Some experiments on reinforcement principles within a psychiatric ward for delinquent soldiers

Several experiments exploring the effects of certain behavioral procedures were performed on a psychiatric ward for delinquent soldiers. Within the context of a point economy, the behavioral procedures were examined for their applicability to this patient group in a hospital-ward setting. The following procedures were studied: (1) use of points as consequences for specific behaviors compared with demonstration of "model" behavior by a ward officer; (2) punishment by a point-fine to control undesired behavior; (3) use of a chaining-type reinforcement contingency to increase desired behavior; (4) differential reinforcement of the individual versus the group to increase the frequency of a verbal performance; and (5) reinforcement of reports of personal problems versus impersonal problems.     

A token reinforcement system for large wards of institutionalized adolescents

Problems associated with the application of token systems to large public institutions for male and female adolescents are discussed. The present experiments demonstrate that two specific behavior problems on an adolescent ward of a state hospital could be controlled through the use of contingent points via a rapid-delivery token procedure and backed up by reinforcers already available in the hospital setting. Sixty male and female patients were maintained by a staff of five aides. Experiment I examined the effects of verbal demands and contingent points on room maintenance behavior. Experiment II examined the effects of verbal demands and contingent points on ward maintenance behavior. Contingent points produced substantial effects on both types of behavior. Several design criteria are elaborated which facilitate working within the limitations of a setting with low priorities on research.     

Modification of severe disruptive and aggressive behavior using brief timeout and reinforcement procedures

Brief timeout for disruptive and aggressive behaviors and reinforcement for appropriate behaviors were used with two retarded patients in a state hospital ward setting. The procedures reduced loud vocal behavior in one patient and aggressive behavior in another to near-zero levels when first applied. The behaviors returned to previous levels when the procedures were removed and were again greatly reduced when timeout and reinforcement were reapplied. The results were significant because the behavior problems were severe and long-standing and the procedures were instituted without greatly disturbing normal ward routine.     

MMPI correlates of performance on a behavior therapy ward.

In a behavioral treatment program for acute psychiatric patients, points were earned for adaptive behavior (e.g. self-care, attending ward activities) and lost for maladaptive behavior (e.g. assaults, verbal abuse). Points earned could be spent for a variety of goods and services (e.g. passes, extra staff time). Statistically significant correlations were found between MMPI scale scores and point-earning behavior. High scores on the F, 5, 6 and 8 scales were associated with low point gain for adaptive behavior, high point loss for maladaptive behavior, a high proportion of points spent to points earned, and a low overall net point earnings. Low score on F scale in combination with high score on 2 scale best predicted point-gain behavior, whereas high score on 8 scale in combination with low score on 1 scale best predicted point-loss behavior. Overall net points were best predicted by low score on F scale in combination with high scores on 0 and 9 scales. When subjects were grouped into common psychiatric profile types, differences were found in point-gain behaviors for items related to personal care and attending ward activities. At least some of these differences could be attributed to two factors: high scores on the 2, 3 and 7 scales were associated with higher than average point earnings, while high scores on the 8 scale were associated with lower than average point earnings.     

Control of the behavior of schizophrenic patients by food

Operant-conditioning principles using food as a reinforcer were applied to control the behavior of 45 chronic schizophrenic patients. The investigation was conducted in a psychiatric ward in which there was 24-hr environmental control.

In order to use food as a reinforcer for controlling psychotic behavior, it was necessary first to deal with the eating deficits in the patients. Approximately 50% of the ward population was selected because of a history of refusal to eat. Their refusal to eat had remained relatively unaffected by one or more of these treatments: spoonfeeding, tubefeeding, intravaneous feeding, and electroshock. These treatments were discontinued, and the patients were left alone at mealtimes. The results show that social reinforcement in such forms as coaxing, persuading, and feeding the patient tend to shape patients into eating problems so they are conditioned to eat only with assistance. When refusal to eat was no longer followed by social reinforcement, the patients soon started eating unassisted. When access to the dining room was made dependent upon a chain of responses including a motor and social component, all patients learned these responses.

     

Reducing delusional speech in chronic, paranoid schizophrenics

Four schizophrenic patients with paranoid and grandiose delusions who had been hospitalized for an average of 17 yr were exposed to social reinforcement contingencies in a multiple baseline design. During the baseline period, each patient was interviewed for four 10-min sessions each day. The elapsed time from onset of conversation to onset of delusional talk was recorded. At the end of each day, the patients engaged in a 30-min informal chat with a nurse-therapist while relaxing with coffee, snacks, and cigarettes. The intervention introduced two contingencies: (1) The 10-min interviews were terminated as soon as the patient began talking delusionally; (2) The patients earned time for their evening chat by talking rationally during their daytime interviews. Increases of from 200 to 600% in the amount of rational talk exhibited during the interviews occurred as the contingencies were introduced for each patient sequentially over time. These increases were maintained in three patients when the amount of reinforcement was halved, but declined when the patients were confronted directly with their delusional ideas. A modest amount of generalization occurred from the day-time interviews to the evening chats but did not extend to the behavior of the patients on the ward.     

Situational determinants of inpatient self-harm

Auto-aggressive individuals have a higher likelihood of engaging in interpersonal violence, and vice versa. It is unclear, however, whether ward circumstances are involved in determining whether aggression-prone patients will engage in auto-aggressive or outwardly directed aggressive behavior. The current study focuses on the situational antecedents of self-harming behavior and outwardly directed aggression of psychiatric inpatients. Inwardly and outwardly aggressive behavior were monitored on a locked 20-bed psychiatric admissions ward for 3.5 years with the Staff Observation Aggression Scale-Revised (SOAS-R). A map of the ward was attached to each SOAS-R form, enabling staff members to specify locations of aggressive incidents. Time of onset, location, and provoking factors of auto-aggressive incidents were compared to those connected to aggression against others or objects. Of a total of 774 aggressive incidents, 154 (20%) concerned auto-aggressive behavior. Auto-aggression was significantly more prevalent during the evening (i.e., 50% compared to 32%), and reached its highest level between 8 and 9 P.M. (17% compared to 7%). The majority of self-harming acts (66%) were performed on patients' bedrooms. Outwardly directed aggression was particularly common in the day-rooms (24%), the staff office (19%), the hallways of the ward (14%), and the dining rooms (10%). Provoking factors of auto-aggressive behavior are less often of an interactional nature compared to outwardly directed aggression. The results suggest that a lack of stimulation and interaction with others increases the risk of self-injurious behavior. Practical and testable measures to prevent self-harm are proposed.     

MULTIPLE-BASELINE ANALYSIS OF A TOKEN ECONOMY FOR PSYCHIATRIC INPATIENTS

Twelve behaviors selected for reinforcement among 16 chronic psychiatric inpatients were divided into four classes: (a) personal hygiene, (b) personal management, (c) ward work, and (d) social skills. A token economy program was introduced for each class in a sequential, cumulative, multiple-baseline format. Corrections were included for methodological deficiencies frequently encountered in past studies. Treatment variables were systematically monitored, and target behavior rates, levels of global individual functioning, general ward behavior, and off-ward behavior were assessed during baseline, implementation, and probe periods. Results indicated abrupt and substantial increases in performance of most target behaviors, significant improvements in global individual functioning (p < .025), positive changes in general ward behavior, and increases in social interaction during off-ward activities. The findings provide strong evidence for the efficacy of a token economy and indicate that the multiple-baseline design can be a useful method for evaluating token economy programs.     

Influence of Deteriorating Ability of Emotional Comprehension on Interpersonal Behavior in Alzheimer-Type Dementia

This study investigated the relationship between the ability to recognize emotion and interpersonal behavior in dementia of the Alzheimer type (DAT). After examining the validity and reliability of the Emotion Recognition Test (ERT), an improved version of the tasks used by Shimokawa et al. (2000), 100 patients with DAT underwent evaluation for general cognition using the Mini-Mental State Examination (MMSE) and emotion recognition using the ERT. Within a week of these tests being administered, ward staff rated the patients using the Interpersonal Behavior Checklist (IBC), composed of two behavior scales: indifference to interpersonal relationships and difficulties with patient treatment/management. After investigating the validity and reliability of the scales, the correlations between the MMSE, the ERT, and the two scales of the IBC were calculated. The results suggested that the MMSE did not correlate with either of the two behavior scales, while the ERT correlated significantly with both of the scales. The study results lead to the conclusion that deteriorating emotion recognition ability, rather than deterioration of general cognition, influences the indifferent and awkward interpersonal behaviors of DAT patients.     

A virtual psychiatric ward for orientating patients admitted for the first time

Misconceptions about psychiatric wards frequently cause newly admitted mental patients to stay away from these wards despite their need for treatment. Although ward orientation is typically conducted by nurses in an attempt to help patients to adapt to the new environment, it is considered time-consuming, and the method of orientation and the explanations given may vary among different nurses. This situation calls for a more effective and standardized approach to orientating mental patients on their first admission. To this end, a computer-based interactive virtual environment was developed based on a real psychiatric ward by using virtual reality (VR) technologies. It enables the patient to navigate around to gain understanding about the ward through a virtual guided tour. The effectiveness of this VR orientation approach was investigated by a randomized controlled trial with consecutive sampling. Fifty-four Chinese participants were randomly assigned to undergo ward orientation by either using the VR-based approach or reading text-based electronic information sheets about the ward with a computer. Subjective and objective measures were obtained respectively using the Chinese version of the State-Trait Anxiety Inventory questionnaire and the heart-rate variability measurement before and after the intervention. In addition, a test on the level of understanding about the ward was administered at the end of the session. The results showed that the VR orientation approach is helpful in reducing patients' anxiety while also improving their level of understanding about the ward.     

THE EFFECTS OF REARRANGING WARD ROUTINES ON COMMUNICATION AND EATING BEHAVIORS OF PSYCHOGERIATRIC PATIENTS

Several aspects of ward routine were changed to study the effects of environmental manipulation on the behavior of 21 psychogeriatric patients. Furniture was rearranged to be more conducive to conversation (i.e., grouped around tables instead of along corridor walls), and mealtime routines were changed to allow patients more time to eat, more freedom in choosing the composition of the meal, and more pleasant surroundings. Patients were divided into experimental and control groups, and data were collected on the frequency of verbal and tactile communication and degree of skill in eating behavior. Following baseline, environmental changes were introduced across behaviors. Results show that the frequency of communication increased for the experimental group, as compared to both baseline and the control group. Eating behavior also improved significantly for the experimental group. The study shows that minor changes in the physical environment can promote therapeutic change in the behavior of patients diagnosed as senile dementia.     

Selbsthilfegruppen im Rahmen stationärer psychotherapeutischer Behandlungen

Psychosomatic in-patient treatment applies a combination of various methods in order to facilitate learning by insight and corrective emotional experiences in a therapeutic community. The establishment of a self-help group on the ward can be a useful complementary element in such a comprehensive approach. However, empirical research on this specific topic does not yet exist. Based on clinical experience, necessary preconditions as well as the pros and cons of integrating self-help into professional treatment are described. The assessment of 850 patients in a clinic for psychosomatic medicine and psychotherapy concerning a self-help group on the ward are presented. Relationships between patients’ evaluation of the self-help group and various other variables as well as the overall treatment effect were studied. Empirical data provide evidence of a differential effect of the self-help group on the ward: the majority of the patients experienced the self-help group as useful. Whether the patient is able to benefit from group therapy seems to be an intermediate variable and the therapists’ attitude towards self-help groups also seems to play an important role.     

Token economy: patient and staff changes

A token economy program conducted with severely regressed, “backward” state hospital patients is described. An evaluation of the effects of the reinforcement program after one year has revealed substantial gains in patient eating, grooming, and dressing behavior and involvement in activities on and off the ward. In addition, several measures of staff attitudes toward patients evidence meaningful gains in staff expectations about the treatability of patients and the degree of the latters' psychological deficit.     

Mixing qualitative methods versus methodologies: A critical reflection on communication and power in inpatient care

This paper offers an illustrative example to demonstrate one way of combining qualitative methods. The context for the study was a UK inpatient psychiatric hospital. Data set one was collected from weekly ward rounds where inpatient staff met with autistic patients to review medication, listen to patient concerns and make plans or adjustments in light of this. Data set two was reflective discursive interviews with patients and staff. The research objective was to critically consider the potential reasons for discrepancies in dissatisfaction reports from patients in the interviews, compared to relative compliance exhibited by patients in the ward rounds. Utilising a video‐reflexive design and critical discursive psychology approach, both data sets were analysed together. It is possible to simultaneously analyse two different data sets, one naturally occurring and one researcher generated because of the epistemological congruence in the overall design. We have presented an argument for the benefits of mixing two qualitative methods, thereby extending the mixed‐methods evidence base beyond the traditional discussions of quantitative and qualitative paradigms.     

Management of chronic psychiatric patients by a token reinforcement system

A token reinforcement system for the reduction of institutionalized behavior in a chronic psychiatric ward is described. Quantitative assessments were made of the effects of the system on five types of positively reinforced behavior, two types of unreinforced behavior, and two types of fined behavior. To assess whether these effects were a function of the token procedures, three experiments were carried out, the first removing tokens for a brief period, the second making tokens non-contingent on behavior, and the third removing fines in one area while maintaining them in another. The token procedures were found to be the source of the observed improvements.     

Transfer of persistence across behaviors

Two experiments tested the applicability to human beings of findings with animals that the number of performances required for the reinforcement of one behavior affects the subsequent effort expended in other instrumental behaviors. In the first experiment, adult depressed psychiatric patients worked on a sorting task for the approval of a staff psychologist. The time spent and the work completed were increased by prior approval from a ward attendant for each completion of several custodial tasks, as compared to the ward attendant's approval for each completion of a single task or a no-pretreatment control condition. In the second experiment, preadolescent learning-disabled students who were required to read and spell correctly a greater number of words per reward token later spent more time and completed more work for reward tokens in mathematics, and handwriting. Two alternative interpretations of these results are evaluated: (a) The degree of accustomed effort per reinforcer becomes a learned component of behavior, or (b) high effort increases the habituation of frustration-produced disruptive responses. The results suggest that individual differences in general persistence may arise, in part, from an accumulation of effort training in the natural environment.     

Level of aspiration and performance of chronic psychiatric patients on a simple motor task

The level of aspiration and performance was examined for 25 male psychiatric inpatients whose mean age was 57.4 yr. and mean length of hospitalization was 23.6 yr. For a simple motor task involving flipping a plastic chip over a goal line, each patient expressed the ward and his personal pretask levels of aspiration, performed the task, and expressed his personal posttask aspiration. The expressions of both the ward and pretask levels of aspiration were less than the mean score of a nonhospitalized referent group. Both performance and posttask levels of aspiration were greater than the pretask level. More patients predicted they would perform worse than the other patients on the ward than predicted they would perform better. The patients appropriately shifted their levels of aspiration either up after success or down after failure. The results were discussed according to expectations from classical theory as well as findings with schizophrenics. Implications for further research were discussed.     

The Equivalence Of Psychotic Syndromes Across Two Media

The study goal was to test the equivalence of ten dimensions of psychotic behavior across two measuring media. The data consisted of ratings of 814 newly admitted schizophrenics made in the interview and on the ward. The factored. A least squares solution of a hypothesis matrix yielded ten clear factors of which eight were defined both by ward and interview measures.