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The effect of self- vs. external-monitoring and locus of control upon the pacing and general adjustment of psychiatric inpatients
THE EFFECT OF SELF- VS. EXTERNAL-MONITORING AND LOCUS OF CONTROL UPON THE PACING AND GENERAL ADJUSTME~ OF PSYCHIATRIC INPATIENTS* CARYDENNISR~~TOW Departmentof Psychology, Northwestern State University of Louisiana, Natchitoches,
LA, U.S.A.
(Receiued 26 February 1980)
Summary-Ninety-six psychiatric inpatients with a history of problematic pacing were identified as internal or external (Rotter Internal-External Locus of Control Scale) and assigned lo one of four monitoring categories: (1) self-monitoring, in which participants recorded their pacing on wrist counters, (2) external-monitoring, in which ward staff informed participants of their pacing, (3) social demand. in which participants were pressured not to pace, but without specific feedback concerning their pacing and (4) no treatment. Dependent measures inciuded the number of cycles paced, distance paced. and staff rated general social adjustment (MACC scale). As hypothesized, internals showed greater reductions in pacing and increases in general adjustment scores in the self-monitoring condition and externals reducing pacing and improved general adjustment on the external monitoring ccndition. Both of the treatment conditions created greater positive change than the social demand condition.
Self-monitoring techniques for altering behavior have developed in recent years (Goldiamond, 1965; Ferster, Nurnberger and Levitt, 1962). At first, self-monitoring was considered a practical procedure for ascertaining the occurrence of an undesirable behavior at different points in time (or before and after treatment), thus measuring the effectiveness of some therapeutic intervention. It was discovered, however, that elf-monitoring per se can result in desirable reactive changes in behavior which may be independent of the treatment itself (McFall and Hammen, 1971). Self-monitoring has been shown effective in reducing vocal tics (Thomas er al., 1971), trichotillomania (Bayer, 1972). alcoholism (Sobell and Sobell, 1973), smoking (McFall, 1970), obesity (Mahoney, 1974) and inappropriate motor behavior (Maletzky, 1974). On the other hand, self-monitoring may lead to an increase in desirable behavior, such as studying ~Mahoney er al., 1973) and athletic performance (McKenzie and Rushall, 1974). The effectiveness of self-monitoring as an agent of behavior change has been shown to be effected by many variables: the nature of target behavior (Emmelkamp and Altee, 1974), desirability of the target behavior, performance standards and the presence of feedback (Kazdin, 1974), the schedule of self-monitoring (Mahoney et al., 1973), the instructions (McFall, 1970) and motivation for accurate self-monitoring and behavior change (Lipinski et al., 197s). Little has been done to relate the effectiveness of self-monitoring to the influence of personality variables. One such possible variable is the notion of ‘generalized expectancy for internal vs. external control of reinforcement’ (locus of control), which is a concept derived from Rotter’s Social Learning Theory (Rotter, 1966). This concept described the extent to which indi~duals perceive themselves to be in control of reinforcements that affect them. Individuals at the internal end of the continuum (internals) believe that they can control events in their environment, while those at the opposite end of the continuum (externals) consider themselves at the mercy of fate, luck, God or ‘generalized others’ (Lefcourt, 1966). Internals and externals have been shown to respond differentially *The study was submitted to Northern Illinois University in partial fulfillment of requirements for the Ph.D. The author greatly appreciates the contribution of Dr. Walter Katkovsky and his other committee members in the completion of this project. Requests for reprints should be sent to Cary D. Rostow, Department of Psychology, Northwestern State University of Louisiana, Natchitoches, LA 71457. 541
542
CARYDENNISROSTOW
in a great many situations (Joe, 1971). For example, internals showed greater change in their attitudes (a potential analogue to therapy) in response to low prestige persuasion than high prestige persuasion, while externals respond in the reverse direction (Ritchie and Phares, 1969; Rostow, 1972). In group therapy, internals appeared to improve to a greater degree with a non-directive approach, while externals seem to have improved more when exposed to the directive approach (Abramowitz et al., 1974). Similarly, externals appeared to prefer forms of therapy over which they have little control (automated desensitization), while internals showed greater satisfaction with less structured modes of therapy, e.g. counseling (Friedman and Dies, 1974). In general, it appears that internals show greater reactivity when they self-monitor while externals benefit more from being externally-monitored. The purpose of this study was to investigate the differential effect of self-monitoring, external-monitoring and genera1 social demand upon the pacing and general social and personal adjustment of hospitalized psychiatric patients, Pacing was chosen as a common, difficult to control behavior, which would allow for validation via unobtrusive observation by ward staff. General adjustment was chosen as a dependent measure order to assess the impact of the treatment conditions upon the non-pacing social and personal behaviors of the participants. It was suspected that exposure to the treatment conditions would result in improved control of non-pacing, objectionable behavior and reduce apparent agitation, both of which would lead to improved ‘adjustment’ ratings by outside observers. The author attempted to avoid the problems of many self-monitoring studies in that (1) the target behavior was considered ‘driven’, and difficult to control, (2) the populations were psychiatrically debilitated, (3) it was not possible to retrospectively record data, (4) there was no other major ongoing therapy and (5) there was a control group designed to evaluate the effect of simple social pressure. METHOD
General procedure The basic experimental design was a 2 (internal-external) by 4 (type of monitoring) by 4 (trail blocks) by 2 (sex) analysis of variance with six patients in each cell. Patients were identified as ‘pacers’ shortly after hospital ward assignment by ward staff. They were assigned to locus of control conditions via I-E test scores (administered verbally to patients by hospital staff) and to monitoring conditions randomly. Participants were run individually in their wards for the 4-week experimental period: 1 week (block) of baseline, 2 weeks (blocks) of treatment and 1 week (block) of follow-up.
Forty-eight male and forty-eight female patients at Elgin State Hospital, Elgin, Illinois, served as participants. They were selected for participation according to the following criteria: They were (I) able to speak and read English at a basic level, (2) able to follow simple instructioIls during the initial interview, (3) between 18 and 55 yr of age, (4) in good physical health, (5) hospitalized for less than a total of 5 yr, (6) volunteers, (7) free from medication changes during the study, (all participants received phenothiazines throughout their hospitalization) (8) in residence at the hospital at least 1 week before the baseline period, (9) indicated by the ward staff or patient’s family to show problematic pacing. Participants who were discharged before the end of the experiment were discarded from the study. A total of 505 patients were referred to serve as participants by the hospital staff, however only 96 met the above criteria and resided in the hospital long enough to be included in the study. Selection of pacing participun ts Staff members on all inpatient units of the hospital were asked to list all patients for whom “compulsive or persistent pacing is a problem which makes persons uncomfort-
Self vs. external-monitoring
543
able in their presence, inhibits their social adjustment or interferes with their learning more adaptive behaviors.” A sample of non-pacers were also identified by ward staff, and the mean pacing of this group on the pacing measure was established for each ward. Only patients whose pacing rate exceeded the non-pacer’s mean were retained as participants. For male subjects, the mean age was 33.6 yr, and the mean time in the hospital was 3.8 yr. Half of the male subjects held schizophrenia (chronic undifferentiated type) as their primary diagnosis while the remainder held chronic brain syndrome (25%), paranoid schizophrenia ( 12.5%) and unclassified psychotic (i 2.5%). For female subjects, the mean age was 30.8 yr and the mean time in the hospital was 3.1 yr. Twenty-five percent of the female subjects were diagnosed schizophrenia (chronic undifferentiated type), while the remainder were diagnosed chronic brain syndrome (25%), paranoid schizophrenia (25x), hebephrenic schizophrenia (12.5X), unclassified psychotic (12.5%). Procedure
and instrument
For each patient, the ward staff was asked to arrive at a ‘peak pacing period’, which was defined as the hour each day in which the patient exhibited his highest rate of pacing. Upon confirmation by the experimenter of this period (patient paced more than the ward mean for that hour), the patient was asked to participate in the experiment and the I-E scale was verbally administered. In order to ascertain the impact of treatment upon the ‘general adjustment’ of the client, the MACC scale (Ellsworth, 1962) was first administered at this time. The MACC scale is a rating instrument of ward behaviors which contains statements which reflect patient social and personal adjustment (“Does he generally cooperate.. . with things asked him?” “ Is he bitter?“). Adequate reliability for psychiatric inpatients (predominantly r = 0.70_0.90) across raters (mental health professionals and paraprofessionals) has been reported (Ellsworth et al., 1968; Kliewer, 1970) and the overall adjustment score correlated highly with judgements of improvement by mental health professionals, patients’ relatives and patients’ own ratings (Ellsworth and Clayton, 1959; Ellsworth et al., 1968; Kliewer, 1970). The MACC scale was rated by ward staff who were not involved in other aspects of the experiment and who were naive concerning the study’s hypotheses. The pacing cycle or lap was the basic pacing measure for each participant in the study. The ward staff were asked to detail in writing the ‘typical’ route dr path the patient paced during the peak pacing period. Upon observational confirmation of the lap description, that particular pacing pattern was labeled the puciny cycle for that participant and its frequency during the sample hour constituted the basic dependent measure of study. A second measure, the pacing steps (the number of pacing cycles multiplied by the average number of steps for a client in his cycle) was employed to control for distance and effort differences among typical patient pacing cycles. Ward staff were not informed of the hypotheses of the study nor did they have knowledge of the participants’ locus of control scores. All data were collected in a 5-week sequence, which was subdivided into four phases: (1) a pre-experiment period of 1 week, in which I-E scale scores, patient consent and the initial MACC scale scores were obtained, (2) a buserate phase of 1 week, during which initial pacing measures were recorded without the subjects’ awareness that this was being done, (3) a monitoring phase of 2 weeks, in which the experimental monitoring conditions occurred, and (4) a follow-up of 1 week in which the participant was led to believe the study had been terminated, although observers continued to record pacing behavior. The pacing measure was grouped into blocks (1 week or five scores per block) and analysis was performed on the four blocks (one baserate, two treatment, and one follow-up). The MACC scale score was taken five times (one pre-experimental, one baserate, two treatment and one follow-up) at the end of each experimental week. E.uperimental-morlitoriny
conditions
During the pre-experimental
(treutment)
period participants
were randomly assigned (within locus
544
CARYDENNISROSTOW
of control and sex) to the monitoring conditions. This assignment did not affect participant treatment during the baserate or follow-up phases. However, at the beginning of the experimental-monitoring phase participants were exposed to a differential set of instruction described below. Self-monitoring. In order to measure the impact of self-monitoring, participants were provided with a self-actuated wrist counter and instructed to depress the recording button each time they completed a pacing cycle. A ward staff member ‘walked’ the patient through the sequence which constituted the pacing cycle in order to demonstrate the operation of the device and to ascertain the extent to which the participant was reliably using the wrist counter. Both the participant and the ward observer monitored the participants’ pacing simultaneously. Patients who demonstrated poor agreement with ward observers (lower than r = 0.70) were rejected for experimental use. Each day the experimenter met briefly with the participant, showed him a graph which represented his pacing (staff recorded) and made a brief comment encouraging him to ‘find more constructive things to do’ if the rate showed an increase or there was no change and complimenting him if the rate showed a decline. Self-monitoring participants differed from those in other conditions in that they were able to continuously monitor their pacing as a means of self-reinforcement. External-monitoring. In order to measure the impact of externally generated feedback. participants were informed that their pacing would be monitored and were introduced to the notion of the pacing cycle. Each day the experimenter would meet briefly with the participant and show him a graph of his pacing. As in the self-monitoring condition, a comment was made encouraging non-pacing activities or complimenting improvement. Social demand. Participants were not given a self-monitoring device, nor were they told they would be systematically monitored by the staff. The experimenter spent a brief period (about 15 min) each day with the participant casually socializing and expressing an interest in the participant’s pacing. Comments were made concerning the patient’s pacing much as they had been in the self-monitoring and external monitoring conditions, but no graph was shown the patient and the means by which information was collected was not discussed. The monitoring of pacing was as unobtrusive as possible. This condition was designed to measure the impact of general social pressure to reduce pacing. No treatment. Participants were not directly contacted following the administration of the I-E scale. Unobtrusive pacing measures were collected as they had been in other conditions. This condition was designed TO control for spontaneous changes in pacing which may have resulted from typical psychiatric hospitalization. RESULTS
Analysis of variance was performed on the three dependent measures (pacing cycle, pacing steps, and MACC score). As previously discussed, the two pacing measures were analysed in four trial blocks (baserate, two blocks of treatment, and follow-up; each consisting of five daily measures) and the MACC scale score was analysed in five blocks (one pre-experimental, one base rate, two blocks of treatment, and follow-up) with each block a separate scale rating 1 week apart. The analysis of variance performed on the pacing cycle score revealed a significant main effect for trial blocks, F (1, 3) = I 15.89, p < 0.001, and a significant interaction between trial blocks and treatment F (1, 9) = 20.67, p c 0.001, and among trial blocks, treatment and locus of control, F (1, 9) = 2.84, p < 0.005. Repeating the ANOVAR separately for internals and externals revealed a significant main effect for trial blocks, F (3, 120) = 60.70, p < 0.001, and a significant interaction between trial blocks and treatment, F (9, 120) = 9.68, p < 0.001, for internals and a significant main effect for trial blocks, F (3, 120) = 55.28, p < 0.001, and a significant interaction between trial blocks and treatment, F(9, 120) = 13.90, p < 0.001, for externals. The interaction among trial blocks, treatment and locus of control is presented graphically in Fig. 1. The results of the analysis performed upon the pacing steps measure did not differ
Self vs. external-monitoring
1
I
DASUIWE TDIATMINT
411
3
1
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545
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TDEATMDNT I
. I Fouow.uF
Fig. 1. Mean pacing cycle scores in the self-monitoring, external-monitoring social demand and control treatment conditions by trial blocks for internals (left) and externals (right).
significantly from those results reported above for the pacing cycle measure, and are not included in this presentation. The analysis of variance performed on the general adjustment score revealed a significant main effect for treatment, F (3, 80) = 4.96, p < 0.005, and trial blocks, F (4, 320) = 202.96, p < 0.001, and a significant interaction between trial blocks and treatment, F (12, 320) = 62.76, p < 0.001, and trial blocks, treatment, and locus of control, F (12, 320) = 3.63, p < 0.001. The ANOVAR which was performed separately for internals and externals revealed a significant main effect for trial blocks, F (4, 160) = 94.33, p < 0.001, and a significant interaction between trial blocks and treatment, F = 30.48, p < 0.001, for internals and a significant main effect for trial blocks, F = 109.98, p < 0.001, and a significant interaction between trial blocks and treatment, F = 36.07, p < 0.001, for externals. The interaction among trial blocks, treatment and locus of control is presented graphically in Fig. 2. In order to examine the sources of these differences, Scheffe multiple comparison tests were run for each graphically represented point of interest. The Scheffe tests revealed that for the pacing cycle measure: (1) Externals showed significantly less pacing in external-monitoring than internals in the third 0, < 0.05) and fourth (p < 0.005) trial blocks. -
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FIG. 2. Mean MACC scale scores in the self-monitoring, external-monitoring, social demand and control treatment conditions by trial blocks for internals (right) and externals (left).
546
CARYDENNISRosrow
(2) Internals showed si~i~cantly less pacing in sea-monitoring than externals in the second (p < 0.05), third 0, < 0.05), and fourth @ < 0.005) trial blocks. (3) Externals showed significantly less pacing in external-monitoring than in self-monitoring for the second ot, < 0.05), third (p < O.Ol), and fourth (p < 0.01) trial blocks. (4) Internals showed significantly less pacing in self-monitoring than external-monitoring for the second (P c 0.05). third (p < 0.05), and fourth (p < 0.005) trial blocks. (5) Internals paced significantly less in self-monitoring than in social demand for the second, third, and fourth (p < 0.005) trial blocks; no differences were found for externals’ pacing between self-monitoring and social demand. (6) Externals paced si~ificantly less in external monitoring than social demand in the third (p < 0.005) and,fourth (p c 0.001) trial blocks; no differences were found in internals’ pacing between external-monitoring and social demand. (7) Internals paced significantly less in self-monitoring than in control in the second (p < O.OOS),third @ < O.OOl), and fourth (p < 0.001) trial blocks; no differences were found in externals’ pacing between self-monitoring and control conditions. (8) Externals paced significantly less’in external-monitoring than in control in the third and fourth (p < 0.01) trial blocks; internals showed significantly less pacing in externalmonitoring than in control in the third trial 01 < 0.05) block. (9) No differences were found between the social demand and the control conditions for internals or externals. The Scheffe differences for the MACC general adjustment score were similar or identical to the pacing differences in all cases. DISCUSSION The results of this study show that externals paced, less when their pacing was externallymonitored than when they were asked to self-monitor their pacing or when general social pressure to stop pacing was employed. Possibly self-monitoring was less effective than external-monitoring because externals do not place very much importance on their own actions as a source of reinforcement, and social demand was less effective in promoting change because the target behavior was not emphasized as,clearly or often as in externalmonitoring It would seem that attending to a clearly identifiable target behavior and having access to a means of obtaining ward staff approval are very important factors in promoting behavior change in externals Conversely, internals paced less when they monitored their own pacing than when their pacing was externally-monitored or when general social pressure to stop pacing was employed. In effect, self-monitoring represents a way of controlling one’s own reinforcements by altering a behavior identified as important. This emphasis on self-control of reinforcements in the self-monitoring condition appears to explain the effectiveness of this condition for promoting behavior change in internals. Perhaps internal patients see staff pressure to change (external-monitoring and social demand) as irrelevant to obtaining reinforcements because of their generalized expectancy that the reinforcements they receive will depend on their own behavior. Interestingly, the social demand condition had no effect on promoting a reduction in pacing for either internals or externals, in that pacing reduction measures for social demand did not differ from those in the no-treatment condition. This finding indicates that social demand or coercion per se is ineffective regardless of the locus of control of the patient. Possibly, patients were too distraught or confused to benefit from the vague, unstructured urgings of the staff, or they may have habituated to inconsistent and nonspecific staff demands. It should be noted that general adjustment scores did increase in the social demand condition over the no-treatment condition, although both monitoring conditions produced increases in general adjustment superior to social demand. This suggests that improved interpersonal contact (social demand) was influencing general adjustment scale behaviors (hygiene, socialization, etc.) to a small degree without having much impact upon pacing.
Self vs. external-monitoring
547
It should be noted that all groups which experienced a reduction in pacing as a function of treatment also showed some return to the original undesirable pacing immediately following the cessation of treatment. Only internals in the self-monitoring condition retained a significant portion of the gains they had made in reducing their pacing. Possibly had there been a second or third week of follow-up the deterioration in gains would have been complete. The failure of the treatment effect to carry across time may be related to the following: (1) the pacing response was of long standing for most participants, and therefore, was overlearned; (2) the length of treatment (2 weeks) was too short to endure into the future; (3) the basic study design (continuous reinforcement) may have been inferior to an intermittent schedule of reinforcement for maintaining the reduction in pacing; (4) the physical environment in which the study was conducted (hospital ward) was conductive to the reemergence of problematic pacing. It is clear that ‘general adjustment’ improved as the target behavior improved, however, the reason for this change is difficult to determine. One possible explanation may be that as the pacing decreased, the patient’was seen as less ‘crazy’ or deviant by the ward staff and others around him. Initially, with a notable lessening in pacing, the ward staff may have been willing to interpret behavior which was not clearly deviant (e.g. loud talking) in the positive direction. With this change in the way the staff viewed the patient, the staff may have begun to treat him differently (i.e. included him in social activities from which he was excluded) and the patient’s behavior may have changed in response to these new reinforcers and learning situations. Another possible explanation for the improvement in general adjustment scores may be that the patient was learning not only to reduce pacing (or to prefer other tasks), but also was learning a way of controlling his behavior which he may apply to other troublesome behavior. For example, ward staff members had often commented to the experimenter that particular patients (externals in the external-monitoring condition) would ask for feedback concerning behavior unrelated to pacing (e.g. “is this the way I should make the bed”?). Perhaps dealing systematically and successfully with any given behavior strengthens a person’s ability to alter other, unrelated behavior. The last possible explanation for this improvement in general adjustment may be that the monitoring promoted interpersonal relationships which promised further rewards to the patient. It seems a safe assumption that the patients in the experiment knew how to bathe themselves, clean their ward, and perform tasks rated on the general adjustment scale as indicators of good adjustment, but generally were unmotivated and apathetic. It is conceivable that monitoring and the staff contacts associated with it, motivated the patient to perform those activities deemed important by the staff. In sum, this study establishes the importance of personality (locus of control) variables in predicting the impact of various forms of monitoring. It confirms the utility of selfand external-monitoring as practical tools for altering well established deviant behaviors of a chronic population. It is suggested that before therapeutic programs which employ monitoring are established, that locus of control be taken into consideration. For example, techniques which may be catagorized as ‘self-control’ oriented (e.g. patient government, insight oriented therapy, covert sensitization) may be more effective with internals, while techniques involving social interaction and external controls (e.g. token economies, directive therapies. aversive conditioning therapies) may prove more effective for externals,
REFERENCES ABRAMOWITZC. V.. ABROMOWITZS. I.. ROBA~K H. B. and JACKKIN C. (1974) Differential effectiveness of directive and non-directive group therapies as a function of client internal-external control. J. cor~sulr. c/in. Psychol. 42. 6. 849-853. BAYERC. A. (1972) Self-monitoring and mild aversive treatment of trichotillomania. J. Behau. T/w. up. Psychiur 3. 139-141. ELLSWORTHR. (1962) The MACC II Behavioral Adjustmen? Scale. Western Psychological Services, Beverly Hills. California.
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ELL~WORTHR., FWTER B., ARTHUR G. and KROEKERD. (1968) Hospital and community adjustment as perceived by psychiatric patients, their families and the staff. J. consult. clin. Psychol. (Monograph sup plement). EMMELKAMP P. and ALTEED. A. (1974) A comparison of “successive approximation’ and ‘self-observation’ in the treatment of agoraphobia. E&au. Ther. 5, 606-613. FERSTERC. H., NURNBERGER J. 1. and LEVITTE. B. (1962) The control of eating. J. Mather. 1, 87-109. FRIEDMANM. L. and DIETR. R. (1974) Reactions of internal and external test-anxious students to counseling and behavior therapies. J. consulr. c/in. Psycho/. 42. 6. 921. GOLDIAMOND I. (1965) Self-control procedures in personal behavior problems. Psycho/. Rep. 17, 851. JOE V. C. (1971) Review of the internal-external control construct as a personality variable. Psycho/. Rep. 28. 619-640. KAZDINA. E. (1974) Reactive self-monitoring: the effect of response desirability, goal setting and feedback. J. cons&. clin. Psychol. 42, 5. 704-7 16.
KLIEWERD. (1970) From Aftercare to Community Cure. Prairie View Mental Health Center, Newton. Kansas. LEFCOURTH. M. (1952) Internal versus external control: a review. Psychol. Bull. 43, 447-450. LIPINSKID. P. and NEIS~N R. 0. (1974) The reactivity and unreliability of self-recording. J. consult. c/in. Psycho/. 42.
118-I23.
MAHONEYM. F.. MOOREB. S., WADE T. C. and MO~JRAN. G. (1973) Effects of continuous and intermittent self-monitoring on academic behavior. J. col~sult. c/in. Psycho/. 41. 3, 65-69. MALETZKYB. M. (1974) Behavior recording as treatment: a brief note Eehau. Ther. 5. 107-l I I. MCFALL R. M. (1970) Effects of self-monitoring on normal smoking behavior. J. consulr. clin. Psychol. 35, 135. MCFALL R. M. and HAMMENC. L. (1971) Motivation, structure and self-monitoring: role of nonspecific factors in smoking reduction. J. consult. c/in. Psycho/. 37, 1, 80-86. MCKENZIE T. L. and RUSHALLB. S. (1974) Effects of self-recording on attendance and performance in a competitive swimming training environment. J. app. behav. Anal. 7, 199-206. RITCHIEE. and PHARFSE. J. (1964) Attitude change as a function of internal-external control and communicator status. J. Personality 37. 429-443. R~~TOWC. D. (1972) Opinion change as a function of locus of control, prestige had covert-overt influence. Unpublished Master’s Thesis, Northern Illinois University. ROTTER J. B. (1966) Generalized expectancies for internal versus external control of reinforcement. Psycho/. Monoyr. General and Applied 80. I (whole number 609). SOBELLL. C. and S~BELLM. B. (1973) A self-feedback technique to monitor drinking behavior in alcoholics. Behav. Res. Ther. 11. 237-238. THOMASE. J., ABRAM D. S. and JOHNSONJ. B. (1971) Self-monitoring and reciprocal inhibition in the modification of multiple tic of Gil/es De La Tourelte’s syndrome. J. Behou. Ther. exp. Psychiat 2, 159-171.
LA, U.S.A.
(Receiued 26 February 1980)
Summary-Ninety-six psychiatric inpatients with a history of problematic pacing were identified as internal or external (Rotter Internal-External Locus of Control Scale) and assigned lo one of four monitoring categories: (1) self-monitoring, in which participants recorded their pacing on wrist counters, (2) external-monitoring, in which ward staff informed participants of their pacing, (3) social demand. in which participants were pressured not to pace, but without specific feedback concerning their pacing and (4) no treatment. Dependent measures inciuded the number of cycles paced, distance paced. and staff rated general social adjustment (MACC scale). As hypothesized, internals showed greater reductions in pacing and increases in general adjustment scores in the self-monitoring condition and externals reducing pacing and improved general adjustment on the external monitoring ccndition. Both of the treatment conditions created greater positive change than the social demand condition.
Self-monitoring techniques for altering behavior have developed in recent years (Goldiamond, 1965; Ferster, Nurnberger and Levitt, 1962). At first, self-monitoring was considered a practical procedure for ascertaining the occurrence of an undesirable behavior at different points in time (or before and after treatment), thus measuring the effectiveness of some therapeutic intervention. It was discovered, however, that elf-monitoring per se can result in desirable reactive changes in behavior which may be independent of the treatment itself (McFall and Hammen, 1971). Self-monitoring has been shown effective in reducing vocal tics (Thomas er al., 1971), trichotillomania (Bayer, 1972). alcoholism (Sobell and Sobell, 1973), smoking (McFall, 1970), obesity (Mahoney, 1974) and inappropriate motor behavior (Maletzky, 1974). On the other hand, self-monitoring may lead to an increase in desirable behavior, such as studying ~Mahoney er al., 1973) and athletic performance (McKenzie and Rushall, 1974). The effectiveness of self-monitoring as an agent of behavior change has been shown to be effected by many variables: the nature of target behavior (Emmelkamp and Altee, 1974), desirability of the target behavior, performance standards and the presence of feedback (Kazdin, 1974), the schedule of self-monitoring (Mahoney et al., 1973), the instructions (McFall, 1970) and motivation for accurate self-monitoring and behavior change (Lipinski et al., 197s). Little has been done to relate the effectiveness of self-monitoring to the influence of personality variables. One such possible variable is the notion of ‘generalized expectancy for internal vs. external control of reinforcement’ (locus of control), which is a concept derived from Rotter’s Social Learning Theory (Rotter, 1966). This concept described the extent to which indi~duals perceive themselves to be in control of reinforcements that affect them. Individuals at the internal end of the continuum (internals) believe that they can control events in their environment, while those at the opposite end of the continuum (externals) consider themselves at the mercy of fate, luck, God or ‘generalized others’ (Lefcourt, 1966). Internals and externals have been shown to respond differentially *The study was submitted to Northern Illinois University in partial fulfillment of requirements for the Ph.D. The author greatly appreciates the contribution of Dr. Walter Katkovsky and his other committee members in the completion of this project. Requests for reprints should be sent to Cary D. Rostow, Department of Psychology, Northwestern State University of Louisiana, Natchitoches, LA 71457. 541
542
CARYDENNISROSTOW
in a great many situations (Joe, 1971). For example, internals showed greater change in their attitudes (a potential analogue to therapy) in response to low prestige persuasion than high prestige persuasion, while externals respond in the reverse direction (Ritchie and Phares, 1969; Rostow, 1972). In group therapy, internals appeared to improve to a greater degree with a non-directive approach, while externals seem to have improved more when exposed to the directive approach (Abramowitz et al., 1974). Similarly, externals appeared to prefer forms of therapy over which they have little control (automated desensitization), while internals showed greater satisfaction with less structured modes of therapy, e.g. counseling (Friedman and Dies, 1974). In general, it appears that internals show greater reactivity when they self-monitor while externals benefit more from being externally-monitored. The purpose of this study was to investigate the differential effect of self-monitoring, external-monitoring and genera1 social demand upon the pacing and general social and personal adjustment of hospitalized psychiatric patients, Pacing was chosen as a common, difficult to control behavior, which would allow for validation via unobtrusive observation by ward staff. General adjustment was chosen as a dependent measure order to assess the impact of the treatment conditions upon the non-pacing social and personal behaviors of the participants. It was suspected that exposure to the treatment conditions would result in improved control of non-pacing, objectionable behavior and reduce apparent agitation, both of which would lead to improved ‘adjustment’ ratings by outside observers. The author attempted to avoid the problems of many self-monitoring studies in that (1) the target behavior was considered ‘driven’, and difficult to control, (2) the populations were psychiatrically debilitated, (3) it was not possible to retrospectively record data, (4) there was no other major ongoing therapy and (5) there was a control group designed to evaluate the effect of simple social pressure. METHOD
General procedure The basic experimental design was a 2 (internal-external) by 4 (type of monitoring) by 4 (trail blocks) by 2 (sex) analysis of variance with six patients in each cell. Patients were identified as ‘pacers’ shortly after hospital ward assignment by ward staff. They were assigned to locus of control conditions via I-E test scores (administered verbally to patients by hospital staff) and to monitoring conditions randomly. Participants were run individually in their wards for the 4-week experimental period: 1 week (block) of baseline, 2 weeks (blocks) of treatment and 1 week (block) of follow-up.
Forty-eight male and forty-eight female patients at Elgin State Hospital, Elgin, Illinois, served as participants. They were selected for participation according to the following criteria: They were (I) able to speak and read English at a basic level, (2) able to follow simple instructioIls during the initial interview, (3) between 18 and 55 yr of age, (4) in good physical health, (5) hospitalized for less than a total of 5 yr, (6) volunteers, (7) free from medication changes during the study, (all participants received phenothiazines throughout their hospitalization) (8) in residence at the hospital at least 1 week before the baseline period, (9) indicated by the ward staff or patient’s family to show problematic pacing. Participants who were discharged before the end of the experiment were discarded from the study. A total of 505 patients were referred to serve as participants by the hospital staff, however only 96 met the above criteria and resided in the hospital long enough to be included in the study. Selection of pacing participun ts Staff members on all inpatient units of the hospital were asked to list all patients for whom “compulsive or persistent pacing is a problem which makes persons uncomfort-
Self vs. external-monitoring
543
able in their presence, inhibits their social adjustment or interferes with their learning more adaptive behaviors.” A sample of non-pacers were also identified by ward staff, and the mean pacing of this group on the pacing measure was established for each ward. Only patients whose pacing rate exceeded the non-pacer’s mean were retained as participants. For male subjects, the mean age was 33.6 yr, and the mean time in the hospital was 3.8 yr. Half of the male subjects held schizophrenia (chronic undifferentiated type) as their primary diagnosis while the remainder held chronic brain syndrome (25%), paranoid schizophrenia ( 12.5%) and unclassified psychotic (i 2.5%). For female subjects, the mean age was 30.8 yr and the mean time in the hospital was 3.1 yr. Twenty-five percent of the female subjects were diagnosed schizophrenia (chronic undifferentiated type), while the remainder were diagnosed chronic brain syndrome (25%), paranoid schizophrenia (25x), hebephrenic schizophrenia (12.5X), unclassified psychotic (12.5%). Procedure
and instrument
For each patient, the ward staff was asked to arrive at a ‘peak pacing period’, which was defined as the hour each day in which the patient exhibited his highest rate of pacing. Upon confirmation by the experimenter of this period (patient paced more than the ward mean for that hour), the patient was asked to participate in the experiment and the I-E scale was verbally administered. In order to ascertain the impact of treatment upon the ‘general adjustment’ of the client, the MACC scale (Ellsworth, 1962) was first administered at this time. The MACC scale is a rating instrument of ward behaviors which contains statements which reflect patient social and personal adjustment (“Does he generally cooperate.. . with things asked him?” “ Is he bitter?“). Adequate reliability for psychiatric inpatients (predominantly r = 0.70_0.90) across raters (mental health professionals and paraprofessionals) has been reported (Ellsworth et al., 1968; Kliewer, 1970) and the overall adjustment score correlated highly with judgements of improvement by mental health professionals, patients’ relatives and patients’ own ratings (Ellsworth and Clayton, 1959; Ellsworth et al., 1968; Kliewer, 1970). The MACC scale was rated by ward staff who were not involved in other aspects of the experiment and who were naive concerning the study’s hypotheses. The pacing cycle or lap was the basic pacing measure for each participant in the study. The ward staff were asked to detail in writing the ‘typical’ route dr path the patient paced during the peak pacing period. Upon observational confirmation of the lap description, that particular pacing pattern was labeled the puciny cycle for that participant and its frequency during the sample hour constituted the basic dependent measure of study. A second measure, the pacing steps (the number of pacing cycles multiplied by the average number of steps for a client in his cycle) was employed to control for distance and effort differences among typical patient pacing cycles. Ward staff were not informed of the hypotheses of the study nor did they have knowledge of the participants’ locus of control scores. All data were collected in a 5-week sequence, which was subdivided into four phases: (1) a pre-experiment period of 1 week, in which I-E scale scores, patient consent and the initial MACC scale scores were obtained, (2) a buserate phase of 1 week, during which initial pacing measures were recorded without the subjects’ awareness that this was being done, (3) a monitoring phase of 2 weeks, in which the experimental monitoring conditions occurred, and (4) a follow-up of 1 week in which the participant was led to believe the study had been terminated, although observers continued to record pacing behavior. The pacing measure was grouped into blocks (1 week or five scores per block) and analysis was performed on the four blocks (one baserate, two treatment, and one follow-up). The MACC scale score was taken five times (one pre-experimental, one baserate, two treatment and one follow-up) at the end of each experimental week. E.uperimental-morlitoriny
conditions
During the pre-experimental
(treutment)
period participants
were randomly assigned (within locus
544
CARYDENNISROSTOW
of control and sex) to the monitoring conditions. This assignment did not affect participant treatment during the baserate or follow-up phases. However, at the beginning of the experimental-monitoring phase participants were exposed to a differential set of instruction described below. Self-monitoring. In order to measure the impact of self-monitoring, participants were provided with a self-actuated wrist counter and instructed to depress the recording button each time they completed a pacing cycle. A ward staff member ‘walked’ the patient through the sequence which constituted the pacing cycle in order to demonstrate the operation of the device and to ascertain the extent to which the participant was reliably using the wrist counter. Both the participant and the ward observer monitored the participants’ pacing simultaneously. Patients who demonstrated poor agreement with ward observers (lower than r = 0.70) were rejected for experimental use. Each day the experimenter met briefly with the participant, showed him a graph which represented his pacing (staff recorded) and made a brief comment encouraging him to ‘find more constructive things to do’ if the rate showed an increase or there was no change and complimenting him if the rate showed a decline. Self-monitoring participants differed from those in other conditions in that they were able to continuously monitor their pacing as a means of self-reinforcement. External-monitoring. In order to measure the impact of externally generated feedback. participants were informed that their pacing would be monitored and were introduced to the notion of the pacing cycle. Each day the experimenter would meet briefly with the participant and show him a graph of his pacing. As in the self-monitoring condition, a comment was made encouraging non-pacing activities or complimenting improvement. Social demand. Participants were not given a self-monitoring device, nor were they told they would be systematically monitored by the staff. The experimenter spent a brief period (about 15 min) each day with the participant casually socializing and expressing an interest in the participant’s pacing. Comments were made concerning the patient’s pacing much as they had been in the self-monitoring and external monitoring conditions, but no graph was shown the patient and the means by which information was collected was not discussed. The monitoring of pacing was as unobtrusive as possible. This condition was designed to measure the impact of general social pressure to reduce pacing. No treatment. Participants were not directly contacted following the administration of the I-E scale. Unobtrusive pacing measures were collected as they had been in other conditions. This condition was designed TO control for spontaneous changes in pacing which may have resulted from typical psychiatric hospitalization. RESULTS
Analysis of variance was performed on the three dependent measures (pacing cycle, pacing steps, and MACC score). As previously discussed, the two pacing measures were analysed in four trial blocks (baserate, two blocks of treatment, and follow-up; each consisting of five daily measures) and the MACC scale score was analysed in five blocks (one pre-experimental, one base rate, two blocks of treatment, and follow-up) with each block a separate scale rating 1 week apart. The analysis of variance performed on the pacing cycle score revealed a significant main effect for trial blocks, F (1, 3) = I 15.89, p < 0.001, and a significant interaction between trial blocks and treatment F (1, 9) = 20.67, p c 0.001, and among trial blocks, treatment and locus of control, F (1, 9) = 2.84, p < 0.005. Repeating the ANOVAR separately for internals and externals revealed a significant main effect for trial blocks, F (3, 120) = 60.70, p < 0.001, and a significant interaction between trial blocks and treatment, F (9, 120) = 9.68, p < 0.001, for internals and a significant main effect for trial blocks, F (3, 120) = 55.28, p < 0.001, and a significant interaction between trial blocks and treatment, F(9, 120) = 13.90, p < 0.001, for externals. The interaction among trial blocks, treatment and locus of control is presented graphically in Fig. 1. The results of the analysis performed upon the pacing steps measure did not differ
Self vs. external-monitoring
1
I
DASUIWE TDIATMINT
411
3
1
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545
a
2
DASUINE 1 TDDATMINT Fouow.lJc
TDEATMDNT I
. I Fouow.uF
Fig. 1. Mean pacing cycle scores in the self-monitoring, external-monitoring social demand and control treatment conditions by trial blocks for internals (left) and externals (right).
significantly from those results reported above for the pacing cycle measure, and are not included in this presentation. The analysis of variance performed on the general adjustment score revealed a significant main effect for treatment, F (3, 80) = 4.96, p < 0.005, and trial blocks, F (4, 320) = 202.96, p < 0.001, and a significant interaction between trial blocks and treatment, F (12, 320) = 62.76, p < 0.001, and trial blocks, treatment, and locus of control, F (12, 320) = 3.63, p < 0.001. The ANOVAR which was performed separately for internals and externals revealed a significant main effect for trial blocks, F (4, 160) = 94.33, p < 0.001, and a significant interaction between trial blocks and treatment, F = 30.48, p < 0.001, for internals and a significant main effect for trial blocks, F = 109.98, p < 0.001, and a significant interaction between trial blocks and treatment, F = 36.07, p < 0.001, for externals. The interaction among trial blocks, treatment and locus of control is presented graphically in Fig. 2. In order to examine the sources of these differences, Scheffe multiple comparison tests were run for each graphically represented point of interest. The Scheffe tests revealed that for the pacing cycle measure: (1) Externals showed significantly less pacing in external-monitoring than internals in the third 0, < 0.05) and fourth (p < 0.005) trial blocks. -
SILF
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0
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FIG. 2. Mean MACC scale scores in the self-monitoring, external-monitoring, social demand and control treatment conditions by trial blocks for internals (right) and externals (left).
546
CARYDENNISRosrow
(2) Internals showed si~i~cantly less pacing in sea-monitoring than externals in the second (p < 0.05), third 0, < 0.05), and fourth @ < 0.005) trial blocks. (3) Externals showed significantly less pacing in external-monitoring than in self-monitoring for the second ot, < 0.05), third (p < O.Ol), and fourth (p < 0.01) trial blocks. (4) Internals showed significantly less pacing in self-monitoring than external-monitoring for the second (P c 0.05). third (p < 0.05), and fourth (p < 0.005) trial blocks. (5) Internals paced significantly less in self-monitoring than in social demand for the second, third, and fourth (p < 0.005) trial blocks; no differences were found for externals’ pacing between self-monitoring and social demand. (6) Externals paced si~ificantly less in external monitoring than social demand in the third (p < 0.005) and,fourth (p c 0.001) trial blocks; no differences were found in internals’ pacing between external-monitoring and social demand. (7) Internals paced significantly less in self-monitoring than in control in the second (p < O.OOS),third @ < O.OOl), and fourth (p < 0.001) trial blocks; no differences were found in externals’ pacing between self-monitoring and control conditions. (8) Externals paced significantly less’in external-monitoring than in control in the third and fourth (p < 0.01) trial blocks; internals showed significantly less pacing in externalmonitoring than in control in the third trial 01 < 0.05) block. (9) No differences were found between the social demand and the control conditions for internals or externals. The Scheffe differences for the MACC general adjustment score were similar or identical to the pacing differences in all cases. DISCUSSION The results of this study show that externals paced, less when their pacing was externallymonitored than when they were asked to self-monitor their pacing or when general social pressure to stop pacing was employed. Possibly self-monitoring was less effective than external-monitoring because externals do not place very much importance on their own actions as a source of reinforcement, and social demand was less effective in promoting change because the target behavior was not emphasized as,clearly or often as in externalmonitoring It would seem that attending to a clearly identifiable target behavior and having access to a means of obtaining ward staff approval are very important factors in promoting behavior change in externals Conversely, internals paced less when they monitored their own pacing than when their pacing was externally-monitored or when general social pressure to stop pacing was employed. In effect, self-monitoring represents a way of controlling one’s own reinforcements by altering a behavior identified as important. This emphasis on self-control of reinforcements in the self-monitoring condition appears to explain the effectiveness of this condition for promoting behavior change in internals. Perhaps internal patients see staff pressure to change (external-monitoring and social demand) as irrelevant to obtaining reinforcements because of their generalized expectancy that the reinforcements they receive will depend on their own behavior. Interestingly, the social demand condition had no effect on promoting a reduction in pacing for either internals or externals, in that pacing reduction measures for social demand did not differ from those in the no-treatment condition. This finding indicates that social demand or coercion per se is ineffective regardless of the locus of control of the patient. Possibly, patients were too distraught or confused to benefit from the vague, unstructured urgings of the staff, or they may have habituated to inconsistent and nonspecific staff demands. It should be noted that general adjustment scores did increase in the social demand condition over the no-treatment condition, although both monitoring conditions produced increases in general adjustment superior to social demand. This suggests that improved interpersonal contact (social demand) was influencing general adjustment scale behaviors (hygiene, socialization, etc.) to a small degree without having much impact upon pacing.
Self vs. external-monitoring
547
It should be noted that all groups which experienced a reduction in pacing as a function of treatment also showed some return to the original undesirable pacing immediately following the cessation of treatment. Only internals in the self-monitoring condition retained a significant portion of the gains they had made in reducing their pacing. Possibly had there been a second or third week of follow-up the deterioration in gains would have been complete. The failure of the treatment effect to carry across time may be related to the following: (1) the pacing response was of long standing for most participants, and therefore, was overlearned; (2) the length of treatment (2 weeks) was too short to endure into the future; (3) the basic study design (continuous reinforcement) may have been inferior to an intermittent schedule of reinforcement for maintaining the reduction in pacing; (4) the physical environment in which the study was conducted (hospital ward) was conductive to the reemergence of problematic pacing. It is clear that ‘general adjustment’ improved as the target behavior improved, however, the reason for this change is difficult to determine. One possible explanation may be that as the pacing decreased, the patient’was seen as less ‘crazy’ or deviant by the ward staff and others around him. Initially, with a notable lessening in pacing, the ward staff may have been willing to interpret behavior which was not clearly deviant (e.g. loud talking) in the positive direction. With this change in the way the staff viewed the patient, the staff may have begun to treat him differently (i.e. included him in social activities from which he was excluded) and the patient’s behavior may have changed in response to these new reinforcers and learning situations. Another possible explanation for the improvement in general adjustment scores may be that the patient was learning not only to reduce pacing (or to prefer other tasks), but also was learning a way of controlling his behavior which he may apply to other troublesome behavior. For example, ward staff members had often commented to the experimenter that particular patients (externals in the external-monitoring condition) would ask for feedback concerning behavior unrelated to pacing (e.g. “is this the way I should make the bed”?). Perhaps dealing systematically and successfully with any given behavior strengthens a person’s ability to alter other, unrelated behavior. The last possible explanation for this improvement in general adjustment may be that the monitoring promoted interpersonal relationships which promised further rewards to the patient. It seems a safe assumption that the patients in the experiment knew how to bathe themselves, clean their ward, and perform tasks rated on the general adjustment scale as indicators of good adjustment, but generally were unmotivated and apathetic. It is conceivable that monitoring and the staff contacts associated with it, motivated the patient to perform those activities deemed important by the staff. In sum, this study establishes the importance of personality (locus of control) variables in predicting the impact of various forms of monitoring. It confirms the utility of selfand external-monitoring as practical tools for altering well established deviant behaviors of a chronic population. It is suggested that before therapeutic programs which employ monitoring are established, that locus of control be taken into consideration. For example, techniques which may be catagorized as ‘self-control’ oriented (e.g. patient government, insight oriented therapy, covert sensitization) may be more effective with internals, while techniques involving social interaction and external controls (e.g. token economies, directive therapies. aversive conditioning therapies) may prove more effective for externals,
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