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Behavior recording as treatment: A brief note
BEI-IAVIO~THERAPY (1974) 5, 107--111
BmEF NoTEs
Behavior Recording as Treatment: A Brief Note BARRY M. MALETZKY 1
Department of Neuropsychiatry, U. S. Lyster Army Hospital, Fort Rucker, Alabama 36360
A wrist counter was used to count unwanted responses in five cases of maladaptive behavior. Each patient totalled his own responses and charted the total on graph paper daily. This simple technique of tracking behaviors was effective at first only while the patient wore the wrist counter. "Booster sessions" of counter wearing on a gradually tapering schedule produced long-lasting remission of symptoms. Counting self-behaviors prior to, during, and after treatment is a well-established behavioral technique which can lend objectively and direction to any therapy (Patterson & Gullion, 1971; Knox, 1972). Several authors (e.g., Rehm & Marston, 1968; R u t n e r & Bugle, 1969) have employed such self-monitoring procedures as p a r t of a therapeutic program, but record-keeping in these cases was used as an adjunct to other reinforcement procedures. Others (e.g., McFall, 1970; Johnson & White, 1971) have demonstrated the powerful effects of self-monitoring instructions. Kanfer (1970) has recently reviewed this area. In all of these reports, positive expectations of the self-monitoring procedure were provided. There is no systematic comment in the literature to date regarding the effect of such self-confrontation as the sole treatment offered. Five individual ease studies are thus described in which the patients involved wore cumulative wrist counters in an attempt to decrease repetitive, u n w a n t e d behaviors. The counters used were manufactured b y Behavior Research Company, Box 3351, Kansas City, Kansas 66103, at a cost of $4.00 each. Patients pushed a button on the counter each time the u n w a n t e d behavior occurred, then recorded their totals at the end of each day on graph paper, thereby keeping a running record of progress. Positive expectations were minimized to evaluate the effects accruing to 1Requests for reprints should be sent to Barry M. Maletzky, e/o Dr. A. J. Maletzky, 4223 E. Lynn St. Seattle, WA 98102. 107 Copyright © 19'74 by Academic Press, Inc. All rights of reproduction in any form reserved.
108
BRmF NOTES Baseline
Counter begun
Discontinued Re-started Discontinued Re-started Discontinued
FREQUENCY 15l iI OF
iO
BEHAVIOR
1
~
I
J
i
E
l
J
I
I
1
1
1
"1 WE[KS
FIG. 1. Frequency of scratching behaviors with and without use of a wrist counter. Case 1.
the recording t e c h n i q u e itself m o r e fully. Thus, all patients w e r e inf o r m e d that c o u n t i n g their behaviors w o u l d assist the therapists in understanding their problems, but that counting w o u l d not necessarily d e c r e a s e u n w a n t e d behaviors. Case 1.
A 52-year-old woman complained of a 30-year history of repetitive scratching resulting in unsightly lesions on arms and legs. A record of scratching with and without wearing the counter is reproduced in Fig. 1. Frequency of scratching Baseline
Counter begun
Discontinued
Re-started
Discontinued
10--
FREQUENCY
OF
5-
BEHAVIOR
0
~
4b.
-L~ W E E K S
FIG. 2. Frequency of inappropriate hand raising with and without use of a wrist counter. Case 3.
BRIEF N O T E S
109
declined over an initial 4-week period but recurred when the counter was not worn (counted by her h u s b a n d ) . "Booster sessions" of gradually decreasing duration were necessary to retain the strength of initial learning. A 12-month follow-up revealed no recurrence of scratching. Case 2. A 20-year-old woman asked for help because of a life-long history of fingernail biting to the point of producing extensive tissue maceration. As with Case 1, responses declined initially over an 8-week period while wearing the counter; initial high levels recurred (as counted b y her parents), however, when again not wearing the counter, necessitating continuing use of the counter I week out of every 4. Case 3. A 9-year-old boy raised his h a n d repeatedly in class, waving it furiously in response to his teacher's questions, despite not knowing the answers on many such occasions. He was seriously disrupting the class and agreed to try to stop this behavior by wearing the wrist counter. Figure 2 depicts the boy's own record of inappropriate hand raising, defined as hand raising without knowing the answer to the question, or h a n d waving. Responses declined over a 4-week initial period, rose again without the counter (recorded by his teacher), then declined to 0 after another 4 weeks with counter and remained there despite no further use of the counter over a 6-month follow-up period. Case 4. A 65-year-old woman complained of a 12-year history of facial tics. Medications and massed practice h a d been of no help. Counting her own tics led to an immediate decline from 76.5 tics daily to 0 over a period of 3 weeks. However, even Baseline
Counter begun
Discontinued
Re-started
Discontinued
25
20 FREQUENCY 15 OF 10 BEHAVIOR 5
0 I
~-
I
~
I
f
I
J
-~
I
[
~
I
I
4b-
I
I
~.~EE K S
FIG. 3. Frequency of out-of-seat responses with and without use of a wrist counter. Case 5.
110
BRIEF NOTES
while wearing the counter, tics recurred during the fourth week at the level of 37.3 daily. By wearing the counter every other day, tics have declined to l0 per day. Further decreases in counter time are planned. Case 5. An 11-year-old girl was noted to be constantly out of her seat in class. No other manifestation of hyperactivity was present. Figure 3 reports frequency of out-of-seat responses with and without the counter, the latter recorded by her classmates. The initial large decline was partially maintained for 2 weeks without the counter (average of 7.5 responses daily by the second week); wearing the counter produced a fnrther decline to an average of 2.5 daily responses maintained without counter over a 6-month follow-up. DISCUSSION No treatment was offered for these patients other than the behavior counting described. Care was taken not to report a positive "set" although no objective means of verifying its presence or absence is now available. Patients were nonetheless uniformly successful in decreasing u n w a n t e d motor behaviors merely b y keeping track of these on the cumulative wrist counters and charting their own progress. However, response frequency increased when counters were removed, necessitating a tapering process in which counters were worn for gradually decreasing durations. Patients typically noted the discriminative stimulus quality of wearing the counter on their wrists; as Case 1 commented, " I ' m more aware of not scratching when I feel that thing on m y wrist." The tapering process a p p e a r e d to stamp in the newly acquired habits of either not responding or responding in a manner incompatible with the original u n w a n t e d behavior. These results, while uncontrolled, support the notion that merely counting an u n w a n t e d behavior can help decrease it. However, a n u m b e r of methodological problems need to be solved before any definitive statement can be made, including the use of adequate controls and objective methods of m e a s u r e m e n t other than patients' self-recording. Of interest is an extension of this technique to cognitive behaviors. Cases 1 and 2 discovered that keeping count of impulses to scratch or bite fingernails decreased urges to commit the response and eventually decreased thoughts about the behaviors as well. REFERENCES JOHNSON, S. M., & WHITE, G. Self-observation as an agent of behavioral change. Behavior Therapy, 1971, 2, 488-497. KANFER, F. H. Self-Monitoring: methodological limitations and clinical applications: Journal of Consulting and Clinical Psychology, 1970, 35, 148-152.
B m ~ F NOTES
111
KNox, D. A behavioral approach to marriage happiness counselling. Champaign, Illinois: Research Press, 1972. Pp. 4-16. McFALL, R. M. Effects of self-monitoring on normal smoking behavior. ]o~rnal o] Consulting and Clinical Psychology, 1970, 35, 135-142. PATTERSON, G. R., & GtJLLIO~, M. E. Living With Children. Champaign, Illinois: Research Press, 1971. Pp. 97-99. REHM, L. P., & MARSTON, A. R. Reduction of social anxiety through modification of self-reinforcement: an instigation therapy technique. ]ournal of Consulting al~ Clinical Psychology, 1968, 32, 565-574. RUTNER, I. T., & BUCLE, C. An experimental procedure for the modification of psychotic behavior. Journal o[ Consulting and Clinical Psychology, 1969, 33, 651-653.
BmEF NoTEs
Behavior Recording as Treatment: A Brief Note BARRY M. MALETZKY 1
Department of Neuropsychiatry, U. S. Lyster Army Hospital, Fort Rucker, Alabama 36360
A wrist counter was used to count unwanted responses in five cases of maladaptive behavior. Each patient totalled his own responses and charted the total on graph paper daily. This simple technique of tracking behaviors was effective at first only while the patient wore the wrist counter. "Booster sessions" of counter wearing on a gradually tapering schedule produced long-lasting remission of symptoms. Counting self-behaviors prior to, during, and after treatment is a well-established behavioral technique which can lend objectively and direction to any therapy (Patterson & Gullion, 1971; Knox, 1972). Several authors (e.g., Rehm & Marston, 1968; R u t n e r & Bugle, 1969) have employed such self-monitoring procedures as p a r t of a therapeutic program, but record-keeping in these cases was used as an adjunct to other reinforcement procedures. Others (e.g., McFall, 1970; Johnson & White, 1971) have demonstrated the powerful effects of self-monitoring instructions. Kanfer (1970) has recently reviewed this area. In all of these reports, positive expectations of the self-monitoring procedure were provided. There is no systematic comment in the literature to date regarding the effect of such self-confrontation as the sole treatment offered. Five individual ease studies are thus described in which the patients involved wore cumulative wrist counters in an attempt to decrease repetitive, u n w a n t e d behaviors. The counters used were manufactured b y Behavior Research Company, Box 3351, Kansas City, Kansas 66103, at a cost of $4.00 each. Patients pushed a button on the counter each time the u n w a n t e d behavior occurred, then recorded their totals at the end of each day on graph paper, thereby keeping a running record of progress. Positive expectations were minimized to evaluate the effects accruing to 1Requests for reprints should be sent to Barry M. Maletzky, e/o Dr. A. J. Maletzky, 4223 E. Lynn St. Seattle, WA 98102. 107 Copyright © 19'74 by Academic Press, Inc. All rights of reproduction in any form reserved.
108
BRmF NOTES Baseline
Counter begun
Discontinued Re-started Discontinued Re-started Discontinued
FREQUENCY 15l iI OF
iO
BEHAVIOR
1
~
I
J
i
E
l
J
I
I
1
1
1
"1 WE[KS
FIG. 1. Frequency of scratching behaviors with and without use of a wrist counter. Case 1.
the recording t e c h n i q u e itself m o r e fully. Thus, all patients w e r e inf o r m e d that c o u n t i n g their behaviors w o u l d assist the therapists in understanding their problems, but that counting w o u l d not necessarily d e c r e a s e u n w a n t e d behaviors. Case 1.
A 52-year-old woman complained of a 30-year history of repetitive scratching resulting in unsightly lesions on arms and legs. A record of scratching with and without wearing the counter is reproduced in Fig. 1. Frequency of scratching Baseline
Counter begun
Discontinued
Re-started
Discontinued
10--
FREQUENCY
OF
5-
BEHAVIOR
0
~
4b.
-L~ W E E K S
FIG. 2. Frequency of inappropriate hand raising with and without use of a wrist counter. Case 3.
BRIEF N O T E S
109
declined over an initial 4-week period but recurred when the counter was not worn (counted by her h u s b a n d ) . "Booster sessions" of gradually decreasing duration were necessary to retain the strength of initial learning. A 12-month follow-up revealed no recurrence of scratching. Case 2. A 20-year-old woman asked for help because of a life-long history of fingernail biting to the point of producing extensive tissue maceration. As with Case 1, responses declined initially over an 8-week period while wearing the counter; initial high levels recurred (as counted b y her parents), however, when again not wearing the counter, necessitating continuing use of the counter I week out of every 4. Case 3. A 9-year-old boy raised his h a n d repeatedly in class, waving it furiously in response to his teacher's questions, despite not knowing the answers on many such occasions. He was seriously disrupting the class and agreed to try to stop this behavior by wearing the wrist counter. Figure 2 depicts the boy's own record of inappropriate hand raising, defined as hand raising without knowing the answer to the question, or h a n d waving. Responses declined over a 4-week initial period, rose again without the counter (recorded by his teacher), then declined to 0 after another 4 weeks with counter and remained there despite no further use of the counter over a 6-month follow-up period. Case 4. A 65-year-old woman complained of a 12-year history of facial tics. Medications and massed practice h a d been of no help. Counting her own tics led to an immediate decline from 76.5 tics daily to 0 over a period of 3 weeks. However, even Baseline
Counter begun
Discontinued
Re-started
Discontinued
25
20 FREQUENCY 15 OF 10 BEHAVIOR 5
0 I
~-
I
~
I
f
I
J
-~
I
[
~
I
I
4b-
I
I
~.~EE K S
FIG. 3. Frequency of out-of-seat responses with and without use of a wrist counter. Case 5.
110
BRIEF NOTES
while wearing the counter, tics recurred during the fourth week at the level of 37.3 daily. By wearing the counter every other day, tics have declined to l0 per day. Further decreases in counter time are planned. Case 5. An 11-year-old girl was noted to be constantly out of her seat in class. No other manifestation of hyperactivity was present. Figure 3 reports frequency of out-of-seat responses with and without the counter, the latter recorded by her classmates. The initial large decline was partially maintained for 2 weeks without the counter (average of 7.5 responses daily by the second week); wearing the counter produced a fnrther decline to an average of 2.5 daily responses maintained without counter over a 6-month follow-up. DISCUSSION No treatment was offered for these patients other than the behavior counting described. Care was taken not to report a positive "set" although no objective means of verifying its presence or absence is now available. Patients were nonetheless uniformly successful in decreasing u n w a n t e d motor behaviors merely b y keeping track of these on the cumulative wrist counters and charting their own progress. However, response frequency increased when counters were removed, necessitating a tapering process in which counters were worn for gradually decreasing durations. Patients typically noted the discriminative stimulus quality of wearing the counter on their wrists; as Case 1 commented, " I ' m more aware of not scratching when I feel that thing on m y wrist." The tapering process a p p e a r e d to stamp in the newly acquired habits of either not responding or responding in a manner incompatible with the original u n w a n t e d behavior. These results, while uncontrolled, support the notion that merely counting an u n w a n t e d behavior can help decrease it. However, a n u m b e r of methodological problems need to be solved before any definitive statement can be made, including the use of adequate controls and objective methods of m e a s u r e m e n t other than patients' self-recording. Of interest is an extension of this technique to cognitive behaviors. Cases 1 and 2 discovered that keeping count of impulses to scratch or bite fingernails decreased urges to commit the response and eventually decreased thoughts about the behaviors as well. REFERENCES JOHNSON, S. M., & WHITE, G. Self-observation as an agent of behavioral change. Behavior Therapy, 1971, 2, 488-497. KANFER, F. H. Self-Monitoring: methodological limitations and clinical applications: Journal of Consulting and Clinical Psychology, 1970, 35, 148-152.
B m ~ F NOTES
111
KNox, D. A behavioral approach to marriage happiness counselling. Champaign, Illinois: Research Press, 1972. Pp. 4-16. McFALL, R. M. Effects of self-monitoring on normal smoking behavior. ]o~rnal o] Consulting and Clinical Psychology, 1970, 35, 135-142. PATTERSON, G. R., & GtJLLIO~, M. E. Living With Children. Champaign, Illinois: Research Press, 1971. Pp. 97-99. REHM, L. P., & MARSTON, A. R. Reduction of social anxiety through modification of self-reinforcement: an instigation therapy technique. ]ournal of Consulting al~ Clinical Psychology, 1968, 32, 565-574. RUTNER, I. T., & BUCLE, C. An experimental procedure for the modification of psychotic behavior. Journal o[ Consulting and Clinical Psychology, 1969, 33, 651-653.