A behaviour modification project with chronic schizophrenics in the community

A major shortcoming of token economies is their failure to ensure carry over of behavioural gains into the community; hence it is logical to investigate the feasibility of behavioural programmes for schizophrenics in their own homes. The token economy literature and the literature on behavioural interventions in the natural environment provide guidelines but also indicate possible difficulties arising from the nature of the illness and the use of the family setting.

Despite numerous accounts of effective behavioural treatment of schizophrenics (Ullman and Krasner, 1965; Ayllon and Azrin, 1968; Atthowe and Krasner, 1968; Stoffelmayr et al., 1973) here and there in the literature a note of caution is sounded. Meyer and Chesser(1970) and Yates (1970) suggest that there is undue optimism. Kazdin (1973) notes that reports of non-response in psychotics range from 10 per cent (Atthowe and Krasner. 1968) to 52 per cent (Panek 1969). Non-response is sometimes attributed to practical or administrative obstacles (Ayllon and Azrin, 1968; Hall and Baker, 1973) or shortcomings in the application or Operant principles (Ayllon and Azrin, 1965; Atthowe and Krasner, 1968; Kazdin and Bootzin, 1972). but more serious objections stem from the view that Operant principles may be applicable only to certain aspects of the behaviour of psychotics, such as apathy and withdrawal fostered by institutional environments. Operant technology may fail to take into account the antecedents of behaviour, including anxiety, delusions and hallucinations or covert consequences such as relief of anxiety (Davison, 1969). ‘Non-functioning’ behaviour, particularly deficit in social interaction, and paranoid behaviour, have been found especially resistant, the former because of initial low levels of the desired behaviour, the latter because of covert self-reinforcement (Libermann, 1968). Kazdin (1973) suggests that there is support from laboratory studies for the view that response patterns in psychotics may be atypical. A further qualification is that one cannot readily generalise from the American ‘chronic schizophrenic’ to his British counterpart (Cooper et al., 1972) nor from the long-stay patient to the chronic schizophrenic in the community.

The literature on behavioural intervention in the family setting gives further cause for caution. Thomas and Walter (1973) report a 27 per cent dropout, and suggest this was due to client inaccessibility, “countervailing environmental influences”, non-compliance, crises and unstable domestic situations. Patterson (1972) and Sajwaj (1973) cite parents' personal problems. Tharp and Wetzel (1969) rejection of Operant methods, and Salzinger et al. (1972) parents' poor verbal ability and low educational achievement as factors related to unsuccessful outcome. In the Project described below, it was hoped that problems would be more clearly identified and that a beginning might be made in selecting suitable cases for behaviour modification in the family setting.