rule system possible. It was found possible to change behaviors on
the ward. At the same time patient activity on the ward increased, and there was increased
contact between personnel and patients. Tantrums and discussions about patients' conduct
on the ward decreased. Follow-up data showed significantly better results in the patients in
the program than in other groups.
IN THE SOCIAL system on wards for treatment of ing results. The applications have been to
drug-addicts a question arises as to the degree psychotics (Atthowe and Krasner, 1968; Ayllon
of freedom that drug-addicts should be allowed. and Azrin, 1968), to mental retardates (Birn-
Some believe that freedom (lack of deliberate brauer et al., 1965; Thompson and Grabowski,
control) will lead to insight and rehabilitation, 1972), to prisoners and predelinquents (Carpenter
and others that a high degree of deliberate and Canom, 1968; Tharp and Wetzel, 1969),
control will lead to addicts abstaining from and recently to drug addicts (O'Brien, Raynes
drugs and thence to rehabilitation. A third view and Patch, 1971).
is that some addicts are impossible to rehabilitate Ayllon and Azrin (1968) have set forth rules
and should be isolated from society. for organizing behavior modification on a ward.
Our view is that this problem should not A most important principle of a token economy
be analysed in terms of freedom. Rather the system is that of Premack (1959), that be­
problem of drug-taking behavior can be seen as havior occurring at a low frequency can be
a problem of control, i.e. what in an organism's increased in frequency if its occurrence is fol­
environment controls its behavior (Skinner, lowed by high frequency behavior. Thus, be­
1971). haviors of high natural frequency could be used
The kind of control that is exerted in a tradi­ as reinforcers by allowing patients to engage in
tional ward for drug addicts is generally quite them according to certain prearranged schedules.
sufficient potentially to control people. The main As the present study concerns a semi-open
disadvantage is that the sanctions are almost ward with a rather high turnover for patients
always negative. In recent years many attempts and staff, it would have been difficult to set up a
have been made to apply operant conditioning token economy, since our control over the
procedures in psychiatric wards, with encourag­ patients' behavior would not have been enough
*An abridged version of this paper was read at the International Symposium on Behavior Modification, 4-6 October
1972, Minneapolis.
fThis research was supported in part by Anton & Dorotea Bexelius' Foundation, and the Foundation for Psychiatric
and Neurological Research, The Medical Faculty University of Uppsala.
{Requests for reprints should be addressed to K. G. Götestam, Psychiatric Research Center, University of Uppsala,
Ulleräker Hospital, S-750 17, Uppsala, Sweden.
1
2 LENNART MELIN and K. GUNNAR GÖTESTAM
to make such an economy effective. Thus, we and psychotropic as well as hypnotic drugs was
concentrated on a direct application of Premack's restricted; but during the month before the
principle, contingency management (Homme, program started the patients received an average
1966). We tried to build up behaviors that could of seven pills a day—five during the day, and
be socially useful, the "rule of relevance" two sleeping pills.
(Ayllon and Azrin, 1968). We picked out certain If a patient with privileges took amphetamines
target behaviors for a management program to she went back to detoxification and lost her
increase their frequency. privileges. It was, however, very difficult to keep
these regulations. If the patient confessed to the
staff that she had taken drugs, it was difficult to
PREVIOUS WARD
punish her honesty. Thus many patients kept
MANAGEMENT
some of their privileges even if they had been
The ward had two general functions: (1) To intoxicated.
detoxify female addicts voluntarily or involuntar­ (2) Social criteria. Every detoxified patient was
ily admitted to the hospital, and (2) To run a to take part in the daily activities offered to her;
voluntary drug-free treatment of detoxified occupational therapy, physical therapy, courses,
addicts. Many patients did not want to take part excursions and routine work on the ward. There
in the drug-free treatment program, and were was also a rule to get up and make the bed before
therefore discharged after detoxification. 8.00 a.m.
The ward had 12 beds, one room with three Important to note is that there were no sanc­
beds, two with two beds and five with one bed. tions, positive or negative, linked to the patients'
One single room was reserved for acute cases. activities. Every morning the patients' medical
There was no systematic distribution of beds status and whereabouts were discussed at a ward
to patients other than availability. The ward also conference and sanctions against them were
held a high staff to patient ratio (1:2). decided, but not according to any specific rules.
The more or less explicit rule system was
described in the following way:
METHOD
(1) Medical criteria. The patients had two
kinds of medical status; intoxicated or detoxified. The study started 31 August 1971 and ended
The criterion was established by a daily chemical 23 April 1972. The initial program (Program I)
analysis of patient's urine. If traces of ampheta­ was modified on 31 January 1972 (Program II).
mine or morphine were found in the urine they
were considered intoxicated and if not, detoxified. Subjects
The decision had very profound social con­ Sixteen female patients out of 61 admitted
sequences. These consequences were, however, during that period took part in the study, all of
delayed to the day after the intoxication, when them intravenous amphetamine addicts. The
the result of the analysis was present. Before criterion for inclusion in the study was that the
urinating the patients were body-checked. As patient had to spend at least 1 day in the re­
this control was not entirely fool-proof, some habilitation phase. Some of the patients also
traceable inert substance was sometimes given had other problems of a neurotic character
to patients. (psychotic patients were excluded).
Intoxicated patients were not allowed any The 16 patients were 16-44 yr of age (median
privileges like leave, outdoor walks with staff, 25-0) and had a history of intravenous ampheta­
or visitors, but once no drugs were found in the mine abuse of 6 months to 13 yr (median 3 yr).
urine they were immediately entitled to outdoor The injected 50-200 mg intravenously 3-5
walks with personnel, and after a week also to times daily. They had been on the ward for
the other privileges. The prescription of sedatives 12-52 days (median 24Ό, mean 27;7).
MANAGEMENT OF AMPHETAMINE ADDICTS 3
For comparison we took a similar 8-month to some extent tied to high frequency behaviors.
period preceding the program (1 January-30 High and low frequency behaviors were identified
August 1971), including all 48 admitted female from time sampled observations made (by the
drug addicts, of whom 32 stayed 12 days or personnel) of patient activities (Schaeffer and
more—12-101 days (median 25Ό, mean 33*5). Martin, 1969, p. 71), and from patient ratings
of activities preferred (Table la).
Preliminaries (3) Rehabilitation Phase (III). When the patient
1. There was a 14-day training program for seemed to get on well in the treatment phase for
personnel. Basic learning principles were ex­ about a week she was moved to the rehabilita­
plained and Schaeffer and Martin's book tion phase (18 cases). Otherwise she had to stay
Behavioral Therapy (1969) was studied. A few in that phase. The decision about the transfer
minor applications of the principles were demon­ from Phase II to Phase III was made at a second
strated. treatment conference at which the patient was
2. Base rates were collected for (a) getting up present. Phase HI contained more high frequency
before 8.00 a.m., (b) doses of prescribed drugs behaviors (reinforcers) than the treatment phase.
(day and night drugs), (c) number of times per The low frequency behaviors on the ward could
week the doctor got home calls from the ward, also be exchanged for work off the ward (Table
and (d) time spent in private room during the lb). In this phase we also worked with the patient
day (8.00 a.m.-4.30 p.m.). to find a way back into society. If the patient did
3. Instructions and discussions about the not get on well in this phase, she was moved back
program. It was stressed that the program should to the treatment phase (2 cases), and if she
be looked upon as a training process. relapsed to taking drugs she was moved back to
the detoxification phase (3 cases).
Procedure After about 4 months, all personnel met to
The new program was designed to have three discuss the program. Those who had worked on
phases: (1) detoxification, (2) treatment and the ward before the program were convinced
(3) rehabilitation. These three phases were car­ that they noticed improvements like better con­
ried out in different locations. A room with three tact with patients, fewer tantrums and more
beds was used for detoxification. Two rooms activity.
with two beds each were used for the treatment The biggest disadvantage was the distribution
phase, and single rooms for the rehabilitation of sanctions for not getting along well in the
phase. The patients could decorate private rooms program. Moving a patient back to a lower phase
but the detoxification room was to be considered always led to conflicts between the patients and
a sickroom and looked very bare. The two treat­ the personnel.
ment rooms were "in-between". Because of this disadvantage a quantification
(1) Detoxification Phase (I). Every patient of activities was worked out, i.e. a point system.
entered this phase on admission, and remained That was done by putting weights (points) on
in there as long as drugs were found in her urine. low frequency behaviors according to a principle
She was considered ill and was not allowed to —the lower the frequency of a specific behavior
take part in any ward activities. When drug-free the higher the weight (Table 2).
she was invited to a treatment conference where The new modified program (Program II) was
she was informed about the program. Forty-five thus quite similar to a token economy program
admitted patients were not interested in the pro­ (Ayllon and Azrin, 1968). There were, however,
gram. some differences: The scores were kept by the
(2) Treatment Phase (II). In this phase the patient's contact man but the scoring was done
patient was allowed to take sleeping pills only in with the patient. The scores could not be used
exceptional cases. Low frequency behaviors were for access to specific privileges. Instead the
4 LENNART MELIN and K. GUNNAR GÖTESTAM
TABLE 1. RELATIONS BETWEEN HIGH FREQUENCY BEHAVIORS AND LOW FREQUENCY BEHAVIORS IN THE TREATMENT AND
REHABILITATION PHASES
(a) Treatment phase
Low frequency behaviors High frequency behaviors (Reinf.)
1. Up in the morning 8 a.m. (dressing, making 1. Staying in room with two beds
bed, cleaning up).
2. Attending morning conference
3. Routine work on ward (with contact man) 2. Leaving ward for walks with personnel
(Scouring, sweeping, dusting)
4. Physical therapy
(b) Rehabilitation phase
Low frequency behaviors High frequency behaviors
1. Up in the morning 8 a.m. 1. Staying in private room
(dressing, making bed, cleaning room)
2. Leaving ward for a few hours without
2. Attending morning conference personnel
3. Routine work on ward (with contact man) 3. Leave for a whole day or more
(Scouring, sweeping, dusting)
4. Taking visitors in own room during the
4. Physical therapy afternoon
5. Activity 2-4 could be exchanged for off ward
activities i.e. work in hospital area or in town
TABLE 2. ACTIVITY SCHEDULE. FIVE POINTS NEEDED FOR MOVING FROM DETOXIFICATION
PHASE (I), 25 POINTS FOR MOVING FROM TREATMENT PHASE (II), AND 25 POINTS A WEEK FOR
STAYING IN REHABILITATION PHASE (III)
Times Maximum
Phase Activity Points per week per week
I -f- II -f III Dressed before 8 a.m. 6
Made bed and room 9 a.m. 12
II + III Work at ward 1 6 6
Working therapy 2 3 6
Gymnastics 3 2 6
Bath excursion 2 2 4
Cooking course 1 1 1
Wednesday conference 1 1 1
Searching for work 4 1 4
III Job outside hospital 25
patient had to meet certain requirements to get treatment phase and 25 per week to remain in
the privileges in the phase. She had to collect the rehabilitation phase.
five points to get out of the detoxification phase, With this modification of the program two
and of course be detoxified, 25 to get out of the advantages were gained: (1) a quantification of
MANAGEMENT OF AMPHETAMINE ADDICTS 5
the rules on the ward and (2) an increased TABLE 3. PERCENTAGE OF THE PATIENTS ON THE WARD,
GETTING UP AND DRESSING BEFORE 8.00 A.M. BASERATES
flexibility for the patient. She could now choose
ARE SHOWN FOR THE MONTH BEFORE THE PREPARATION OF
activities more freely and even take a day off in
THE PROGRAM. PROGRAM I WENT FROM WEEK 1 TO 21,
the rehabilitation phase when she had collected AND PROGRAM II FROM WEEK 22 TO 33. A KRUSKAL-
enough points for the week. WALLIS ANALYSIS OF THE DIFFERENCE BETWEEN THE THREE
PERIODS (INCLUDING ALL PHASES) SHOWS A SIGNIFICANCE
ON THE 0001 LEVEL. (H = 269, df = 2)
RESULTS
To avoid placebo effects, all baselines were Baserate Program I Program II
collected during the month before the program,
during which time there was no systematic regis­ Detoxification
tration of baserate for behaviors. But as these phase 21 26 40
Treatment phase 60 62 89
were considered important they could quite
Rehabilitation
satisfactorily be acquired from the 'day reports' phase 60 71 91
on every patient.
An interrater reliability check was made
during the program. During the 2 weeks tested hypnotics and neuroleptic drugs. No narcotics
the percentage of accord for getting up in the or central stimulants were prescribed on the
morning was 97, which was considered satis­ ward. The baserates for night and day drugs
factory. were then compared with rates collected during
(a) Getting up, and dressing in the morning the first 7 weeks of program I. This comparison
before 8.00 a.m. The relation was calculated shows a decrease for both day and night medi­
between the presence of these behaviors and cine. The decrease is significant at the 0-05 level
number of days spent on ward. These behaviors for both the day drugs (/ = 12-8; df=6) and
were not common and considered by the per­ the night drugs (7 = 2-14; #* = 6).
sonnel to be a sign of rehabilitation. At the (d) Times per week the doctor" received home
beginning of the program these behaviors were calls from the ward. Baserate and rate in Program
systematically collected for all patients in all I were collected for the last 2 weeks of the
phases. As can be seen in Table 3, there is a preceding month. This is personnel behavior
systematic increase in these behaviors during that was dependent on patient behavior. The
the program compared to the baserates. This personnel were instructed to call the doctor when
increase was found for all three phases. A problems arose on the ward at night and to
Kruskal-Wallis analysis (Siegel, 1956) of the discourage him from prescribing barbiturate
difference between the three periods shows a and other drugs. During the baserate period
significance at the 0-05 level (H = 2&-9;df= 2). the doctor was called 12 times (6 times per week),
(b) Time spent in private room during daytime more than half the calls dealing with prescription
(8.00 Ö.W.-4.30 p.m.). It was not possible to of night drugs. During the next 7 weeks he
collect a baserate for this behavior from day was called three times (0-4 times/week), none of
reports, so our data contain only a comparison which calls dealt with prescription of drugs.
between the two programs. Other than that
patients in the detoxification phase spent con­
siderably more time in their rooms, there was FOLLOW-UP
no difference between the two programs in all A follow-up study is continuously performed
the three phases (χ2 = 0-05, P > 0-05). at the clinic, by personnel not involved in the
(c) Doses of prescribedpsychotropic drugs (day treatment of the patients. The patients are investi­
and night drugs). Baserates, collected during the gated after J, 3, 6, and 12 months and yearly,
last 2 weeks of the preceding month, are of dose thereafter. They are asked about drug status,
per patient in 24 hr. The drugs were sedatives, family relations, and work or school perfor-