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Interaction-priming: A method of reinstating patient-family relationships
Behav.
Kes.
& Therapy,
CASE
1973,
Vol.
11,pp.I33
HISTORIES
Interaction-priming:
to 136.
AND
Perpamon
Press.
Printed
SHORTER
in England
COMMUNICATIONS
A method of reinstating patient-family
relationships*
(Received 19 April 1972) probability of successful discharge for long-term mental hospital patients has been found to depend on strong family and social relationships (Chapman, Day and Burstein, 1961; Chase and Silverman, 1943; Paul, 1969; Meichenbaum, 1966; Ullmann, 1967). Yet, long-term institutionalization often results in the weakening of these relationships. These findings suggest that successful discharge would be facilitated by procedures that maintained or restored these social relationships. The present study attempted to develop such a procedure, based on the principles of Response Priming (O’Brien, Azrin and Henson, 1969) and Reinforcer Sampling (Ayllon and Azrin, 1968). Response Priming views complex behavior such as family visits as chains of responses and states that the probability of the completion of the chain (visit) increases during later portions of the chain. The present procedure applies this principle by not requiring visitors to engage in those behaviors remote from the completion of the chainbut rather, by making visits available to them at the terminal portion of the chain. This was done by not requiring visitors to come to the hospital to visit the patient, but rather, by directly transporting the patient to the visitor’s home. The Reinforcer Sampling rationale (Ayllon and Azrin, 1968) suggests that future visits would likely increase if visits were reinforcing to the family and the patient. Thus, the patients’ behavior was analyzed during visits in the families’ homes. Between visits, instruction was given to the patients for improving the reinforcing quality of these types of behavior for subsequent visits. The rationale was that the Response Priming Procedure would produce visits and the Reinforcer Sampling Procedure would show the families and patients that being together was enjoyable. The relationships should, therefore, be maintained and, hopefully, thereby increase the likelihood of successful discharge for the long-term hospitalized patients.
THE
METHOD Patients Three chronic patients of a token economy ward of a State hospital (see: Ayllon and Azrin, 1968) served. Mary was 56 years of age, had been institutionalized for 30 yr and on admission was diagnosed ‘dementia1 praecox, hebephrenic type’. Sally was 64, had spent 20 yr in the hospital and on admission was diagnosed ‘involutional psychosis, melancholia’. The third patient, Janet, was 36, had been institutionalized for 14 yr and on admission was diagnosed ‘schizophrenic reaction, chronic undifferentiated type’. Each of the three patients had been on the token economy ward for over 18 months and had received virtually no visits with relatives over the immediately preceding year. Procedures A. No~mnl- Visitity Procedwr. The normal policy concerning visits was that any relative or friend upon request could visit the patient at any time whether on the ward, off the ward or in the families’ home for any duration. This visiting procedure had been communica:ed to the families prior to the study. B. Inviration-O/z/F Procedure. Each family was sent a letter every week explaining the importance of visits to the patients’ treatment, reiterating the open-visit policy described above, and included a stamped self-addressed post-card. The families were instructed to designate dates on the card on which they would visit. One of the listed dates was circled in red and the families were informed that if they did not return the card or check one of the alternate dates, they would bc expected to visit the hospital on the date circled. C. Invircrtion-Pllts-T,crns~ortatiorl Proced~rre. The same letter and post-cards described above were sent each week with a statement that if it were too inconvenient for the family to visit the hospital, the hospital would provide the patient transportation home for a short visit. The families were assured that a staff member * This research was supported by the Illinois Department National Institute of Mental Health. Reprints may be obtained Laboratory, Anna State Hospital, Anna, Illinois 62901.
133
of Mental Health and Grant 17981 from the from either author at the Behavior Research
134
CASE HISTORltS AND
SHORTER
C'OMMIJNI(‘ATI~!NS
would be present and that the visit would end at their option. Also. to cn~urc the fam~l~cs chat wc over-extend our visit, the staff member would say, “We should return to the hocpital. n~lu.” at tervals and unless objected to by the family, the visit would end at that point. As a rcmindcr. was contacted by telephone at least 2 days in advance of scheduledvitits and the >pcCtick elf the discussed (e.g. time of day, longest possible duration v,ith the stalf men~hcr l>~c
\\ould
nor inthe family visit were hat snacks
15 min
E.vperinrenttrl Des&a The sequence
of the proccdurc:
M~S an AHCBC
(I) Normal Visiting Procedure for 54 weeks, (2) Inviiation-Only Procedure for 3 weeks. (3) Invitation-Plus-Ttzisportation Procedure (4) Invitation-Only fr3r 3 week?. and (5) Invitation-Pltls-Transportation Procedure
design:
for 6 week\, for 9 :s;cks.
During visits to the home, the staff member evaluated the setting as it related to the beh:>viornl needs of the patient. (Four different stafT members qcrvcd in thii capacity throughout the study.) The ward program then developed those skills that were sacn to bc useful or rcquircd in the home. For cr;;rmple, a patient was trained to speak louder since her relative was hard of hearing. Anrjther patient practiced washing and ironing of clothing since her mother earned money hy doing so for ncishbors. Similarly. a patient wa$ taught to shop for groceries and to cook family meals since her husband suggectcd such assistance would be welcomed. During: visits, the staff armngcd for the patients to perform skills that \\ould be u~ful to the family especially during an extended home visit. F-I~amples of such useful activities web-e: durtinl: furniture. cooking meals and washing dishes. The performance of the patient was assessed during the v&it and the hospital program was modified on the basis of these assessments to assure grcatcr satisfaction on the subsequent visits. Particular value was placed on the families’ solicited assessment of the patient’\ oerformance.
RESlJLTS The duration of visits, both on the v,ard and in !hc visitor.5 l~omc \vac rcwrded by the ili>spital stafl‘ and \vas defined as the time the patient and visitor spent together. Figure 1 S~OM.\ that under the Normal Visiting Proccdurc, the families spent a mcnn of less th:ln 1 min per week visiting \vith the patients, 0, 1 and I min for each patient respectively. linder the Invitation-Only Proccdurc. the‘ f;lrnilic> 4pcnt n\) time visiting ~IO\\CLCI-. C;IL./I ill‘ the familie\ with the patients. During the Invit:lti3n-Plus-‘~r~ln.;port;lti(~ll I’r<~cedarc, averaged more than Y0 min per \tcek visiting xith the patients: the man f:)r the .q patienic \,;I\ more than 2 hr per week. Not sho\%n in Fig 1 is the finding that the mean time per \veek \pcnt visiting increased from 99 min during the first 6 week period to I71 min during the final 9 week period of Invitati~,rl-l’lus-Trans~~~~rt;tt ion. During the final 9 weeks of the study, the amount of time the families spent visiting uith the patient? was limited not by the families’ reluctance. but rather. by administrati\c limitations (t’.g. c;irs. personnel time). \%iting procedure The general atmosphere that prevailed durin g the Invitation-Plrl~-‘Tt’an~l~crrtr~!i~~n can be seen from the following individual accounts: Mucus. During the 30 conrecu!ivc yr Mary had hccn hocpitalizcd. neither hc‘r hu\bnnd nor other family members had ever visited her. During the Invitation-l’lus-Transportativn pro~edurc. ,,c\~YxI dilt‘ercnt family members visited with her, hut she mcst enjoyed visiting \rith her husband \ihtl \%:I\ r-ctircd bul cuntinued working his farm. At his and her requests, Mary was discharged to live \
CASE HISTORIES
AND
SHORTER
13.5
COMMUNIC’ATIONS
hwzet. Janet had been hospitalized for 14 yr and had been visited by her mother only twice during the preceeding year. Although Janet’s visits with her mother and her own 2 adolescent sons were generally successful, the mother was chronically medically ill and impoverished. No room was available in the home for Janet and no other family members were within visiting distance. The mother expressed a desire for home discharge but the financial and space limitations precluded that action. It appeared that Janet’s return to the community would be limited to shelter-care placement unless she could return to the community with an employable skill. She was, therefore, enrolled in a vocational training program but vocational placement was unsuccessful. She remains hospitalized
w
z ;
g PATIENT
2
+Z
FIG. 1. The mean time families spent visiting with their hospitalized relatives in min per week, under 3 visiting procedures. The patients were 3 women, each of whom had been hospitalized for more than 14 yr and had received few visits over this period. The Normal Visiting Procedure was an open invitation for the families to visit at their discretion. The Invitation-Only Procedure also included a weekly letter explaining the need for such visits and an invitation. The Invitation-Plus-Transportation Procedure included the weekly invitation letter, but in addition, included a provision that if it were too inconvenient for the family to visit, the hospital would provide transportation for the patient to the families home for short visits. In addition, the patients performed activities in the homes that were useful to the families and the hospital program was modified to improve the performance of these useful activities.
DISCUSSION The Invitation-Plus-Transportation visiting procedure reinstated and maintained the patient-family social relationships; whereas, neither the Normal Visiting nor Invitation-Only procedures did so. Response Priming (O’Brien, Azrin and Henson, 1968) initiated visits and Reinforcer Sampling (Ayllon and Azrin, 1968) maintained and increased the time families spent visiting with patients. The importance of these results is best demonstrated by the consequent requests of each family that the patients be returned from the hospital to live with them in the community. That one patient who had been hospitalized without visits for 30 consecutive yr was successfully discharged to live with her husband emphasizes the importance of the patient-family relationships. The Invitation-Plus-Transportation visiting procedure was demonstrated to reinstate and maintain relationships between hospitalized patients and their families, and thereby, to increase the likelihood of successful return to the community for the long-term hospitalized patients. Anna State Hospital, Anna, Illinois 62906, U.S.A.
F. O’BKIEN N. H. AZRIN
136
CASE HISTORIES AND SHORTER
COMMUNICATIONS
REFERENCES AYLL~N T. and AZRIN N. H. (1968a) The Token Economy: A Motivational System for Therapy and Rehabilitation. Appleton-Century-Crofts, New York. AYLLON T. and AZRIN N. H. (1968b) Reinforcer Sampling: a technique for increasing the behavior of mental patients. J. appt. Behav. Anal. 1, 21-34. CHAPMAN L. J., DAY D. and BURSTEIN A. (1961) The process-reactive distinction and prognosis in schizophrenia. J. nerv. ment. Dis. 133, 383-391. CHASE L. S. and SILVERMAN S. (1943) Prognosis in schizophrenia: an analysis of prognostic criteria in 150 schizophrenics treated with metrazol or insulin. J. new. ment. Dis. 98, 464-473. MEICHENBAUM D. H. (1966) Effects of social reinforcement on the level of abstraction in schizophrenics. J. abnorm. sot. Psychoi. 71. 354-362. PAUL G. L. (1969) Chronic mental patient: current status-future direction. Psycho/. BuII. 71, 81-94. O’BRIEN F., AZRIN N. H. and HENSON K. (1969) increased communications of chronic mental patients by reinforcement and by response priming. J. appl. Behav. Atzal. 2, 23-29. ULLMANN L. P. (1967) Institufiort and Outcome: CIComparative S/u&* of Psychicrtric Hospitals. Pergamon. New York.
Kes.
& Therapy,
CASE
1973,
Vol.
11,pp.I33
HISTORIES
Interaction-priming:
to 136.
AND
Perpamon
Press.
Printed
SHORTER
in England
COMMUNICATIONS
A method of reinstating patient-family
relationships*
(Received 19 April 1972) probability of successful discharge for long-term mental hospital patients has been found to depend on strong family and social relationships (Chapman, Day and Burstein, 1961; Chase and Silverman, 1943; Paul, 1969; Meichenbaum, 1966; Ullmann, 1967). Yet, long-term institutionalization often results in the weakening of these relationships. These findings suggest that successful discharge would be facilitated by procedures that maintained or restored these social relationships. The present study attempted to develop such a procedure, based on the principles of Response Priming (O’Brien, Azrin and Henson, 1969) and Reinforcer Sampling (Ayllon and Azrin, 1968). Response Priming views complex behavior such as family visits as chains of responses and states that the probability of the completion of the chain (visit) increases during later portions of the chain. The present procedure applies this principle by not requiring visitors to engage in those behaviors remote from the completion of the chainbut rather, by making visits available to them at the terminal portion of the chain. This was done by not requiring visitors to come to the hospital to visit the patient, but rather, by directly transporting the patient to the visitor’s home. The Reinforcer Sampling rationale (Ayllon and Azrin, 1968) suggests that future visits would likely increase if visits were reinforcing to the family and the patient. Thus, the patients’ behavior was analyzed during visits in the families’ homes. Between visits, instruction was given to the patients for improving the reinforcing quality of these types of behavior for subsequent visits. The rationale was that the Response Priming Procedure would produce visits and the Reinforcer Sampling Procedure would show the families and patients that being together was enjoyable. The relationships should, therefore, be maintained and, hopefully, thereby increase the likelihood of successful discharge for the long-term hospitalized patients.
THE
METHOD Patients Three chronic patients of a token economy ward of a State hospital (see: Ayllon and Azrin, 1968) served. Mary was 56 years of age, had been institutionalized for 30 yr and on admission was diagnosed ‘dementia1 praecox, hebephrenic type’. Sally was 64, had spent 20 yr in the hospital and on admission was diagnosed ‘involutional psychosis, melancholia’. The third patient, Janet, was 36, had been institutionalized for 14 yr and on admission was diagnosed ‘schizophrenic reaction, chronic undifferentiated type’. Each of the three patients had been on the token economy ward for over 18 months and had received virtually no visits with relatives over the immediately preceding year. Procedures A. No~mnl- Visitity Procedwr. The normal policy concerning visits was that any relative or friend upon request could visit the patient at any time whether on the ward, off the ward or in the families’ home for any duration. This visiting procedure had been communica:ed to the families prior to the study. B. Inviration-O/z/F Procedure. Each family was sent a letter every week explaining the importance of visits to the patients’ treatment, reiterating the open-visit policy described above, and included a stamped self-addressed post-card. The families were instructed to designate dates on the card on which they would visit. One of the listed dates was circled in red and the families were informed that if they did not return the card or check one of the alternate dates, they would bc expected to visit the hospital on the date circled. C. Invircrtion-Pllts-T,crns~ortatiorl Proced~rre. The same letter and post-cards described above were sent each week with a statement that if it were too inconvenient for the family to visit the hospital, the hospital would provide the patient transportation home for a short visit. The families were assured that a staff member * This research was supported by the Illinois Department National Institute of Mental Health. Reprints may be obtained Laboratory, Anna State Hospital, Anna, Illinois 62901.
133
of Mental Health and Grant 17981 from the from either author at the Behavior Research
134
CASE HISTORltS AND
SHORTER
C'OMMIJNI(‘ATI~!NS
would be present and that the visit would end at their option. Also. to cn~urc the fam~l~cs chat wc over-extend our visit, the staff member would say, “We should return to the hocpital. n~lu.” at tervals and unless objected to by the family, the visit would end at that point. As a rcmindcr. was contacted by telephone at least 2 days in advance of scheduledvitits and the >pcCtick elf the discussed (e.g. time of day, longest possible duration v,ith the stalf men~hcr l>~c
\\ould
nor inthe family visit were hat snacks
15 min
E.vperinrenttrl Des&a The sequence
of the proccdurc:
M~S an AHCBC
(I) Normal Visiting Procedure for 54 weeks, (2) Inviiation-Only Procedure for 3 weeks. (3) Invitation-Plus-Ttzisportation Procedure (4) Invitation-Only fr3r 3 week?. and (5) Invitation-Pltls-Transportation Procedure
design:
for 6 week\, for 9 :s;cks.
During visits to the home, the staff member evaluated the setting as it related to the beh:>viornl needs of the patient. (Four different stafT members qcrvcd in thii capacity throughout the study.) The ward program then developed those skills that were sacn to bc useful or rcquircd in the home. For cr;;rmple, a patient was trained to speak louder since her relative was hard of hearing. Anrjther patient practiced washing and ironing of clothing since her mother earned money hy doing so for ncishbors. Similarly. a patient wa$ taught to shop for groceries and to cook family meals since her husband suggectcd such assistance would be welcomed. During: visits, the staff armngcd for the patients to perform skills that \\ould be u~ful to the family especially during an extended home visit. F-I~amples of such useful activities web-e: durtinl: furniture. cooking meals and washing dishes. The performance of the patient was assessed during the v&it and the hospital program was modified on the basis of these assessments to assure grcatcr satisfaction on the subsequent visits. Particular value was placed on the families’ solicited assessment of the patient’\ oerformance.
RESlJLTS The duration of visits, both on the v,ard and in !hc visitor.5 l~omc \vac rcwrded by the ili>spital stafl‘ and \vas defined as the time the patient and visitor spent together. Figure 1 S~OM.\ that under the Normal Visiting Proccdurc, the families spent a mcnn of less th:ln 1 min per week visiting \vith the patients, 0, 1 and I min for each patient respectively. linder the Invitation-Only Proccdurc. the‘ f;lrnilic> 4pcnt n\) time visiting ~IO\\CLCI-. C;IL./I ill‘ the familie\ with the patients. During the Invit:lti3n-Plus-‘~r~ln.;port;lti(~ll I’r<~cedarc, averaged more than Y0 min per \tcek visiting xith the patients: the man f:)r the .q patienic \,;I\ more than 2 hr per week. Not sho\%n in Fig 1 is the finding that the mean time per \veek \pcnt visiting increased from 99 min during the first 6 week period to I71 min during the final 9 week period of Invitati~,rl-l’lus-Trans~~~~rt;tt ion. During the final 9 weeks of the study, the amount of time the families spent visiting uith the patient? was limited not by the families’ reluctance. but rather. by administrati\c limitations (t’.g. c;irs. personnel time). \%iting procedure The general atmosphere that prevailed durin g the Invitation-Plrl~-‘Tt’an~l~crrtr~!i~~n can be seen from the following individual accounts: Mucus. During the 30 conrecu!ivc yr Mary had hccn hocpitalizcd. neither hc‘r hu\bnnd nor other family members had ever visited her. During the Invitation-l’lus-Transportativn pro~edurc. ,,c\~YxI dilt‘ercnt family members visited with her, hut she mcst enjoyed visiting \rith her husband \ihtl \%:I\ r-ctircd bul cuntinued working his farm. At his and her requests, Mary was discharged to live \
CASE HISTORIES
AND
SHORTER
13.5
COMMUNIC’ATIONS
hwzet. Janet had been hospitalized for 14 yr and had been visited by her mother only twice during the preceeding year. Although Janet’s visits with her mother and her own 2 adolescent sons were generally successful, the mother was chronically medically ill and impoverished. No room was available in the home for Janet and no other family members were within visiting distance. The mother expressed a desire for home discharge but the financial and space limitations precluded that action. It appeared that Janet’s return to the community would be limited to shelter-care placement unless she could return to the community with an employable skill. She was, therefore, enrolled in a vocational training program but vocational placement was unsuccessful. She remains hospitalized
w
z ;
g PATIENT
2
+Z
FIG. 1. The mean time families spent visiting with their hospitalized relatives in min per week, under 3 visiting procedures. The patients were 3 women, each of whom had been hospitalized for more than 14 yr and had received few visits over this period. The Normal Visiting Procedure was an open invitation for the families to visit at their discretion. The Invitation-Only Procedure also included a weekly letter explaining the need for such visits and an invitation. The Invitation-Plus-Transportation Procedure included the weekly invitation letter, but in addition, included a provision that if it were too inconvenient for the family to visit, the hospital would provide transportation for the patient to the families home for short visits. In addition, the patients performed activities in the homes that were useful to the families and the hospital program was modified to improve the performance of these useful activities.
DISCUSSION The Invitation-Plus-Transportation visiting procedure reinstated and maintained the patient-family social relationships; whereas, neither the Normal Visiting nor Invitation-Only procedures did so. Response Priming (O’Brien, Azrin and Henson, 1968) initiated visits and Reinforcer Sampling (Ayllon and Azrin, 1968) maintained and increased the time families spent visiting with patients. The importance of these results is best demonstrated by the consequent requests of each family that the patients be returned from the hospital to live with them in the community. That one patient who had been hospitalized without visits for 30 consecutive yr was successfully discharged to live with her husband emphasizes the importance of the patient-family relationships. The Invitation-Plus-Transportation visiting procedure was demonstrated to reinstate and maintain relationships between hospitalized patients and their families, and thereby, to increase the likelihood of successful return to the community for the long-term hospitalized patients. Anna State Hospital, Anna, Illinois 62906, U.S.A.
F. O’BKIEN N. H. AZRIN
136
CASE HISTORIES AND SHORTER
COMMUNICATIONS
REFERENCES AYLL~N T. and AZRIN N. H. (1968a) The Token Economy: A Motivational System for Therapy and Rehabilitation. Appleton-Century-Crofts, New York. AYLLON T. and AZRIN N. H. (1968b) Reinforcer Sampling: a technique for increasing the behavior of mental patients. J. appt. Behav. Anal. 1, 21-34. CHAPMAN L. J., DAY D. and BURSTEIN A. (1961) The process-reactive distinction and prognosis in schizophrenia. J. nerv. ment. Dis. 133, 383-391. CHASE L. S. and SILVERMAN S. (1943) Prognosis in schizophrenia: an analysis of prognostic criteria in 150 schizophrenics treated with metrazol or insulin. J. new. ment. Dis. 98, 464-473. MEICHENBAUM D. H. (1966) Effects of social reinforcement on the level of abstraction in schizophrenics. J. abnorm. sot. Psychoi. 71. 354-362. PAUL G. L. (1969) Chronic mental patient: current status-future direction. Psycho/. BuII. 71, 81-94. O’BRIEN F., AZRIN N. H. and HENSON K. (1969) increased communications of chronic mental patients by reinforcement and by response priming. J. appl. Behav. Atzal. 2, 23-29. ULLMANN L. P. (1967) Institufiort and Outcome: CIComparative S/u&* of Psychicrtric Hospitals. Pergamon. New York.