BRIEF REPORTS WORKSHOP TO TRAIN COMMUNITY-CARE STAFF BEHAVIOR MODIFICATION A
William Monica Macie
TO USE TECHNIQUES
J. DeRisi, Ph.D. Myron, O.T.R. Goding, MS. W.
lAs
California has been steadily closing its state mental hospitals, it has been licensing community-care facilities to provide residences for the many otherwise homeless patients who have been released. Many of the ex-patients have behavioral problems that operators and staff of community-care facilities have not been trained to deal with. The Oxnard (Calif.) Community Mental Health Center serves a catchment area that has 131 community-care facilities housing a total of 450 ex-patients. When the center found that it was providing almost continuous consultation and emergency services to operators seeking advice about problems of simple behavioral management, we designed and implemented a pilot training workshop to help operators and staff deal with their residents’ problems. As part of an NIM H-supported demonstration project, the center uses behavior modification techniques with chronic patients who come for outpatient and partial hospitalization services. Thus the workshop emphasized behavior modification: behavioral methods are tangible and practical and can be easily taught to laymen. The specific goals were to enable operators to specify behavioral excesses and deficits of residents; observe and accurately record the frequency of specified behaviors; and identify, choose, and effectively control reinforcers to produce maximum effect on the specified behaviors. In addition, operators would be taught to use social and tangible reinforcers to change behavior, to understand the undesirable side-effects of punishment and aversive control, and to discriminate between
Dr. DeRisi is a research specialist for the Department of Health, 744 P Street, Sacramento, California 95814. Ms. Myron is a registered occupational therapist at the Oxnard (Calif.) Community Mental Health Center, and Mrs. Coding is a social worker at the Ventura County (Calif.) Health Services Agency.
636
HOSPITAL
& COMMUNITY
PSYCHIATRY
ethical and unethical uses of behavior modification. During the workshop the operators would execute two behavior-change programs for selected residents. We chose a group-educational model for the workshop. In such a model participants learn by making a functional analysis of current behavior problems, recording behavioral data, and trying interventions. The success or failure of the behavior-change programs is evaluated initially by group leaders who rapidly phase themselves out of active participation in the process as the students become proficient. At the end of the program the critiques are made entirely by the group members. The rationale for this educational model is that it trains as primary therapists those individuals who spend the most time with the target population in the natural environment, thus ensuring maximum generalization of treatment. Thirteen community-care-facility operators interested in the workshop either attended themselves or selected an employee to attend. We held nine weekly sessions at the Oxnard CM HC, each lasting two hours. Students made a deposit of $10 at the first class, which they could earn back by perfect attendance. A student who had to miss a session was told to send someone else to the class to take notes and to report on the behaviorchange projects. After a three-week break, we held a follow-up session in a local restaurant. At each weekly session we tried to cover one subject completely. The subjects included specifying, recording, and graphing behavior; choosing and using reinforcers; shaping and modeling; psychopharmacology; licensing regulations; and activity programs. Written material augmented the lectures. At the end of each session we gave assignments, based on the information covered, to be completed in the facility; the assignments were reviewed during the next week’s class. We gave weekly quizzes to check the accuracy and degree of assimilation of the course work, and during the workshop we showed two teaching films. Except for a two-hour lecture on psychoactive medications by a clinic nurse, all the information given in the workshop focused on behavior modification. We introduced the students to social learning theory and showed them how it explained either acceptable or dis(Continued on page 641)
(Continued
from
page
&36)
turbing behavior. We defined and explained terms such as reinforcement, shaping,. and modeling. For the first behavior-change project we showed students how to formulate a behavioral description of one of their residents. That exercise led them to consider the specific behaviors that they wished to increase or decrease and the consequences or reinforcers that might be used. During subsequent sessions each student selected a resident’s behavior that he wanted to modify. He learned how to quantify the behavior and graph its incidence during a baseline period. We emphasized the importance of the baseline measurement since, without it, the effect of the intervention could not be evaluated. Students
then
measured
‘
applied
and
appropriate
graphed
their
consequences
effects
on
and
behavior.
The behaviors chosen by the operators revealed the wide range of management problems they encountered: a relatively simple problem was poor grooming, a more complex one was delusional speech in conversations. Of the 22 behavior-change programs completed by students during the workshop, 18 showed that the residents made at least a 60-per-cent improvement over previous levels of performance. Both students and instructors were pleased by the results. At the follow-up session held three weeks after the workshop was completed, we awarded certificates of completion and refunded tuition to the 12 students who had perfect attendance. In addition, we asked each operator to fill out an evaluation form covering all the subject matter presented in the workshops. Feedback from the operators indicated several areas needing improvement. Nine of the participants felt that the workshop was not long enough, and many wanted more information on medication and activity programs. The most popular elements in the curriculum were recording and graphing behavior. The enthusiasm demonstrated by the students, their high attendance rate at the workshop sessions, and the success of their behavior-change programs indicated that community-care-facility operators can be taught to apply behavioral methods in their own setting. Center staff spent 90 man-hours running the workshop, which is a small amount of time compared to the potential number of hours that could be spent on the behavior problems of the 114 residents of the 13 homes. The workshop became a regular part of the center’s program and now includes families of ex-patients.
USING FAMILY PHOTOGRAPHS TO IMPROVE COMMUNICATION IN
THERAPY
SESSIONS
used the technique with a 16-year-old girl, Miss J, who was referred to me for psychological evaluation and ongoing counseling. Miss J was reticent, to say the least, and generally passive-aggressive in her approach. Communication with her was difficult, and, after a rather laborious evaluation session, she settled into an almost impenetrable sullenness. Although week after week the counseling time passed mostly in silence, she continued to attend the sessions of her own accord and to tell her mother that the sessions were progressing satisfactorily. It was difficult to see any measurable improvement, so I began to search for ways to alter the pattern of our relationship. After one silent session with Miss J, I had an appointment with a young man who was more open and responsive. During our conversation he mentioned that on his way to the center he had stopped at the drugstore to pick up some snapshots of a recent family outing. I asked to see them, and a strikingly spontaneous and informative interchange followed. He told anecdotes about several of the pictures and gave background details. He spoke openly about his family, his friends, and himself. I laughed at several photographs with him; occasionally I asked questions. We shared a very personal and honest experience.
I was impressed
with
what
had
occurred.
I thought
that a similar situation might help to improve my relationship with Miss J. Later that day I called and asked her to bring several family photographs to our next session. At that session Miss J watched as I looked at the plctures. I smiled at some, laughed at others, and made vague exclamations after studying others. It didn’t take long for her to react. Which one are you looking at?” she asked. I showed her and said, I like this one of you; your hair looks nice that way.” Then I asked, ‘ ‘
“
“What
were
you
so happy
about
in this one?”
Miss
J
became more at ease and began to talk, and our new relationship had begun. In the months that followed, I asked other clients to bring in randomly selected family photographs. I also asked other psychologists and caseworkers at the center to try the same technique. Thus far the reactions of other clients have been good and, in some instances, impressive. While the technique appears to be a particularly effective way to build rapport in the early stages of therapy, its usefulness is not limited to that phase. As the therapeutic relationship progresses, the periodic use of photographs can help the therapist find out about various aspects of the client’s life and any changes that have taken place. A useful question to encourage a here-and-now focus is How have you changed since then?” Such a question will also help the ‘ ‘
F. William A
few
Gosciewski, years
ago
in my
Ph.D. work
with
clients
at
a com-
munity mental health center, I began using family photographs to facilitate evaluations of clients and to increase therapeutic communications with them. I first
Dr. Gosciewski is associate professor of psychology at Edinhoro (Pa.) State College and a consulting psychologist at the St. Vincent Hospital Community Mental Health Center in Erie, Pennsylvania. His mailing address is 12291 Lakeview Drive, Edinboro, Pennsylvania 16412.
VOLUME
26
NUMBER
10
OCTOBER
1975
641
William Monica Macie
TO USE TECHNIQUES
J. DeRisi, Ph.D. Myron, O.T.R. Goding, MS. W.
lAs
California has been steadily closing its state mental hospitals, it has been licensing community-care facilities to provide residences for the many otherwise homeless patients who have been released. Many of the ex-patients have behavioral problems that operators and staff of community-care facilities have not been trained to deal with. The Oxnard (Calif.) Community Mental Health Center serves a catchment area that has 131 community-care facilities housing a total of 450 ex-patients. When the center found that it was providing almost continuous consultation and emergency services to operators seeking advice about problems of simple behavioral management, we designed and implemented a pilot training workshop to help operators and staff deal with their residents’ problems. As part of an NIM H-supported demonstration project, the center uses behavior modification techniques with chronic patients who come for outpatient and partial hospitalization services. Thus the workshop emphasized behavior modification: behavioral methods are tangible and practical and can be easily taught to laymen. The specific goals were to enable operators to specify behavioral excesses and deficits of residents; observe and accurately record the frequency of specified behaviors; and identify, choose, and effectively control reinforcers to produce maximum effect on the specified behaviors. In addition, operators would be taught to use social and tangible reinforcers to change behavior, to understand the undesirable side-effects of punishment and aversive control, and to discriminate between
Dr. DeRisi is a research specialist for the Department of Health, 744 P Street, Sacramento, California 95814. Ms. Myron is a registered occupational therapist at the Oxnard (Calif.) Community Mental Health Center, and Mrs. Coding is a social worker at the Ventura County (Calif.) Health Services Agency.
636
HOSPITAL
& COMMUNITY
PSYCHIATRY
ethical and unethical uses of behavior modification. During the workshop the operators would execute two behavior-change programs for selected residents. We chose a group-educational model for the workshop. In such a model participants learn by making a functional analysis of current behavior problems, recording behavioral data, and trying interventions. The success or failure of the behavior-change programs is evaluated initially by group leaders who rapidly phase themselves out of active participation in the process as the students become proficient. At the end of the program the critiques are made entirely by the group members. The rationale for this educational model is that it trains as primary therapists those individuals who spend the most time with the target population in the natural environment, thus ensuring maximum generalization of treatment. Thirteen community-care-facility operators interested in the workshop either attended themselves or selected an employee to attend. We held nine weekly sessions at the Oxnard CM HC, each lasting two hours. Students made a deposit of $10 at the first class, which they could earn back by perfect attendance. A student who had to miss a session was told to send someone else to the class to take notes and to report on the behaviorchange projects. After a three-week break, we held a follow-up session in a local restaurant. At each weekly session we tried to cover one subject completely. The subjects included specifying, recording, and graphing behavior; choosing and using reinforcers; shaping and modeling; psychopharmacology; licensing regulations; and activity programs. Written material augmented the lectures. At the end of each session we gave assignments, based on the information covered, to be completed in the facility; the assignments were reviewed during the next week’s class. We gave weekly quizzes to check the accuracy and degree of assimilation of the course work, and during the workshop we showed two teaching films. Except for a two-hour lecture on psychoactive medications by a clinic nurse, all the information given in the workshop focused on behavior modification. We introduced the students to social learning theory and showed them how it explained either acceptable or dis(Continued on page 641)
(Continued
from
page
&36)
turbing behavior. We defined and explained terms such as reinforcement, shaping,. and modeling. For the first behavior-change project we showed students how to formulate a behavioral description of one of their residents. That exercise led them to consider the specific behaviors that they wished to increase or decrease and the consequences or reinforcers that might be used. During subsequent sessions each student selected a resident’s behavior that he wanted to modify. He learned how to quantify the behavior and graph its incidence during a baseline period. We emphasized the importance of the baseline measurement since, without it, the effect of the intervention could not be evaluated. Students
then
measured
‘
applied
and
appropriate
graphed
their
consequences
effects
on
and
behavior.
The behaviors chosen by the operators revealed the wide range of management problems they encountered: a relatively simple problem was poor grooming, a more complex one was delusional speech in conversations. Of the 22 behavior-change programs completed by students during the workshop, 18 showed that the residents made at least a 60-per-cent improvement over previous levels of performance. Both students and instructors were pleased by the results. At the follow-up session held three weeks after the workshop was completed, we awarded certificates of completion and refunded tuition to the 12 students who had perfect attendance. In addition, we asked each operator to fill out an evaluation form covering all the subject matter presented in the workshops. Feedback from the operators indicated several areas needing improvement. Nine of the participants felt that the workshop was not long enough, and many wanted more information on medication and activity programs. The most popular elements in the curriculum were recording and graphing behavior. The enthusiasm demonstrated by the students, their high attendance rate at the workshop sessions, and the success of their behavior-change programs indicated that community-care-facility operators can be taught to apply behavioral methods in their own setting. Center staff spent 90 man-hours running the workshop, which is a small amount of time compared to the potential number of hours that could be spent on the behavior problems of the 114 residents of the 13 homes. The workshop became a regular part of the center’s program and now includes families of ex-patients.
USING FAMILY PHOTOGRAPHS TO IMPROVE COMMUNICATION IN
THERAPY
SESSIONS
used the technique with a 16-year-old girl, Miss J, who was referred to me for psychological evaluation and ongoing counseling. Miss J was reticent, to say the least, and generally passive-aggressive in her approach. Communication with her was difficult, and, after a rather laborious evaluation session, she settled into an almost impenetrable sullenness. Although week after week the counseling time passed mostly in silence, she continued to attend the sessions of her own accord and to tell her mother that the sessions were progressing satisfactorily. It was difficult to see any measurable improvement, so I began to search for ways to alter the pattern of our relationship. After one silent session with Miss J, I had an appointment with a young man who was more open and responsive. During our conversation he mentioned that on his way to the center he had stopped at the drugstore to pick up some snapshots of a recent family outing. I asked to see them, and a strikingly spontaneous and informative interchange followed. He told anecdotes about several of the pictures and gave background details. He spoke openly about his family, his friends, and himself. I laughed at several photographs with him; occasionally I asked questions. We shared a very personal and honest experience.
I was impressed
with
what
had
occurred.
I thought
that a similar situation might help to improve my relationship with Miss J. Later that day I called and asked her to bring several family photographs to our next session. At that session Miss J watched as I looked at the plctures. I smiled at some, laughed at others, and made vague exclamations after studying others. It didn’t take long for her to react. Which one are you looking at?” she asked. I showed her and said, I like this one of you; your hair looks nice that way.” Then I asked, ‘ ‘
“
“What
were
you
so happy
about
in this one?”
Miss
J
became more at ease and began to talk, and our new relationship had begun. In the months that followed, I asked other clients to bring in randomly selected family photographs. I also asked other psychologists and caseworkers at the center to try the same technique. Thus far the reactions of other clients have been good and, in some instances, impressive. While the technique appears to be a particularly effective way to build rapport in the early stages of therapy, its usefulness is not limited to that phase. As the therapeutic relationship progresses, the periodic use of photographs can help the therapist find out about various aspects of the client’s life and any changes that have taken place. A useful question to encourage a here-and-now focus is How have you changed since then?” Such a question will also help the ‘ ‘
F. William A
few
Gosciewski, years
ago
in my
Ph.D. work
with
clients
at
a com-
munity mental health center, I began using family photographs to facilitate evaluations of clients and to increase therapeutic communications with them. I first
Dr. Gosciewski is associate professor of psychology at Edinhoro (Pa.) State College and a consulting psychologist at the St. Vincent Hospital Community Mental Health Center in Erie, Pennsylvania. His mailing address is 12291 Lakeview Drive, Edinboro, Pennsylvania 16412.
VOLUME
26
NUMBER
10
OCTOBER
1975
641
