Behav Res. & Therapy.
1975. Vol. 13. pp. 239-341. Perp;tmon Press Prmtrd I” Grrat
CASE HISTORIES
AND SHORTER
Bntam
COMMUNICATIONS
A hehaviour modification project with chronic schizophrenics in the community*
(Received
3 December
1974)
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 general& 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, “countervailcrises and unstable domestic situations. Patterson (1972) and ing environmental influences”. non-compliance. 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.
THE
PROJECT
Chronic schizophrenic patients and their families were interviewed at home on at least two occasions and treatment programmes devised and implemented where feasible. Progress was monitored and the reasons for failure to initiate intervention or for discontinuance of treatment were analysed. The patients were 12 consecutively referred outpatient schizophrenics under the care of the community psychiatric nurses. (In no case had either the patient or the family themselves requested additional help). The nurses were given referral criteria as follows: (I) Diagnosis of chronic schizophrenia, (2) Receiving Modecate, (3) Living at home with relatives. (4) Not at work or day centre. (5) Either behavioural deficit such as self-neglect or undesirable behaviour such as habitual psychotic talk. There were 7 female and 5 male patients. ages ranging from 21 to 68 yr. with 8 patients in their 30s or 40s. Duration of diagnosed illness ranged from 2 to 20 yr; aggregate time spent in hospital ranged from 2 months to 6 yr; number of admissions ranged from 2 to 23. All patients belonged to Social Class 4 or 5. The referrals indicated behavioural deficit in 7 cases. deficit plus undesirable behaviour in 4, and undesirable behaviour in 1.
RESULTS
Obstacles
Obstacles
to instituting
behavioural
programmes
in 7 of the I2 cases. Six types were identified: quo prqferred (6 cases). Examples: (i) The patient helped in the home and kept his mother company. They said their way of life was satisfactory. (ii) The relatives insisted the patient was perfectly well. (2) Patient’s non-compliance (4 cases). Examples: (i) The patient denied having problems, objected to her family being interviewed. She said
(I)
were judged
Suggested
insuperable
goals not agreed
byfhmily-status
*Appreciation is expressed to Dr. R. Gaind and the Community Project was supported by a grant to Dr. Gaind from the Department the Locally Organised Research Fund. 339
Sisters of St. Olave’s Hospital. of Health and Social Security
This from
340
CASE HISTORIES
AND SHORTER
COMML’NICATIONS
hospital staff were trying to get control of her for sexual purposes. (ii) The patient said any change in his way of life “would make his voices come back”. (3) Family fear qfparient (3 cases). Examples: (i) The parents were sometimes assaulted when they did not comply with patient‘s wishes. and feared that a plan involving selective reinforcement would cause further violence. (ii) The relatives had read of schizophrenics’ committing murder and believed they must ‘humour’ him. (4) Concem for patient’s health (4 cases). Examples: (i) The patient had suffered relapse during a previous rehabilitation programme. and the family feared this might recur. (ii) The family feared the patient might become depressed if renewed attempts to help him proved disappointing. (5) Mental illness among relatives (3 cases). The relatives were judged unable to co-operate. Examples: (i) The patient’s daughter was acutely disturbed. (ii) The patient’s twin was also schizophrenic and they spent a lot of time discussing their delusional beliefs. (6) Patient requiring re-admrssiorl (I case). This patient appeared deluded. restless and incoherent. and was readmitted following the initial interviews.
Inferverltiorls
A rewarding relationship was established through friendly conversation and providing services such as help with financial problems. delivering messages. explanations about medication. Care was taken to avoid placing the patient under stress through excessive demands on his ability to adapt to change or cope with difficult assignments, and to avoid using operant procedures in any way that might demean the patient in his own eyes or those of his family. This necessitated careful use of language to describe procedures. emphasis on the patient’s assets. ensuring that no patient should feel ‘spied on’ or discussed behind his back. When progress was below expectation, the author accepted responsibility; credit for achievements was given to the patient and the relatives. No attempt was made to educate these families in learning principles. Rather, they were guided in practical efforts to deal with problems. (It was considered that a more sophisticated approach would not have been feasible.) The five cases where a behavioural programme was instituted are reported. Case Report 1. The referral indicated that the patient “did nothing” all day and complained constantly of feeling weak. She ate nothing at mid-day. remained indoors except to visit the corner shop and refused to attend the Church Club with her husband and sister, explaining that she was “too weak” because of attacks by rats. The family was given a sheet for recording what she ate and praised her for eating: her talk about weakness was ignored. After 2 weeks she was eating regularly and her talk about weakness had decreased. The second goal was club attendance. Non-attendance was followed by disapproval: this proved ineffectual. Attendance was achieved after the author accompanied her. but after attending for 3 weeks. she refused to return. Her delusional talk increased and she was readmitted. Case Report 2. This patient worked full-time from hospital, but on discharge lay in bed till mid-day. and spent the rest of his time sitting silently. He refused medication. Initial problems included the patient’s unwillingness to admit visitors and the relatives’ fear of violence. The author attempted to make visits reinforcing and discussed with his parents the progress achieved in hospital where he accepted guidance and was never violent. The author modelled the behaviour asked of the patient’s mother: calling him to get up. saying he would get breakfast downstairs. The mother ceased taking food to the patient’s room and rewarded earlier rising with breakfast and approval After 3 days the patient was rising when called. The next goal was going out of the house. The patient’s sister agreed to discontinue daily visits and the patient agreed to visit her instead. This step was not achieved. and the patient thereafter refused to admit hospital staff. Two months later. after a serious suicidal attempt. he requested readmission. saying he was in danger because everyone said he was homosexual. Case Report 3. This patient’s delusional talk was more frequent at home than in hospital. her family responding with solicitous questioning and reassurance. Initial obstacles included the patient’s dislike of intcrference and her denial of problems. and both fear of the patient and concern for her wellbeing on the family’s part. Although the patient became quite friendly towards the author she did not accept need for change nor recording of her behaviour-the latter was done in her absence. The parents recorded the frcqucncy of the target behaviour and their own responses. They were then asked to ignore the behaviour and this was modelled during the family interviews. However. potentially important variables, especially life events and changes in medication. made evaluation impossible. In addition. the actual as opposed to reported changes in the relatives’ behaviour could not be monitored. For these reasons, the programme was discontinued. (The family said they would continue to ignore psychotic talk. believing this to be effective.) Case Report 4. According to the relatives and the nurse. it was 3 yr since this patient had risen before noon, done any housework or left the hat. The patient’s IQ. was below average, and the four brothers with whom she lived were also thought to be of low intelligence. Chores were divided into tasks of approximately equal difficulty. and for the first X weeks the patient was reinforced with praise from the family and gifts of chocolate depending on number of tasks completed. The latter rose from 0 to X per week over this period. Then she was requested IO rise before 10.30 and over 4 weeks the frequency of this behaviour rose from 0 to 4. After systematic reinforcement was extended to this behaviour. its frequency rose to 6 times a week. ‘Going shoppmg’ was added and rose from 0 to 4 times a week over a 6 week period. To date (over a further X-week period) number of tasks and times out of flat have contmued to rise. Bathtng and cooking were included without specific reinforcement. and have been reinstated. Case Report 5. The patient. who had not worked for 14 yr, said he had “lost his confidence”. Hc did some local shopping. attended the Clinic, but vvas otherwise housebound. A list of items of increasing dithculty was drawn up and he agreed to attempt one each week. He was reinforced with family approval. In addition. the author spent an hour in conversation with him when he had succeeded but left earlier when he had not. To date (over 5 months) the patient has achieved the following: visits to Post Office. Bank. park. more distant shops. journeys of increasing distance.
CASEHISTORIES ANV SHORTER CoMMUNlCATIONS
341
DISCCSSIO*I As anticipated. problems arose in this project relating both to the nature of the patients’ illness and to the community setting. The ‘non-compliance’ problems reflect the lack of insight characteristic of schizophrenia, and the family’s awareness of the seriousness of the condition and the unpredictablity of some schizophrenics’ behaviour. as well as the long-term nature of the illness with family adaptation over time and low expectations of jmprovement. Delusional beliefs exerting control over behaviour were factors both in preventing intervention and in discontinuance. and perhaps also detracted from the amount of progress achieved. These problems. specific to the illness. were compounded by problems inherent in the community approach: lack of authority over people in the community as opposed to the ward setting; the difficulty of obtaining reliable data. Because few cases reached the intervention stage. and because of the possibility of relapse and the long term nature of those where intervention continues, it is hard to draw pointers for future work. Hindsight suggests that the project might have been more effective with patients selected differently: there is reason to suppose that those referred were the ‘hard core’ of the community nurses’ caseload. Patients with less severe handicap. without florid symptoms. might benefit more from this approach. Non-compliance might have been more readily overcome had newly discharged patients been chosen, or a more directive approach been adopted. Nevertheless. the gains achieved represent improvement where other forms of intervention over a number of years had failed. Expenditure of staff time amounted to weekly visits lasting 30 min on average over a period up to 6 months. The families and patients involved have expressed satisfaction with the progress achieved. It is concluded that efforts to introduce and evaluate behaviour modification in the families of chronic schizophrenics should be continued. Further study of reasons for patient and family non-compliance and of ways of reducing this must be a priority in future work. before the efficacy of a behavioural approach can be evaluated. St. Olaue’s Hospital.
BARBARAL. H~D~QN
Lower Road. Rotherhithe, London SE 16. E~~gfa~yd
REFERENCES ATTHOWEJ. M. JNR and KRASKERL. (1968) A preliminary report on the application of contingent reinforcement procedures (token economy) on a “chronic” psychiatric ward. J. a&norm. Psychol. 73, 37-43. AYLLON T. and AZRIN N. H. (1965) The measurement and reinforcement of behaviour in psychotics. I. exp. Analysis Behau. 8, 357-383. AYLLONT. and AZRIN N. H. (1968) The Token Economy: A Motivational System for Therapy & Re~~abiiitazio~~. Appleton-Century Crofts, New York. C~IIPER J. E.. KENDELLR. E.. GIJRLANDB. J., SHARPEL., COPLANDJ. R. M. & SIMONR. (1972) Psychiatric Diagnosis in New York and London. Maudsley Monograph No. 20.. Oxford. DAVISONG. C. (1969) Appraisal of behaviour modification techniques with adults in institutional settings. In FRANKSC. M. (Ed.) Behaviour Therapy: Appraisal & Status. McGraw Hill, New York. FAIRWEATHER G. W.. SANDERSD. H.. CRESSLERD. and MAYNARDH. (3969) Co~~~~~ry I&for clre Metltally if!. Aidine. Chicago. HALL J. and BAKER R. (1973) Token economy systems: breakdown and control. Behau. Res & Therapy 2, 253-263.
KANFERF. H. and PHILLIPSJ. (1970) Lrarning Foundations of Behaviour Therapy. Wiley, New York. KAZDIN A. E. and B~~T~Is R. R. (1977) The token economy: An evaluative review. J. appl. Behac. Analy. 5.343-312.
KAZDIN
A. E. (1973) The failure of some patients to respond to token programs. J. Behar. Therapy &
exp. Ps~c~~iat.4, 7-- 14.
LIBERMANR. P. (1968)A review of behaviour modification projects in California B&at. Rc~s.& ~~1~~~~~~ 6, 331-341. MEYERV. and CHESSERE. S. (1970) Brhaciour Therapy iti Clinical Psychiatry. Penguin, Harmondsworth. PANEK M. (1969) Token economies on a shoestring: successes and failures. Unpublished research report, Northern State Hospital. Sedro Wooiey. Washington, U.S.A. PAKTERSON G. R. (1973) Reprogrammmg the families of aggressive boys. In C. E. Thorenson (Ed.), Behauiour Modj~catio~~ in Educariorr. N.S.S.E. New York. SAJWAJT. (1973) Difficuitles in the use of behaviourai techniques by parents in changing child behaviour: guide to success. J. R;c~rc.Mer,r Dis. 156, 395-403. SALZINGERK.. FELDMANR. and PORTN~YS. (1972) Training parents of brain-damaged children in the use of operant conditioning procedures. Behac. Therapy 1, 4-32. STOFFELMAYR B. E.. FAULKNERG. E. and MITCHELLW. S. (1973) The Rehabilitation 01 Chronic Hospitalised Patients-A Comparatiw Study of Operanr Conditioning Methods and Social Therapy Techniques. Final Report to the Scottish Home and Health Department. THARP R. and WETZEL R. J. (1969) B~,/~~~iff~~ ,~od~earion in the Natural ~~~~jro~z~~~r.Academic Press, New York. THOMAS E. J. and WALTERC. (1973) Guidelines for behavioural practice in the open community agency: procedure and evaluation. Behar. Res. & Therapy 2, 193-205. ULLMANL. P. and KRASNERL. (Eds.) (1965) Case Studies in BrhaGour Modification. Hoit Rinehart and Winston. New York. YATESA. (1970) Behaciour Tiwapy. Wiley. New York.
1975. Vol. 13. pp. 239-341. Perp;tmon Press Prmtrd I” Grrat
CASE HISTORIES
AND SHORTER
Bntam
COMMUNICATIONS
A hehaviour modification project with chronic schizophrenics in the community*
(Received
3 December
1974)
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 general& 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, “countervailcrises and unstable domestic situations. Patterson (1972) and ing environmental influences”. non-compliance. 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.
THE
PROJECT
Chronic schizophrenic patients and their families were interviewed at home on at least two occasions and treatment programmes devised and implemented where feasible. Progress was monitored and the reasons for failure to initiate intervention or for discontinuance of treatment were analysed. The patients were 12 consecutively referred outpatient schizophrenics under the care of the community psychiatric nurses. (In no case had either the patient or the family themselves requested additional help). The nurses were given referral criteria as follows: (I) Diagnosis of chronic schizophrenia, (2) Receiving Modecate, (3) Living at home with relatives. (4) Not at work or day centre. (5) Either behavioural deficit such as self-neglect or undesirable behaviour such as habitual psychotic talk. There were 7 female and 5 male patients. ages ranging from 21 to 68 yr. with 8 patients in their 30s or 40s. Duration of diagnosed illness ranged from 2 to 20 yr; aggregate time spent in hospital ranged from 2 months to 6 yr; number of admissions ranged from 2 to 23. All patients belonged to Social Class 4 or 5. The referrals indicated behavioural deficit in 7 cases. deficit plus undesirable behaviour in 4, and undesirable behaviour in 1.
RESULTS
Obstacles
Obstacles
to instituting
behavioural
programmes
in 7 of the I2 cases. Six types were identified: quo prqferred (6 cases). Examples: (i) The patient helped in the home and kept his mother company. They said their way of life was satisfactory. (ii) The relatives insisted the patient was perfectly well. (2) Patient’s non-compliance (4 cases). Examples: (i) The patient denied having problems, objected to her family being interviewed. She said
(I)
were judged
Suggested
insuperable
goals not agreed
byfhmily-status
*Appreciation is expressed to Dr. R. Gaind and the Community Project was supported by a grant to Dr. Gaind from the Department the Locally Organised Research Fund. 339
Sisters of St. Olave’s Hospital. of Health and Social Security
This from
340
CASE HISTORIES
AND SHORTER
COMML’NICATIONS
hospital staff were trying to get control of her for sexual purposes. (ii) The patient said any change in his way of life “would make his voices come back”. (3) Family fear qfparient (3 cases). Examples: (i) The parents were sometimes assaulted when they did not comply with patient‘s wishes. and feared that a plan involving selective reinforcement would cause further violence. (ii) The relatives had read of schizophrenics’ committing murder and believed they must ‘humour’ him. (4) Concem for patient’s health (4 cases). Examples: (i) The patient had suffered relapse during a previous rehabilitation programme. and the family feared this might recur. (ii) The family feared the patient might become depressed if renewed attempts to help him proved disappointing. (5) Mental illness among relatives (3 cases). The relatives were judged unable to co-operate. Examples: (i) The patient’s daughter was acutely disturbed. (ii) The patient’s twin was also schizophrenic and they spent a lot of time discussing their delusional beliefs. (6) Patient requiring re-admrssiorl (I case). This patient appeared deluded. restless and incoherent. and was readmitted following the initial interviews.
Inferverltiorls
A rewarding relationship was established through friendly conversation and providing services such as help with financial problems. delivering messages. explanations about medication. Care was taken to avoid placing the patient under stress through excessive demands on his ability to adapt to change or cope with difficult assignments, and to avoid using operant procedures in any way that might demean the patient in his own eyes or those of his family. This necessitated careful use of language to describe procedures. emphasis on the patient’s assets. ensuring that no patient should feel ‘spied on’ or discussed behind his back. When progress was below expectation, the author accepted responsibility; credit for achievements was given to the patient and the relatives. No attempt was made to educate these families in learning principles. Rather, they were guided in practical efforts to deal with problems. (It was considered that a more sophisticated approach would not have been feasible.) The five cases where a behavioural programme was instituted are reported. Case Report 1. The referral indicated that the patient “did nothing” all day and complained constantly of feeling weak. She ate nothing at mid-day. remained indoors except to visit the corner shop and refused to attend the Church Club with her husband and sister, explaining that she was “too weak” because of attacks by rats. The family was given a sheet for recording what she ate and praised her for eating: her talk about weakness was ignored. After 2 weeks she was eating regularly and her talk about weakness had decreased. The second goal was club attendance. Non-attendance was followed by disapproval: this proved ineffectual. Attendance was achieved after the author accompanied her. but after attending for 3 weeks. she refused to return. Her delusional talk increased and she was readmitted. Case Report 2. This patient worked full-time from hospital, but on discharge lay in bed till mid-day. and spent the rest of his time sitting silently. He refused medication. Initial problems included the patient’s unwillingness to admit visitors and the relatives’ fear of violence. The author attempted to make visits reinforcing and discussed with his parents the progress achieved in hospital where he accepted guidance and was never violent. The author modelled the behaviour asked of the patient’s mother: calling him to get up. saying he would get breakfast downstairs. The mother ceased taking food to the patient’s room and rewarded earlier rising with breakfast and approval After 3 days the patient was rising when called. The next goal was going out of the house. The patient’s sister agreed to discontinue daily visits and the patient agreed to visit her instead. This step was not achieved. and the patient thereafter refused to admit hospital staff. Two months later. after a serious suicidal attempt. he requested readmission. saying he was in danger because everyone said he was homosexual. Case Report 3. This patient’s delusional talk was more frequent at home than in hospital. her family responding with solicitous questioning and reassurance. Initial obstacles included the patient’s dislike of intcrference and her denial of problems. and both fear of the patient and concern for her wellbeing on the family’s part. Although the patient became quite friendly towards the author she did not accept need for change nor recording of her behaviour-the latter was done in her absence. The parents recorded the frcqucncy of the target behaviour and their own responses. They were then asked to ignore the behaviour and this was modelled during the family interviews. However. potentially important variables, especially life events and changes in medication. made evaluation impossible. In addition. the actual as opposed to reported changes in the relatives’ behaviour could not be monitored. For these reasons, the programme was discontinued. (The family said they would continue to ignore psychotic talk. believing this to be effective.) Case Report 4. According to the relatives and the nurse. it was 3 yr since this patient had risen before noon, done any housework or left the hat. The patient’s IQ. was below average, and the four brothers with whom she lived were also thought to be of low intelligence. Chores were divided into tasks of approximately equal difficulty. and for the first X weeks the patient was reinforced with praise from the family and gifts of chocolate depending on number of tasks completed. The latter rose from 0 to X per week over this period. Then she was requested IO rise before 10.30 and over 4 weeks the frequency of this behaviour rose from 0 to 4. After systematic reinforcement was extended to this behaviour. its frequency rose to 6 times a week. ‘Going shoppmg’ was added and rose from 0 to 4 times a week over a 6 week period. To date (over a further X-week period) number of tasks and times out of flat have contmued to rise. Bathtng and cooking were included without specific reinforcement. and have been reinstated. Case Report 5. The patient. who had not worked for 14 yr, said he had “lost his confidence”. Hc did some local shopping. attended the Clinic, but vvas otherwise housebound. A list of items of increasing dithculty was drawn up and he agreed to attempt one each week. He was reinforced with family approval. In addition. the author spent an hour in conversation with him when he had succeeded but left earlier when he had not. To date (over 5 months) the patient has achieved the following: visits to Post Office. Bank. park. more distant shops. journeys of increasing distance.
CASEHISTORIES ANV SHORTER CoMMUNlCATIONS
341
DISCCSSIO*I As anticipated. problems arose in this project relating both to the nature of the patients’ illness and to the community setting. The ‘non-compliance’ problems reflect the lack of insight characteristic of schizophrenia, and the family’s awareness of the seriousness of the condition and the unpredictablity of some schizophrenics’ behaviour. as well as the long-term nature of the illness with family adaptation over time and low expectations of jmprovement. Delusional beliefs exerting control over behaviour were factors both in preventing intervention and in discontinuance. and perhaps also detracted from the amount of progress achieved. These problems. specific to the illness. were compounded by problems inherent in the community approach: lack of authority over people in the community as opposed to the ward setting; the difficulty of obtaining reliable data. Because few cases reached the intervention stage. and because of the possibility of relapse and the long term nature of those where intervention continues, it is hard to draw pointers for future work. Hindsight suggests that the project might have been more effective with patients selected differently: there is reason to suppose that those referred were the ‘hard core’ of the community nurses’ caseload. Patients with less severe handicap. without florid symptoms. might benefit more from this approach. Non-compliance might have been more readily overcome had newly discharged patients been chosen, or a more directive approach been adopted. Nevertheless. the gains achieved represent improvement where other forms of intervention over a number of years had failed. Expenditure of staff time amounted to weekly visits lasting 30 min on average over a period up to 6 months. The families and patients involved have expressed satisfaction with the progress achieved. It is concluded that efforts to introduce and evaluate behaviour modification in the families of chronic schizophrenics should be continued. Further study of reasons for patient and family non-compliance and of ways of reducing this must be a priority in future work. before the efficacy of a behavioural approach can be evaluated. St. Olaue’s Hospital.
BARBARAL. H~D~QN
Lower Road. Rotherhithe, London SE 16. E~~gfa~yd
REFERENCES ATTHOWEJ. M. JNR and KRASKERL. (1968) A preliminary report on the application of contingent reinforcement procedures (token economy) on a “chronic” psychiatric ward. J. a&norm. Psychol. 73, 37-43. AYLLON T. and AZRIN N. H. (1965) The measurement and reinforcement of behaviour in psychotics. I. exp. Analysis Behau. 8, 357-383. AYLLONT. and AZRIN N. H. (1968) The Token Economy: A Motivational System for Therapy & Re~~abiiitazio~~. Appleton-Century Crofts, New York. C~IIPER J. E.. KENDELLR. E.. GIJRLANDB. J., SHARPEL., COPLANDJ. R. M. & SIMONR. (1972) Psychiatric Diagnosis in New York and London. Maudsley Monograph No. 20.. Oxford. DAVISONG. C. (1969) Appraisal of behaviour modification techniques with adults in institutional settings. In FRANKSC. M. (Ed.) Behaviour Therapy: Appraisal & Status. McGraw Hill, New York. FAIRWEATHER G. W.. SANDERSD. H.. CRESSLERD. and MAYNARDH. (3969) Co~~~~~ry I&for clre Metltally if!. Aidine. Chicago. HALL J. and BAKER R. (1973) Token economy systems: breakdown and control. Behau. Res & Therapy 2, 253-263.
KANFERF. H. and PHILLIPSJ. (1970) Lrarning Foundations of Behaviour Therapy. Wiley, New York. KAZDIN A. E. and B~~T~Is R. R. (1977) The token economy: An evaluative review. J. appl. Behac. Analy. 5.343-312.
KAZDIN
A. E. (1973) The failure of some patients to respond to token programs. J. Behar. Therapy &
exp. Ps~c~~iat.4, 7-- 14.
LIBERMANR. P. (1968)A review of behaviour modification projects in California B&at. Rc~s.& ~~1~~~~~~ 6, 331-341. MEYERV. and CHESSERE. S. (1970) Brhaciour Therapy iti Clinical Psychiatry. Penguin, Harmondsworth. PANEK M. (1969) Token economies on a shoestring: successes and failures. Unpublished research report, Northern State Hospital. Sedro Wooiey. Washington, U.S.A. PAKTERSON G. R. (1973) Reprogrammmg the families of aggressive boys. In C. E. Thorenson (Ed.), Behauiour Modj~catio~~ in Educariorr. N.S.S.E. New York. SAJWAJT. (1973) Difficuitles in the use of behaviourai techniques by parents in changing child behaviour: guide to success. J. R;c~rc.Mer,r Dis. 156, 395-403. SALZINGERK.. FELDMANR. and PORTN~YS. (1972) Training parents of brain-damaged children in the use of operant conditioning procedures. Behac. Therapy 1, 4-32. STOFFELMAYR B. E.. FAULKNERG. E. and MITCHELLW. S. (1973) The Rehabilitation 01 Chronic Hospitalised Patients-A Comparatiw Study of Operanr Conditioning Methods and Social Therapy Techniques. Final Report to the Scottish Home and Health Department. THARP R. and WETZEL R. J. (1969) B~,/~~~iff~~ ,~od~earion in the Natural ~~~~jro~z~~~r.Academic Press, New York. THOMAS E. J. and WALTERC. (1973) Guidelines for behavioural practice in the open community agency: procedure and evaluation. Behar. Res. & Therapy 2, 193-205. ULLMANL. P. and KRASNERL. (Eds.) (1965) Case Studies in BrhaGour Modification. Hoit Rinehart and Winston. New York. YATESA. (1970) Behaciour Tiwapy. Wiley. New York.
