Journal ol Consulting and Clinical Psychology 1975, Vol. 43, No. 5, 676-682
Role Playing and Incentives in the Modification of the Social Interaction of Chronic Psychiatric Patients David Warren Doty State University of New Yor/c at Albany This article studied the relative and combined effectiveness of role playing and monetary incentives to increase the social interaction and responsiveness of chronic male psychiatric patients. Noninteractive patients were assigned either to one of three treatment conditions (role playing only, incentive only, or combination) or two control conditions (nonspecific control or no-treatment control) for a total of four sessions. Dependent measures were extracted both from observations of the subjects' ward behavior (% time spent alone) over a 4-week period and from observations of the subjects' participation in structured small group discussions at pretreatment and posttreatment. All subject groups were equated on pretreatment ward behavior measures, age, length of hospitalization, and drug status. Trend analyses of ward data and post hoc t tests with the discussion data consistently indicated significant positive changes at posttreatment for only those groups receiving monetary incentives. Results are discussed with regard to their potential specificity to short-term treatment, their suggestions for institutional treatment practices, and the fact that they point up the utility of direct, objective assessment of social behavior in institutional settings.
Social isolation and a relative absence of social interactions constitute the modal behavior pattern of hospitalized psychiatric patients (e.g., Bockhoven, 1963; Dunham & Weinberg, 1960; Gutride, Goldstein, & Hunter, 1973; Ullmann, 1967). Since this behavior pattern has often played an integral part of the individual's prehospital adjustment (Barthell & Holmes, 1968), and tends to make him refractory to active treatment efforts within the institution (Braginsky, Braginsky, & Ring, 1969; Ullmann, 1967), modification of these behaviors is essential to the individual's eventual return to the com-
munity. This study attempted to demonstrate relevant variables that increase the social responsiveness of psychiatric patients. Response classes similar to those of interest here have previously been characterized both as "apathy" (Schaeffer & Martin, 1966) and as depressive behavior (Lazarus, 1968; Lewinsohn, Weinstein, & Shaw, Note 1). Although Schaeffer and Martin (1966) demonstrated the responsiveness of apathetic behaviors to response-contingent token reinforcement procedures, their study did not have as its primary focus the social proximity and interaction behavior that is of interest here. A recent study of Gutride et al. (1973) did This article was based on the author's doctoral examine the effects of structured learning dissertation submitted to the University of Illinois at therapy (modeling plus role playing plus soUrbana-Champaign in partial fulfillment of the requirements for the PhD. Sincere gratitude is ex- cial reinforcement) on the social interaction tended to Irving Berman, Fred Kraus, and Leonard behavior of hospitalized patients. However, Levitz who served as therapists for the study and failure to include appropriate controls made to Donald Peterson for his helpful advice during the it impossible to separate the effects of the conduct of the research. Behavioral observations three therapeutic ingredients either from each were collected by Jenifer Hokman Doty, the author's late wife, Judy McArdle, Mary Borkovec, Martha other or from the effects of nonspecific (atWilzbach, William Smith, Sharon Drude, Michael tention-placebo) treatment variables. Further Tallman, Gary Anderson, Steven Rubin, Benjamin examination of the relevant treatment and Cooley, David Jarman, and Robert McGrath. subject variables is clearly indicated. Requests for reprints should be sent to David W. Following Paul (1969) and Zusman Doty, Department of Psychology, State University of New York at Albany, Albany, New York 12222. (1966), it is felt that a conceptualization 676
MODIFICATION OF THE SOCIAL INTERACTION emphasizing both hospital and patient characteristics in formulating potential treatments should prove most productive in this regard. Approaches focusing solely on the oppressive, dependency-creating nature of the "total institution" (e.g., Goffman, 1961) or on the personality defects and manipulative tactics of the patients (e.g., Braginsky et al., 1969) are seen as committing stimulus and organism errors, respectively. Furthermore, it is felt that patient characteristics are best viewed in terms of behavioral competencies (Peterson, 1968) rather than underlying personality dynamics, and environmental characteristics, in terms of response alternatives made available and reinforced by the hospital milieu (Ullmann, 1967). Therefore, the treatments evaluated in this study, which emerged from a model involving an interaction of these patient and hospital characteristics, included both (a) training in the social skills necessary for continued interactive behavior and (b) instituting positive payoff for the desired social proximity and interaction. The major questions of interest were: Do training in social skills or incentives, or a combination of both contribute to either the daily social interaction rates or the social responsiveness of psychiatric patients? And do psychiatric patients demonstrating differing levels of pretreatment social responsiveness appear to be differentially responsive to treatments focusing on skill training and incentives? The answers to these questions should indicate relevant treatment variables as well as identify the variables antecedent to the social withdrawal and isolation evidenced by so many psychiatric patients. METHOD General Procedure The basic experimental design was a repeatedmeasures group paradigm. Subjects were randomly assigned from stratified blocks formed on the basis of pretreatment levels of daily social interaction either to one of three active treatment conditions {incentive, role playing, or combination) («= 12 each) or to one of two control conditions (nonspecific or no treatment; Ns = 12 and 8, respectively. Three therapists each met for a total of four sessions with one group of four subjects from each
677
of the active treatment conditions and the nonspecific control condition. Two of the three therapists also met for assessment purposes with a four-member group of subjects assigned to the no-treatment condition.
Subjects Subjects were 56 male open-ward psychiatric patients at the Veterans Administration Hospital, Danville, Illinois, who were nominated for the study by nursing personnel on their wards as being noninteractive, relatively cooperative, and not engaging in active delusional or hallucinatory behavior. None of the subjects were participating in other forms of active psychological treatment except chemotherapy or assignment to recreational activities at the time of the study. They were assigned randomly to one of five groups equated on nine variables including age, length of continuous and accumulated hospitalization, drug status, unit of residence, and the major dependent measures (described below). The total sample averaged 47.98 years of age, 89.66 months (7.47 years) of accumulated hospitalization, a score of 13.06, average near the midpoint, on the Ullmann-Giovannoni (1964) Process-Reactive scale, and 52 of the 56 subjects were receiving psychotropic medication at the time of the study. These 56 subjects were selected from a total of 96 patients who had originally been nominated by ward personnel. Prospective subjects were dropped from consideration for failure to attend a prescreening interview with the author (32 subjects) and for various scheduling difficulties (8 subjects).
Assessment Instruments and Procedures Ward behavior observations. Ward behavior was observed at predetermined times using a scale that recorded the subjects' location on the ward, his proximity to others, whether or not he was interacting with others, and all other concurrent appropriate and inappropriate behaviors (e.g., smoking, grooming, posture, idiosyncratic repetitive motions, etc.). After these recordings had been summarized into "trial" scores (one trial = one 2-day block of observations), they provided the dependent measure of primary interest, "% alone," defined as the percentage of observations during each 2-day trial that each subject was observed further than 4 feet from the closest other person. The form utilized for recording these observations was provided by Doty (1972). These observations were made during a 4-day period 2 weeks prior to treatment, during the 2 weeks concurrent with the experimental treatments, and during a 4-day period 2 weeks following treatment by one of eight graduate student trainees working at the host hospital. The eight ward observers formed four observer pairs, each of which was responsible for the observations on one of the hospital's four psychiatric (nongeriatric) units. All
678
DAVID W. DOTY
observations were made during the scheduled ward free times, which fell either shortly before or after meals. For IS of the 56 subjects, two observers made parallel observations, permitting estimates of the reliability of the observational judgments. The observers were blind to both the nature of the dependent variable to be extracted from their recordings and the group assignments of the subjects. Social responsiveness assessments. In order to obtain an assessment of the subjects' social responsiveness that was independent of his day-to-day ward behavior and that would maximally reflect behaviors learned during treatment, observations were made of the subjects and the therapist's responses under standardized group discussion conditions both at the very beginning and end of treatment. Subjects in the "no-treatment" condition participated in these discussions at times concurrent with the other treatment groups. The therapists conducted a discussion of the subjects' reactions to their hospital experience by proceeding gradually from general, undirected questions to more specific group-oriented questions, and eventually to specific individual-oriented questions. Trained observers, unaware of the experimental group identity of the subjects, collected timesampled recordings of both therapist and subject responses during 'these discussions allowing computation of three dependent measures for each subject: (a) % silent—the percentage of total discussion time that each subject remained silent; (b) responsiveness to group questions—the percentage of the observational time intervals that included both a grouporiented therapist question and a response by the subject, and (c) responsiveness to individual questions—the percentage of time intervals including individual-oriented questions and a response by the subject.
Treatment Conditions The four experimental groups (incentive, role playing, combination, nonspecific control) were scheduled to meet with one of the therapists for a total of four sessions over a 2-week period. Treatment sessions were all conducted on the same days in order that treatment variables were not confounded with time of day. Although sufficient review of material was programmed into the treatment sessions to make the penalty for absenteeism minimal, any subject who missed a session was contacted personally by the author prior to the next session and reminded of his agreement to attend and of the potential monetary earnings ($2.50/session, described below) for participation. These procedures, coupled with the therapists' escorting all subjects to treatment sessions, increased attendance from 40% in the initial assessment sessions to 79% during treatment. Subjects assigned to the no-treatment control condition (n = 8) participated in the social responsiveness assessment discussions led by one of the therapists. Further descriptions of the specific treatment conditions are given below. More detailed specifications are given by Doty (1972).
Social skills training/role playing condition. In order to establish the interpersonal skills necessary to elicit positive reinforcement from other people, the subjects were guided through a series of increasingly difficult role-playing situations of social interactions on the ward. Within the framework of emphasizing attention to the behavior that occurred during each session, the subjects were instructed, role played, and were given feedback concerning behaviors such as discussion topic selection, eye contact, first-name references, speaking up, explaining one's own feelings to others, questioning others regarding their reactions and feelings, and generalizing from current topics of discussion to new ones. Noncontingent encouragement for behavior changes was provided all members of this condition. Incentive condition. In order to test the notion that many noninteractive patients have the full complement of social skills necessary for active interactions with others, this condition employed minimal incentives in a delayed contingency for increased ward social proximity and interaction behaviors. Therefore, the crucial ingredient defining this condition was small monetary payoffs (up to $2.50 per session) for the ward social interactions that the subjects engaged in between treatment sessions. The ward behavior observations served as the basis for these contingent payoffs. However, subjects were told that the information was provided by the aide staff on their ward in order to minimize the reactivity of the actual observers. The sessions focused on such things as payment of the money earned by the subjects (interaction earned twice as much as proximity) and detailed specification of what each subject did to earn his reward. During all sessions the subjects' attention was directed away from "session" behavior and toward recent and future ward behavior. Combination condition. This treatment condition was a straightforward combination of the major ingredients of the social skills training/role-playing condition and the incentive condition. Everyone involved in conducting these treatments felt that these elements were successfully combined without significantly diluting either of them. Nonspecific control condition. This treatment was modeled after the attention-control group used by Wollersheim (1968) in that it was designed to control for the nonspecific therapy elements such as attention and positive regard from the therapist, knowledge of the target behaviors, and the expectancy that the four treatment sessions would lead to positive behavior change by the subjects. The vehicle for this control was lectures by the therapists following a transactional games analysis orientation and attempting to examine the supposed intrapsychic reasons why the subjects did not engage in more social interaction. Opportunities for the subjects to role play sample interactions or mention of concrete incentives for behavior change were specifically and intentionally avoided. No-treatment control condition. The only contact that the subjects in this condition had with the
MODIFICATION OF THE SOCIAL INTERACTION therapists was in the pretreatment and posttreatment social responsiveness assessments. In fact, these subjects were never told that they would receive treatment and, therefore, received none of the nonspecific treatment elements such as knowledge of the target behaviors, encouragement to change, etc.
Therapists Three clinical psychology graduate students from the University of Illinois, who were serving at the host hospital as clinical psychology trainees, participated as therapists in the study. Each of the three therapists conducted a four member group from each of the therapist-contact conditions (role playing, incentive, combination, and nonspecific control). Additionally, two of the therapists each conducted the pretreatment and posttreatment social responsiveness assessment discussions for four-member groups of subjects assigned to the no treatment control. All of the therapists had a minimum of nine months of supervised clinical training at the host institution and in other clinical practica. Following study of the treatment manuals (Doty, 1972) by the therapists, their orientations toward treatment were assessed by the Therapist Orientation Sheet (Paul, 1969) and a questionnaire designed to elicit their predictions as to the relative efficacy of the various treatment conditions. Numerous discussions of the treatment procedures both before and during treatment and tape-recorder monitoring of the treatment sessions, spot-checked by the author, insured that all prescribed procedures were followed by the therapists.
RESULTS In order to make the statistical analyses as meaningful as possible it was necessary in some cases to drop some subjects' data from consideration. For instance, eight subjects were dropped for failure to adequately expose themselves to the treatments (only subjects attending three or more sessions were included), and nine subjects were dropped from the analysis of the ward data because of incomplete data. Thus, criteria for data selection were as objective as possible, and attrition rates were approximately the same across the various subject groups. The success of the random stratified-block subject-assignment procedure in establishing the preexperimental group equation was checked using Treatment X Therapist analyses of variance for the group means and Bartlett's test of homogeneity of variance on the following variables both before treatment and rechecked after the data rejection mentioned above: age, length of continuous and accu-
679
mulated hospitalization, and the dependent measures (% Alone, % Silence, responsiveness to group questions and responsiveness to individual questions). Psychotropic drug status and unit of residence were equated by assignment. Of 19 F ratios only 1, the interaction test for age, was significant (p < .OS). However, age showed nonsignificant correlations with all dependent measures, indicating ihis slight failure to preexperimentally equate did not affect the later analyses. Furthermore, Bartlett's chi-squares were all highly nonsignificant (p>.SO). From this data, it can be seen that the equation of groups was quite effective. Since these tests were done after data selection was completed, they constitute further evidence that the data selection did not differentially affect treatment or therapist groups. Analysis oj Ward Data The % alone scores, summarized into nine 2-day trials, were subjected to a three-way (treatments, therapists, and trials) repeatedmeasures analysis of variance. Of primary interest in demonstrating differential changes across trials for the various treatment groups was the Treatment X Trials interaction. This test approached but did not attain significance, 77(32, 192) = 1.31, criterion F.OB = 1.46), indicating a tendency, although nonsignificant, toward differential group responsiveness to treatment. The most significant effect was that for trials, 7^(8, 192) = 2.69, P < .01, which reflected a slight tendency for all subjects to reduce their % alone scores across trials. There was considerable variance between trial means within this trend, however. The ward behavior data was also summarized into three 4-day blocks that corresponded to baseline, end of treatment, and follow-up period, and was further subjected to a two-way trend analysis. Table 1, which gives the results of that analysis, shows that the overall Treatment X Trials interaction was significant beyond the .OS level, and the quadratic effect for that interaction was significant beyond the .025 level. Further examination of this latter effect using Scheffe"'s test for post hoc comparisons indicated that the
DAVID W. DOTY
680 TABLE 1
TREND ANALYSIS OF WARD BEHAVIOR DATA FOR TRIALS 1 AND 2, 5 AND 6, AND 8 AND 9, BY TREATMENTS AND TRIALS Source
df
MS
F
Treatments (A) Error between subjects
4 34 2 8 4 4 68 34 34
1,166.41 1,074.86
1.09
Trials (B) AX B Linear Quadratic Error within subjects Linear Quadratic
395.54 436.99 402.51 471.46
1.87 2.07* 1.34 3.85**
211.55 300.50 122.59
*t < .05. ** p < .025.
groups receiving incentive ingredients (combination and incentive) demonstrated significantly different quadratic trends (p < .005), from the remaining three groups combined and that the combination and social skills training/role-playing groups demonstrated significantly different quadratic trends (p < .01). Similar comparisons between combined groups receiving role-playing ingredients and the other three groups and between the combination and incentive groups proved nonsignificant. Analysis of Social Responsiveness Data Although the overall three-way analyses of variance failed to demonstrate significant Treatment X Trial interactions, results of individual group t tests between the pretreatment and posttreatment means for individual groups demonstrated that only in the incentive and combination conditions did significant changes occur. More specifically, significant decreases in the percentage of time each subject remained silent (% silence) during these discussions occurred in both the combination, t(9) = 2.02, p < .05, and the incentive conditions, f(6) = 2.61, p < .025. Also, significant increases in the responsiveness of individual subjects to group-oriented questions (responsiveness to group questions) for both the combination 2(7) = 2.52, p < .025, and the incentive conditions, t(6) = 3.68, p < .01.
Comparisons of the changes evidenced by the combination and incentive treatments with the changes demonstrated by the two control conditions produced consistent statistical significance. As shown in Table 2, all betweengroups comparisons showed highly significant differences in effectiveness of the treatment and control conditions in producing behavior change as indexed by these two measures of social responsiveness. It should be pointed out that the examinations of behavior change of the individual treatment groups presented above are consistent across both the ward and discussion data in demonstrating significance only for the two conditions that employed minimal incentives for changes in ward behavior. Construct validation of dependent measures and treatment targets. Since the results of the analyses of overall treatment effects across trials were impressive only in their consistency across analyses and dependent measures, correlational analyses between major pretreatment and change scores were undertaken to examine the treatment responsiveness of individuals evidencing differing levels of pretreatment social responsiveness. Such analyses could provide both construct validity to the battery of behavioral indexes gathered in the study and suggestive evidence that, regardless of minimal overall effectiveTABLE 2 t TESTS OF DIFFERENCES BETWEEN COMBINED AND INCENTIVE GROUPS AND CONTROL GROUPS ON % SILENCE AND RESPONSIVENESS TO GROUP QUESTIONS MEASURES or CHANGE
Measure and treatment group
Control group Nonspecific No treatment t t
% silence Combined Incentive Responsiveness to group questions Combined Incentive * p < .025. ** p < .005.
2.27* 2.56*
4.68** 5.05**
5.04** 4.40**
5.22** 5.17**
MODIFICATION OF THE SOCIAL INTERACTION ness, the individual treatment conditions affected the domains of subject behavior that were their intended targets. Total sample and specific treatment group correlations between pretreatment measures of social responsiveness and change scores on the % alone measure from pretreatment (Trial 2) to posttreatment (Trial 6) and to follow-up (Trial 9) were examined. While interpretations of these results must be cautious and merely suggestive, due to the low number of subjects involved in many of the correlations and the fact that the coefficients are not totally independent of one another, they do provide some evidence that the experimental treatments affected changes in the target behavior for which they were designed. That is, there is a definite tendency for the coefficients in the role-playing condition (all rs between —.458 and —.708) to indicate association between low pretreatment social responsiveness and improvement on the % alone measures. Furthermore, an opposite tendency for an association between improvement in the ward data and relatively high pretreatment social responsiveness is suggested by the results in the incentive condition (four of six rs between .243 and .923). DISCUSSION The present study offers several kinds of evidence that the social interaction and responsiveness behaviors of male psychiatric patients can be increased through the use of minimal incentives, both alone and in combination with role-playing techniques. Although analyses of variance failed to demonstrate consistent overall treatment group differences, a trend analysis utilizing the major data points, pretreatment-posttreatment comparisons for specific conditions, and correlational analyses were consistent in supporting the effectiveness of incentives over role playing in modifying these behaviors within the confines of the relatively short (four sessions) treatments examined. The restriction of treatment to four sessions may have produced results with limited generality, in that very different results might have been obtained in an examination of more extended treatment. Both the generalization
681
of the incentive effects to the social responsiveness discussions in which the monetary contingencies were not operative and the consistent superior effectiveness of incentives over role playing may be effects specific to short-term treatment. The improvement of the incentive condition subjects on the contingency-free responsiveness measures may be explained by the fact that, as mentioned above, all of the dependent measures no doubt contain elements sensitive to both incentive and competency factors. However, in longer term treatments these behavior changes in the incentive condition might very well have assumed smaller proportions relative to those for the role-playing conditions. Within the framework of two-stage learning theory conceptualizations, this would be explained by saying that longer treatments would allow time for new learning in the role-playing condition above and beyond the performance effects on previously learned behaviors brought about by the incentive manipulations. It may be that an additional control condition using noncontingent incentives might have shed further light on these hypotheses. The superiority of the incentive conditions over those focusing on role playing alone provides at least two suggestions for future institutional treatment practices. First, the failure of the role-playing condition subjects to demonstrate significant changes either on the ward behavior or the insession assessment data suggests that short-term treatments that fail to provide concrete incentives for behavior change outside the treatment sessions may prove fruitless. Second, but equally important, the behavior changes evidenced by the treatment that focused solely on incentives serves as an indictment of the incentives and encouragements typically supplied by the traditional hospital milieu. As argued earlier, continued social responsiveness and interaction is important for the consensual validation of significant events it offers the patient and because it would seem to be a prerequisite for positive response to most traditional treatment programs and for the individual's eventual release from the hospital. The present
DAVID W. DOTY
682
evidence would suggest that with a minimum of effort institutions could provide the incentive necessary to encourage its patients to become active and interested participants in, rather than passive and withdrawn recipients of, their treatment. Above and beyond these tentative suggestions for program development, the study demonstrates the feasibility and utility of the direct, objective measurement of social behavior that is necessary both for the assessment of an individual's competencies and the evaluation of treatment approaches. REFERENCE NOTE 1. Lewinsohn, P. M., Weinstein, M. S., & Shaw, D. A. Depression: A clinical research approach. Unpublished manuscript, University of Oregon, 1968. REFERENCES Barthell, C. N., & Holmes, O. S. High school yearbooks: A non-reactive measure of social isolation in graduates who later became schizophrenic. Journal of Abnormal Psychology, 1968, 73, 313317. Bockhoven, J. S. Moral treatment in American psychiatry. New York: Springer, 1963. Braginsky, B., Braginsky, D., & Ring, K. Methods of madness: The mental hospital as a last resort. New York: Holt, 1969. Doty, D. W. Role playing and incentives in the modification of the social interaction behaviors of psychiatric patients. Unpublished doctoral dissertation, University of Illinois, 1972.
Dunham, H. W., & Weinberg, S. K. The culture of the state mental hospital. Detroit: Wayne State University Press, 1960. Goffman, E. Asylums. New York: Doubleday, 1961. Outride, M. E., Goldstein, A. P., & Hunter, G. F. The use of modeling and role playing to increase social interaction among social psychiatric patients. Journal of Consulting and Clinical Psychology, 1973, 40, 408-415. Lazarus, A. A. Learning theory and the treatment of depression. Behaviour Research and Therapy, 1968, 6, 83-89. Paul, G. L. Chronic mental patient: Current status —future directions. Psychological Bulletin, 1969, 71, 81-94. Peterson, D. R. The clinical study of social behavior. New York: Appleton-Century-Crofts, 1968. Schaeffer, H. H., & Martin, P. L. Behavioral therapy for "apathy" of hospitalized schizophrenics. Psychological Reports, 1966, 19, 1147-1158. Ullmann, L. P. Institution and outcome: A comparative study of psychiatric hospitals. Oxford, Eng.: Pergamon Press, 1967. Ullmann, L. P., & Giovannoni, J. M. The development of a self-report measure of the process-reactive continuum. Journal of Nervous and Mental Disease, 1964, 138, 38-42. Wollersheim, J. P. The effectiveness of learning theory-based group therapy in the treatment of overweight women. Unpublished doctoral dissertation, University of Illinois, 1968. Zusman, J. Some explanations of the changing appearance of psychotic patients: Antecedents of the social breakdown syndrome concept. In E. M. Gruenberg (Ed.), Evaluating the effectiveness of community mental health services. New York: Milbank Memorial Fund, 1966. (Received January 23, 1975)
Role Playing and Incentives in the Modification of the Social Interaction of Chronic Psychiatric Patients David Warren Doty State University of New Yor/c at Albany This article studied the relative and combined effectiveness of role playing and monetary incentives to increase the social interaction and responsiveness of chronic male psychiatric patients. Noninteractive patients were assigned either to one of three treatment conditions (role playing only, incentive only, or combination) or two control conditions (nonspecific control or no-treatment control) for a total of four sessions. Dependent measures were extracted both from observations of the subjects' ward behavior (% time spent alone) over a 4-week period and from observations of the subjects' participation in structured small group discussions at pretreatment and posttreatment. All subject groups were equated on pretreatment ward behavior measures, age, length of hospitalization, and drug status. Trend analyses of ward data and post hoc t tests with the discussion data consistently indicated significant positive changes at posttreatment for only those groups receiving monetary incentives. Results are discussed with regard to their potential specificity to short-term treatment, their suggestions for institutional treatment practices, and the fact that they point up the utility of direct, objective assessment of social behavior in institutional settings.
Social isolation and a relative absence of social interactions constitute the modal behavior pattern of hospitalized psychiatric patients (e.g., Bockhoven, 1963; Dunham & Weinberg, 1960; Gutride, Goldstein, & Hunter, 1973; Ullmann, 1967). Since this behavior pattern has often played an integral part of the individual's prehospital adjustment (Barthell & Holmes, 1968), and tends to make him refractory to active treatment efforts within the institution (Braginsky, Braginsky, & Ring, 1969; Ullmann, 1967), modification of these behaviors is essential to the individual's eventual return to the com-
munity. This study attempted to demonstrate relevant variables that increase the social responsiveness of psychiatric patients. Response classes similar to those of interest here have previously been characterized both as "apathy" (Schaeffer & Martin, 1966) and as depressive behavior (Lazarus, 1968; Lewinsohn, Weinstein, & Shaw, Note 1). Although Schaeffer and Martin (1966) demonstrated the responsiveness of apathetic behaviors to response-contingent token reinforcement procedures, their study did not have as its primary focus the social proximity and interaction behavior that is of interest here. A recent study of Gutride et al. (1973) did This article was based on the author's doctoral examine the effects of structured learning dissertation submitted to the University of Illinois at therapy (modeling plus role playing plus soUrbana-Champaign in partial fulfillment of the requirements for the PhD. Sincere gratitude is ex- cial reinforcement) on the social interaction tended to Irving Berman, Fred Kraus, and Leonard behavior of hospitalized patients. However, Levitz who served as therapists for the study and failure to include appropriate controls made to Donald Peterson for his helpful advice during the it impossible to separate the effects of the conduct of the research. Behavioral observations three therapeutic ingredients either from each were collected by Jenifer Hokman Doty, the author's late wife, Judy McArdle, Mary Borkovec, Martha other or from the effects of nonspecific (atWilzbach, William Smith, Sharon Drude, Michael tention-placebo) treatment variables. Further Tallman, Gary Anderson, Steven Rubin, Benjamin examination of the relevant treatment and Cooley, David Jarman, and Robert McGrath. subject variables is clearly indicated. Requests for reprints should be sent to David W. Following Paul (1969) and Zusman Doty, Department of Psychology, State University of New York at Albany, Albany, New York 12222. (1966), it is felt that a conceptualization 676
MODIFICATION OF THE SOCIAL INTERACTION emphasizing both hospital and patient characteristics in formulating potential treatments should prove most productive in this regard. Approaches focusing solely on the oppressive, dependency-creating nature of the "total institution" (e.g., Goffman, 1961) or on the personality defects and manipulative tactics of the patients (e.g., Braginsky et al., 1969) are seen as committing stimulus and organism errors, respectively. Furthermore, it is felt that patient characteristics are best viewed in terms of behavioral competencies (Peterson, 1968) rather than underlying personality dynamics, and environmental characteristics, in terms of response alternatives made available and reinforced by the hospital milieu (Ullmann, 1967). Therefore, the treatments evaluated in this study, which emerged from a model involving an interaction of these patient and hospital characteristics, included both (a) training in the social skills necessary for continued interactive behavior and (b) instituting positive payoff for the desired social proximity and interaction. The major questions of interest were: Do training in social skills or incentives, or a combination of both contribute to either the daily social interaction rates or the social responsiveness of psychiatric patients? And do psychiatric patients demonstrating differing levels of pretreatment social responsiveness appear to be differentially responsive to treatments focusing on skill training and incentives? The answers to these questions should indicate relevant treatment variables as well as identify the variables antecedent to the social withdrawal and isolation evidenced by so many psychiatric patients. METHOD General Procedure The basic experimental design was a repeatedmeasures group paradigm. Subjects were randomly assigned from stratified blocks formed on the basis of pretreatment levels of daily social interaction either to one of three active treatment conditions {incentive, role playing, or combination) («= 12 each) or to one of two control conditions (nonspecific or no treatment; Ns = 12 and 8, respectively. Three therapists each met for a total of four sessions with one group of four subjects from each
677
of the active treatment conditions and the nonspecific control condition. Two of the three therapists also met for assessment purposes with a four-member group of subjects assigned to the no-treatment condition.
Subjects Subjects were 56 male open-ward psychiatric patients at the Veterans Administration Hospital, Danville, Illinois, who were nominated for the study by nursing personnel on their wards as being noninteractive, relatively cooperative, and not engaging in active delusional or hallucinatory behavior. None of the subjects were participating in other forms of active psychological treatment except chemotherapy or assignment to recreational activities at the time of the study. They were assigned randomly to one of five groups equated on nine variables including age, length of continuous and accumulated hospitalization, drug status, unit of residence, and the major dependent measures (described below). The total sample averaged 47.98 years of age, 89.66 months (7.47 years) of accumulated hospitalization, a score of 13.06, average near the midpoint, on the Ullmann-Giovannoni (1964) Process-Reactive scale, and 52 of the 56 subjects were receiving psychotropic medication at the time of the study. These 56 subjects were selected from a total of 96 patients who had originally been nominated by ward personnel. Prospective subjects were dropped from consideration for failure to attend a prescreening interview with the author (32 subjects) and for various scheduling difficulties (8 subjects).
Assessment Instruments and Procedures Ward behavior observations. Ward behavior was observed at predetermined times using a scale that recorded the subjects' location on the ward, his proximity to others, whether or not he was interacting with others, and all other concurrent appropriate and inappropriate behaviors (e.g., smoking, grooming, posture, idiosyncratic repetitive motions, etc.). After these recordings had been summarized into "trial" scores (one trial = one 2-day block of observations), they provided the dependent measure of primary interest, "% alone," defined as the percentage of observations during each 2-day trial that each subject was observed further than 4 feet from the closest other person. The form utilized for recording these observations was provided by Doty (1972). These observations were made during a 4-day period 2 weeks prior to treatment, during the 2 weeks concurrent with the experimental treatments, and during a 4-day period 2 weeks following treatment by one of eight graduate student trainees working at the host hospital. The eight ward observers formed four observer pairs, each of which was responsible for the observations on one of the hospital's four psychiatric (nongeriatric) units. All
678
DAVID W. DOTY
observations were made during the scheduled ward free times, which fell either shortly before or after meals. For IS of the 56 subjects, two observers made parallel observations, permitting estimates of the reliability of the observational judgments. The observers were blind to both the nature of the dependent variable to be extracted from their recordings and the group assignments of the subjects. Social responsiveness assessments. In order to obtain an assessment of the subjects' social responsiveness that was independent of his day-to-day ward behavior and that would maximally reflect behaviors learned during treatment, observations were made of the subjects and the therapist's responses under standardized group discussion conditions both at the very beginning and end of treatment. Subjects in the "no-treatment" condition participated in these discussions at times concurrent with the other treatment groups. The therapists conducted a discussion of the subjects' reactions to their hospital experience by proceeding gradually from general, undirected questions to more specific group-oriented questions, and eventually to specific individual-oriented questions. Trained observers, unaware of the experimental group identity of the subjects, collected timesampled recordings of both therapist and subject responses during 'these discussions allowing computation of three dependent measures for each subject: (a) % silent—the percentage of total discussion time that each subject remained silent; (b) responsiveness to group questions—the percentage of the observational time intervals that included both a grouporiented therapist question and a response by the subject, and (c) responsiveness to individual questions—the percentage of time intervals including individual-oriented questions and a response by the subject.
Treatment Conditions The four experimental groups (incentive, role playing, combination, nonspecific control) were scheduled to meet with one of the therapists for a total of four sessions over a 2-week period. Treatment sessions were all conducted on the same days in order that treatment variables were not confounded with time of day. Although sufficient review of material was programmed into the treatment sessions to make the penalty for absenteeism minimal, any subject who missed a session was contacted personally by the author prior to the next session and reminded of his agreement to attend and of the potential monetary earnings ($2.50/session, described below) for participation. These procedures, coupled with the therapists' escorting all subjects to treatment sessions, increased attendance from 40% in the initial assessment sessions to 79% during treatment. Subjects assigned to the no-treatment control condition (n = 8) participated in the social responsiveness assessment discussions led by one of the therapists. Further descriptions of the specific treatment conditions are given below. More detailed specifications are given by Doty (1972).
Social skills training/role playing condition. In order to establish the interpersonal skills necessary to elicit positive reinforcement from other people, the subjects were guided through a series of increasingly difficult role-playing situations of social interactions on the ward. Within the framework of emphasizing attention to the behavior that occurred during each session, the subjects were instructed, role played, and were given feedback concerning behaviors such as discussion topic selection, eye contact, first-name references, speaking up, explaining one's own feelings to others, questioning others regarding their reactions and feelings, and generalizing from current topics of discussion to new ones. Noncontingent encouragement for behavior changes was provided all members of this condition. Incentive condition. In order to test the notion that many noninteractive patients have the full complement of social skills necessary for active interactions with others, this condition employed minimal incentives in a delayed contingency for increased ward social proximity and interaction behaviors. Therefore, the crucial ingredient defining this condition was small monetary payoffs (up to $2.50 per session) for the ward social interactions that the subjects engaged in between treatment sessions. The ward behavior observations served as the basis for these contingent payoffs. However, subjects were told that the information was provided by the aide staff on their ward in order to minimize the reactivity of the actual observers. The sessions focused on such things as payment of the money earned by the subjects (interaction earned twice as much as proximity) and detailed specification of what each subject did to earn his reward. During all sessions the subjects' attention was directed away from "session" behavior and toward recent and future ward behavior. Combination condition. This treatment condition was a straightforward combination of the major ingredients of the social skills training/role-playing condition and the incentive condition. Everyone involved in conducting these treatments felt that these elements were successfully combined without significantly diluting either of them. Nonspecific control condition. This treatment was modeled after the attention-control group used by Wollersheim (1968) in that it was designed to control for the nonspecific therapy elements such as attention and positive regard from the therapist, knowledge of the target behaviors, and the expectancy that the four treatment sessions would lead to positive behavior change by the subjects. The vehicle for this control was lectures by the therapists following a transactional games analysis orientation and attempting to examine the supposed intrapsychic reasons why the subjects did not engage in more social interaction. Opportunities for the subjects to role play sample interactions or mention of concrete incentives for behavior change were specifically and intentionally avoided. No-treatment control condition. The only contact that the subjects in this condition had with the
MODIFICATION OF THE SOCIAL INTERACTION therapists was in the pretreatment and posttreatment social responsiveness assessments. In fact, these subjects were never told that they would receive treatment and, therefore, received none of the nonspecific treatment elements such as knowledge of the target behaviors, encouragement to change, etc.
Therapists Three clinical psychology graduate students from the University of Illinois, who were serving at the host hospital as clinical psychology trainees, participated as therapists in the study. Each of the three therapists conducted a four member group from each of the therapist-contact conditions (role playing, incentive, combination, and nonspecific control). Additionally, two of the therapists each conducted the pretreatment and posttreatment social responsiveness assessment discussions for four-member groups of subjects assigned to the no treatment control. All of the therapists had a minimum of nine months of supervised clinical training at the host institution and in other clinical practica. Following study of the treatment manuals (Doty, 1972) by the therapists, their orientations toward treatment were assessed by the Therapist Orientation Sheet (Paul, 1969) and a questionnaire designed to elicit their predictions as to the relative efficacy of the various treatment conditions. Numerous discussions of the treatment procedures both before and during treatment and tape-recorder monitoring of the treatment sessions, spot-checked by the author, insured that all prescribed procedures were followed by the therapists.
RESULTS In order to make the statistical analyses as meaningful as possible it was necessary in some cases to drop some subjects' data from consideration. For instance, eight subjects were dropped for failure to adequately expose themselves to the treatments (only subjects attending three or more sessions were included), and nine subjects were dropped from the analysis of the ward data because of incomplete data. Thus, criteria for data selection were as objective as possible, and attrition rates were approximately the same across the various subject groups. The success of the random stratified-block subject-assignment procedure in establishing the preexperimental group equation was checked using Treatment X Therapist analyses of variance for the group means and Bartlett's test of homogeneity of variance on the following variables both before treatment and rechecked after the data rejection mentioned above: age, length of continuous and accu-
679
mulated hospitalization, and the dependent measures (% Alone, % Silence, responsiveness to group questions and responsiveness to individual questions). Psychotropic drug status and unit of residence were equated by assignment. Of 19 F ratios only 1, the interaction test for age, was significant (p < .OS). However, age showed nonsignificant correlations with all dependent measures, indicating ihis slight failure to preexperimentally equate did not affect the later analyses. Furthermore, Bartlett's chi-squares were all highly nonsignificant (p>.SO). From this data, it can be seen that the equation of groups was quite effective. Since these tests were done after data selection was completed, they constitute further evidence that the data selection did not differentially affect treatment or therapist groups. Analysis oj Ward Data The % alone scores, summarized into nine 2-day trials, were subjected to a three-way (treatments, therapists, and trials) repeatedmeasures analysis of variance. Of primary interest in demonstrating differential changes across trials for the various treatment groups was the Treatment X Trials interaction. This test approached but did not attain significance, 77(32, 192) = 1.31, criterion F.OB = 1.46), indicating a tendency, although nonsignificant, toward differential group responsiveness to treatment. The most significant effect was that for trials, 7^(8, 192) = 2.69, P < .01, which reflected a slight tendency for all subjects to reduce their % alone scores across trials. There was considerable variance between trial means within this trend, however. The ward behavior data was also summarized into three 4-day blocks that corresponded to baseline, end of treatment, and follow-up period, and was further subjected to a two-way trend analysis. Table 1, which gives the results of that analysis, shows that the overall Treatment X Trials interaction was significant beyond the .OS level, and the quadratic effect for that interaction was significant beyond the .025 level. Further examination of this latter effect using Scheffe"'s test for post hoc comparisons indicated that the
DAVID W. DOTY
680 TABLE 1
TREND ANALYSIS OF WARD BEHAVIOR DATA FOR TRIALS 1 AND 2, 5 AND 6, AND 8 AND 9, BY TREATMENTS AND TRIALS Source
df
MS
F
Treatments (A) Error between subjects
4 34 2 8 4 4 68 34 34
1,166.41 1,074.86
1.09
Trials (B) AX B Linear Quadratic Error within subjects Linear Quadratic
395.54 436.99 402.51 471.46
1.87 2.07* 1.34 3.85**
211.55 300.50 122.59
*t < .05. ** p < .025.
groups receiving incentive ingredients (combination and incentive) demonstrated significantly different quadratic trends (p < .005), from the remaining three groups combined and that the combination and social skills training/role-playing groups demonstrated significantly different quadratic trends (p < .01). Similar comparisons between combined groups receiving role-playing ingredients and the other three groups and between the combination and incentive groups proved nonsignificant. Analysis of Social Responsiveness Data Although the overall three-way analyses of variance failed to demonstrate significant Treatment X Trial interactions, results of individual group t tests between the pretreatment and posttreatment means for individual groups demonstrated that only in the incentive and combination conditions did significant changes occur. More specifically, significant decreases in the percentage of time each subject remained silent (% silence) during these discussions occurred in both the combination, t(9) = 2.02, p < .05, and the incentive conditions, f(6) = 2.61, p < .025. Also, significant increases in the responsiveness of individual subjects to group-oriented questions (responsiveness to group questions) for both the combination 2(7) = 2.52, p < .025, and the incentive conditions, t(6) = 3.68, p < .01.
Comparisons of the changes evidenced by the combination and incentive treatments with the changes demonstrated by the two control conditions produced consistent statistical significance. As shown in Table 2, all betweengroups comparisons showed highly significant differences in effectiveness of the treatment and control conditions in producing behavior change as indexed by these two measures of social responsiveness. It should be pointed out that the examinations of behavior change of the individual treatment groups presented above are consistent across both the ward and discussion data in demonstrating significance only for the two conditions that employed minimal incentives for changes in ward behavior. Construct validation of dependent measures and treatment targets. Since the results of the analyses of overall treatment effects across trials were impressive only in their consistency across analyses and dependent measures, correlational analyses between major pretreatment and change scores were undertaken to examine the treatment responsiveness of individuals evidencing differing levels of pretreatment social responsiveness. Such analyses could provide both construct validity to the battery of behavioral indexes gathered in the study and suggestive evidence that, regardless of minimal overall effectiveTABLE 2 t TESTS OF DIFFERENCES BETWEEN COMBINED AND INCENTIVE GROUPS AND CONTROL GROUPS ON % SILENCE AND RESPONSIVENESS TO GROUP QUESTIONS MEASURES or CHANGE
Measure and treatment group
Control group Nonspecific No treatment t t
% silence Combined Incentive Responsiveness to group questions Combined Incentive * p < .025. ** p < .005.
2.27* 2.56*
4.68** 5.05**
5.04** 4.40**
5.22** 5.17**
MODIFICATION OF THE SOCIAL INTERACTION ness, the individual treatment conditions affected the domains of subject behavior that were their intended targets. Total sample and specific treatment group correlations between pretreatment measures of social responsiveness and change scores on the % alone measure from pretreatment (Trial 2) to posttreatment (Trial 6) and to follow-up (Trial 9) were examined. While interpretations of these results must be cautious and merely suggestive, due to the low number of subjects involved in many of the correlations and the fact that the coefficients are not totally independent of one another, they do provide some evidence that the experimental treatments affected changes in the target behavior for which they were designed. That is, there is a definite tendency for the coefficients in the role-playing condition (all rs between —.458 and —.708) to indicate association between low pretreatment social responsiveness and improvement on the % alone measures. Furthermore, an opposite tendency for an association between improvement in the ward data and relatively high pretreatment social responsiveness is suggested by the results in the incentive condition (four of six rs between .243 and .923). DISCUSSION The present study offers several kinds of evidence that the social interaction and responsiveness behaviors of male psychiatric patients can be increased through the use of minimal incentives, both alone and in combination with role-playing techniques. Although analyses of variance failed to demonstrate consistent overall treatment group differences, a trend analysis utilizing the major data points, pretreatment-posttreatment comparisons for specific conditions, and correlational analyses were consistent in supporting the effectiveness of incentives over role playing in modifying these behaviors within the confines of the relatively short (four sessions) treatments examined. The restriction of treatment to four sessions may have produced results with limited generality, in that very different results might have been obtained in an examination of more extended treatment. Both the generalization
681
of the incentive effects to the social responsiveness discussions in which the monetary contingencies were not operative and the consistent superior effectiveness of incentives over role playing may be effects specific to short-term treatment. The improvement of the incentive condition subjects on the contingency-free responsiveness measures may be explained by the fact that, as mentioned above, all of the dependent measures no doubt contain elements sensitive to both incentive and competency factors. However, in longer term treatments these behavior changes in the incentive condition might very well have assumed smaller proportions relative to those for the role-playing conditions. Within the framework of two-stage learning theory conceptualizations, this would be explained by saying that longer treatments would allow time for new learning in the role-playing condition above and beyond the performance effects on previously learned behaviors brought about by the incentive manipulations. It may be that an additional control condition using noncontingent incentives might have shed further light on these hypotheses. The superiority of the incentive conditions over those focusing on role playing alone provides at least two suggestions for future institutional treatment practices. First, the failure of the role-playing condition subjects to demonstrate significant changes either on the ward behavior or the insession assessment data suggests that short-term treatments that fail to provide concrete incentives for behavior change outside the treatment sessions may prove fruitless. Second, but equally important, the behavior changes evidenced by the treatment that focused solely on incentives serves as an indictment of the incentives and encouragements typically supplied by the traditional hospital milieu. As argued earlier, continued social responsiveness and interaction is important for the consensual validation of significant events it offers the patient and because it would seem to be a prerequisite for positive response to most traditional treatment programs and for the individual's eventual release from the hospital. The present
DAVID W. DOTY
682
evidence would suggest that with a minimum of effort institutions could provide the incentive necessary to encourage its patients to become active and interested participants in, rather than passive and withdrawn recipients of, their treatment. Above and beyond these tentative suggestions for program development, the study demonstrates the feasibility and utility of the direct, objective measurement of social behavior that is necessary both for the assessment of an individual's competencies and the evaluation of treatment approaches. REFERENCE NOTE 1. Lewinsohn, P. M., Weinstein, M. S., & Shaw, D. A. Depression: A clinical research approach. Unpublished manuscript, University of Oregon, 1968. REFERENCES Barthell, C. N., & Holmes, O. S. High school yearbooks: A non-reactive measure of social isolation in graduates who later became schizophrenic. Journal of Abnormal Psychology, 1968, 73, 313317. Bockhoven, J. S. Moral treatment in American psychiatry. New York: Springer, 1963. Braginsky, B., Braginsky, D., & Ring, K. Methods of madness: The mental hospital as a last resort. New York: Holt, 1969. Doty, D. W. Role playing and incentives in the modification of the social interaction behaviors of psychiatric patients. Unpublished doctoral dissertation, University of Illinois, 1972.
Dunham, H. W., & Weinberg, S. K. The culture of the state mental hospital. Detroit: Wayne State University Press, 1960. Goffman, E. Asylums. New York: Doubleday, 1961. Outride, M. E., Goldstein, A. P., & Hunter, G. F. The use of modeling and role playing to increase social interaction among social psychiatric patients. Journal of Consulting and Clinical Psychology, 1973, 40, 408-415. Lazarus, A. A. Learning theory and the treatment of depression. Behaviour Research and Therapy, 1968, 6, 83-89. Paul, G. L. Chronic mental patient: Current status —future directions. Psychological Bulletin, 1969, 71, 81-94. Peterson, D. R. The clinical study of social behavior. New York: Appleton-Century-Crofts, 1968. Schaeffer, H. H., & Martin, P. L. Behavioral therapy for "apathy" of hospitalized schizophrenics. Psychological Reports, 1966, 19, 1147-1158. Ullmann, L. P. Institution and outcome: A comparative study of psychiatric hospitals. Oxford, Eng.: Pergamon Press, 1967. Ullmann, L. P., & Giovannoni, J. M. The development of a self-report measure of the process-reactive continuum. Journal of Nervous and Mental Disease, 1964, 138, 38-42. Wollersheim, J. P. The effectiveness of learning theory-based group therapy in the treatment of overweight women. Unpublished doctoral dissertation, University of Illinois, 1968. Zusman, J. Some explanations of the changing appearance of psychotic patients: Antecedents of the social breakdown syndrome concept. In E. M. Gruenberg (Ed.), Evaluating the effectiveness of community mental health services. New York: Milbank Memorial Fund, 1966. (Received January 23, 1975)
