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Treatment of chronic schizophrenia by behaviour therapy: Case reports
TREATMENT OF CHRONIC SCHIZOPHRENIA BEHAVIOUR THERAPY: CASE REPORTS
BY
Departmentof Psychiatry,UCLA Center for the HealthSciences, Los Angeles 24, California (Received 25 November 1963) cases of schizophrenic reaction, chronic paranoid type are reported using the method of modifying behaviour by means of direct manipulation of rewards and punishments. Psychotropic medication was used as an adjunct to therapy. Sign&ant improvement was obtained ia all three patients within a relatively short time and in two cases the improvement has been maintained six months after summary--Three
discharge. IN RECENTyears there has been increasing interest in the application of principles of learning to psychotherapeutic endeavours (e.g. reviews by Eysenck, 1960; Wolpe, 1958). Procedures such as desensitization (Clark, 1963; Meyer, 1957; Rachman, 1959; Wolpe, 1958, 1961), aversion therapy (Clark, 1963; Freund, 1960; Raymond, 1956; Wolpe, 1960), operant conditioning (Ayllon and Hat&ton, 1962; Ayllon, 1963; Lindsley, 1956; Rickard and Dignam, 1960) and negative practice (Yates, 1958) have been attempted with a wide variety of patient types. Most effort, however, has been devoted to those patients demonstrating neurotic difficulties, particularly monosymptomatic neurosis such as phobia. Such techniques have appeared quite promising (Rachman, 1961) and in the case of phobic disorders, desensitization appears to be the treatment of choice (Lazarus, 1960, 1961). Less evidence is available with regard to the efficiency of such procedures when applied to hospitalized psychiatric patients who have demonstrated long standing psychotic difficulties. Work with this particular patient sample has typically employed operant conditioning techniques and has been limited either to modifying behaviour for ward management purposes (Ayllon, 1960; Ring et al., 1960) or has not been demonstrated to be of “significant” value to the patient (Bryan and Lichtenstein, 1963; Rickard and Dignam, 1960). It is the purpose of this paper to present the history and management (by direct manipulation of social rewards and punishments) of three patients diagnosed as schizophrenic reaction, chronic paranoid type. Ca>e 1.
R. R.
A 32-year-old married insurance sales manager who was admitted complaining of hallucinations, ideas of reference with regards to television and newspaper articles and paranoid delusions. He was convinced that his life was intimately bound up with his own insurance policies and by omitting a payment on his insurance premium he had lost part of himself. He had shown evidence of decreased work efficiency and began to drink heaviiy. His appetite and sleeping habits were poor. His wife reported increasing abruptness and irritability in his treatment of her and the two children. Mental status examination on admission showed him to be reserved, sonewhat withdrawn and suspicious. He showed very little evidence of anxiety, affect being moderately flattened. Speech was not always 1
2
TRUDY KENNEDY
coherent. He had a well delineated delusional system centering around various aspects of life insurance. His ideation was grandiose and persecutory. He was above average intelligence and was well orientated to time, place and person. Psychological testing confirmed the clinical diagnosis of schizophrenic reaction, chronic, paranoid type. This patient was seen for half-an-hour interviews on a three times a week basis. He was started on psychotropic medications, 300 mg chlorpromazine daily, which was later reduced to 100 mg daily. The first interviews were primarily to obtain an adequate factual history and to attempt to gain the confidence of the patient. The therapist gave no indication of consistent approval or disapproval of any statements made by the patient. During the second week of treatment, each frankly delusional statement was objected to by the therapist, using both verbal and non-verbal (i.e. facial expression) cues of disapproval. Facts known to the therapist were brought forward as objections to delusional statements. The therapist insisted that the patient speak of problems concerning his job and family relationships and by so doing he gained the attention and presumable approval of the therapist. A gradual change in his speech content developed and each demonstration of change to a more reality orientated approach to problems was strongly reinforced both by the therapist’s attitude and by direct expression of approval. This attitude was continued in the general ward routine by the nursing staff, who verbalized their approval and appreciation of his modified speech and behaviour. He was elected ward president and this in itself was a reinforcement of his changed behaviour. Towards the end of his stay in the hospital he was able to continue studying for his examinations as a chartered life underwriter. Such studying was reinforced by permitting him to remain in his room. Since leaving the hospital, he has been seen at monthly intervals by another therapist. His first foliow-up assessment was conducted eight weeks after his discharge. At this time he was working full-time and his wife stated that he was more tolerant of her and the children. Sessions since then have been fifteen minutes in duration and entirely devoted to discussion of practical matters concerning his job and home life. He does not bring forward any delusional ideas and is functioning well in a responsible job as an insurance sales manager, with six to eight men working in subordinate positions. His stay in the hospital was less than three months. Case 2. P.R. A 35year-old female, twice divorced, ex-high school teacher was admitted complaining that an FBI investigation was held two and one-half years previously, following her application for a job with the Federal government, and she was blacklisted. As a result of this, there had been total disruption of her social, personal and professional life. She had always had difficulty in interpersonal relationships, both in her work and with her family. Having been a school teacher for eight and a half years, she applied for a job with the Federal government as a social director. Following her failure to obtain employment she developed a persecutory delusional system centering around the FBI and consequently had not worked for two and a half years apart from casual jobs as, for example, a waitress. She remained at home with her aging parents. She had withdrawn completely from all social contacts and was concerned almost entirely with a campaign to have herself cleared by the FBI and with a number of bizarre food fads. Mental status examination on admission showed a rather masculine aggressive woman. She was intensely suspicious and hostile. Her speech was spontaneous and very discursive. Her mood was tense and irritable. She showed a number of obsessional traits, including a continual demand for definition of words. She demonstrated a systematized delusional system concerning the influence of the FBI on her life.
TREATMENT OF CHRONIC SCHIZOPHRENIA BY BEHAVIOUR THERAPY:
CASE REPORTS
3
She stated that she would never be able to work again until they had cleared her. She appeared to be of above average intelligence and was orientated in time, place and person. She showed no insight into her condition. Psychological testing indicated an extremely paranoid individual with slight loosening of associations and poor reality testing. The only aspect of herself that she deemed worthwhile appeared to lie in intellectual pursuits and abilities. The course of treatment with this patient was similar to Case 1. She was given chlorpromazine up to 600 mg daily which was reduced within a month to a maintenance dose of 100 mg daily, and was seen for half-an-hour intervals three times a week. Therapy sessions were directed entirely to such subjects as how to behave with other people, her profession and her relationships with her family. The subject of persecution by the FBI was strongly negatively reinforced by withdrawal of the therapist’s attention and sometimes “punished” by verbal means, whereas discussions of the “approved” topics were positively reinforced by expressions of interest and offers of help. She found considerable difficulty in following ward routine, demanding definitions of words and reasons for the simplest rules. This latter behaviour was modified by giving her a printed list of the do’s and don’ts to carry about, which she then followed implicitly. Both the therapist and the ward milieu were used as social reinforcing agents through their verbalizations of approval when the patient acted in a normative manner. As the patient improved slightly, she was appointed ward librarian and was able to use her abilities to catalogue and in her professional list making. A marked change ili her behaviour on the ward was noted after some weeks of this treatment. From an extremely hostile, argumentative, aggressive woman, disliked by the other patients, she became very helpful and had a great feeling of responsibility to the ward. This changed behaviour was strongly encouraged by both the nursing staff and the therapist and also by the changed attitudes of the other patients who began to confide in her. As her adjustment to ward routine continued she became ward representative on the inter-ward council and was able to perform well in jobs inside the hospital. After a two-month stay, the patient obtained a teaching position in a school for physically handicapped children and began a special college course for this type of teaching. Each step of her preparation for obtaining this job and for entering college was discussed with the therapist whose approval was made obvious. Her first follow-up assessment was four weeks after discharge. At this point she was attending regular classes and maintaining good grades. She was looking forward to the beginning of the semester, when her job would begin. Socially, she was now on good terms with her sister and her sister’s family and was living with her parents. There was no extension of social contacts outside her immediate family. Since then she has been seen for 15 min periods at monthly intervals and has been able to maintain her improvement, continuing to teach successfully. Case 3. D. R. The patient was a 2%year-old sjngle woman, previously diagnosed as schizophrenic reaction, chronic, paranoid type. In the autumn of 1959, the patient became delusional, had ideas of persecution and was hospitalized for 21 months. Following this she was able to return to work for a one-year period as a cosmetic demonstrator. During this period she received weekly outpatient psychiatric care. In November 1961, she again developed a similar delusional system, was again hospitalized and received 13 electroshock treatments without improvement. She was almost continuously hospitalized until January 1963. After June 1962, she was treated by a variety of means, including 50 insulin comas, the last
4
TRUDY
KENNEDY
nine of which were combined with ECT. She also received large doses of Thorazine and Stelazine and an attempt at insight therapy was made, all without appreciable response. The last five months prior to her readmission here as a day patient, were spent in a State hospital where treatment was by means of Prolixin 7.5 mg daily and supportive interviews once a month. In her recent admission, she was pleasant and tidy in appearance. She was actively hallucinating, continually breaking off her conversation to reply to unseen threatening voices whichashe heard. Her persecutory delusional system was centered upon the idea of a contraption in her teeth which audibly transmitted her thoughts. As a result she was convinced of her importance to the government in space research. She was of average intelligence and well orientated in time, place and person. She was almost completely withdrawn from social contacts since she was frightened of people receiving her thoughts. Her only significant contact was an extremely malignant symbiotic relationship with her father. Psychological evaluation indicated that her delusional system was quite fixed and inflexible and that her paranoid ideation was of long standing. As can be seen from the history this patient has had every variety of treatment without any sign&ant improvement and had been unable to make even an attempt at working for the last three years. It appears that on return to state hospitalization in June 1962, she had been discouraged from talking about her delusions and had been told that she must learn to “live with her voices”. This kind of treatment was continued on her return as a day patient here. She was encouraged to travel to and from the hospital by public transport. Delusional speech was strongly negatively reinforced with expressions of disbelief and at times completely ignored by the therapist. She was seen for frequent short interviews, in the surrounding campus and nearby shopping centre. Whenever possible, interviews took place outside the hospital. Since her main difficulties centered around communication with other people, the fact that she was able to speak to her therapist in public places rather than in the shelter of the hospital, acted as a direct reinforcer. Evidence of her delusional voices not being heard by other people was constantly pointed out in these situations and any contacts she ma&, for example, in various shops, were strongly reinforced by approval given to her by the therapist. She was actively encouraged to inquire about prices and to buy small articles, such as soap, cigarettes, which had always previously been done by her parents. When she was reluctant to do this it was insisted upon by the therapist whose attitude became extremely negative if she failed to carry through these suggestions. Eventually she was able to find and maintain a part time job where she helped out five hours daily selling ice cream. This was the first time she had worked in three years. She maintained this job for three months and expressed the opinion that she was happy and found it the most satisfying aspect of her life. Considerable resistance was found on the part of the patient’s father to even her minimal improvement and some two months after final discharge, the patient required readmission to a state hospital. DISCUSSION This paper presents the treatment of three chronic schizophrenic patients by means of direct and intentional manipulation of rewards and punishments. Behaviour judged by the therapist to be socially appropriate within the limited environment was rewarded by increased attention by therapist and nursing personnel, while inappropriate behaviour was met with punishment and the withdrawal of social approval. Behaviour that was desired by the therapist on the part of the patient was explicitly stated and directly taught. The
TRRATMENTOF CHRONlC SCHIZOPHRENIABY BEHAVIOURTHERAPY: CASE REPORTS
5
therapist made no attempt to produce the so called “repressed” ideations or affects and ignored developmental history within the therapeutic context. It is therefore apparent that the method of treatment employed differed from the usual techniques insofar as behaviour desired was directly reinforced and time was not spent in the search for hypothetical mediating responses. Unlike previously reported studies of behaviour therapy with chronic psychotic patients (Ayllon, 1963; Lindsley 1956, 1960), the goal of treatment was that of social rehabilitation. It should be noted that these gaals were achieved with considerable rapidity. It is rather unlikely that the average length of hospitalization for a chronically psychotic patient receiving orthodox treatment is only three months. In the three cases treated by operant conditioning methods, all three were discharged within three months, two were employed while still under hospital care, and two have maintained their social adjustment six months after discharge. While it is impossible to be certain, it does seem reasonable to assume that such gross bchavioural changes on the part of these very disturbed patients can be attributed to the approach adopted. Furthermore, if this is so, then it is apparent that bchaviour therapy of the operant conditioning type, may be a potent tool in the treatment of hospitalized psychotic patients. A further note seems necessary. The ethical problem posed to individuals engaged in psychotherapy has been explored by Rieff (1959), London (1963) and Szasz (1961) and those problems specific to the behaviour therapist have been indicated by London and Krasner (1961). In the treatment of these three cases, behavioural changes were sought only in the context of social rehabilitation. It must be emphasized that no attempts were made to aher moral or ethical attitudes. Acknowledgments-This research project was supported by a Travel Grant from the Astor Foundation. Thanks are due to Jlums H. BRYANfor his critical reading of the manuscript.
REFERENCES AYLLON T. (1960) Some
Behavioral
Problems
Associated
with Euting in Chronic
Schizophrenic
Patients.
Read at‘an A.P.A. meeting, Chicago. A~LLON T. (1963) Intensive treatment of _ nsvchotic behaviour by stimulus satiation and food reinforcement. _ Behav. ‘Res. ?her. 1, 53-61.
AYLLONT. and HAUGHT~NE. (1962) Control of the behavior of schizophrenic patients by food. J. exp. analyt. Behav. 5, 343-352. BRYANJ. H. and LICMZN~XEIN E. (1963) Failure to verbally condition socially desirable speech. Psychol. Repts. (Ill press). CLARKD. F. (1963) The treatment of monosymptomatic phobia by systematic desensitization. Behav. Res. Ther. 1, 63-68. EYSENCKH. J. (1960) Behaviour
Therapy and the Neuroses. Pergamon Press, Oxford. F~EIJNDK. (1960) Problems in the treatment of homosexuality, in Behaviour Therapy and the Neuroses (Ed. H. J. Eysenck). Pergamon Press, oxford. KIN0 G. F., ARMTAGES. and TILTONJ. (1960) A therapeutic approach to schizophrenics of extreme pathology. 1. abnorm. (sot.) Psychol. 61, 276-286. KRMNER L. (1961) Behavior Control and Social Responsibility. Paper presented at W.P.A. meeting, Seattle. LAZARUSA. A. (1960) The elimination of children’s phobias by deconditioning, in Behaviour Therapy and the Neuroses (Ed. H. J. Eysenck). Pergamon Press, Oxford. LAZARUSA. A. (1961) Group therapy of phobic disorders by systematic desensitization. J. abnorm. (sot.) Psychol.
63,504-510.
LRJDSLEY0. R. (1956) Gperant conditioning methods applied to research in chronic schizophrenia. Psych&. Res. Rep. 5, 118-139.
6
TRUDY
KENNEDY
LINDSLEY0. R. (1960) Characteristics of the behavior of chronic psychosis as revealed by free-operant conditioning methods. Dis. new. Syst. 21, 66-78. LONJXN P. (1963) The Modes and Morals of Psychotherapy. Holt, Reinhart and Winston, New York. MEYERV. (1957) The treatment of two phobic patients on the basis of learning theory. J. abnorm. (sot.) Psychol. 55, 261-265. RACHMANS. (1959) Treatment of anxiety and phobic reactions by desensitization. J. abnorm. (sot.) Psycho/. 102,421427. RACHMANS. (1961) Sexual disorders and behavior therapy. Amer. J. Psychiat. 46, 57-70. RAYMONDM. J. (1956) Case of fetishism treated by aversion therapy. &it. Med. J. 2, 854-856. RICKARD H. C., DIGNAM P. J. and HORNER R. F. (1960) Verbal manipulation in a psychotherapeutic relationship. J. clin. Psychol. 16, 364-370. RIEFF P. (1959) Freud; The Mind of the Moralist. Viking, New York. SZASZ T. S. (1961) The Myth of Mental Illness: Foundations of a Theory of Personal Conduct HoeberHarper, New York. WOLPEJ. (1958) Psychotherapy by Reciprocal Inhibition. Stanford University Press, Stanford, California WOLPEJ. (1961) The desensitization treatment of neuroses. J. new. ment. Dis. 132, 189-208. YATESA. J. (1958) The application of learning theory to the treatment of tics. J. abnorm. (sot.) Psychol. 56, 175-182.
BY
Departmentof Psychiatry,UCLA Center for the HealthSciences, Los Angeles 24, California (Received 25 November 1963) cases of schizophrenic reaction, chronic paranoid type are reported using the method of modifying behaviour by means of direct manipulation of rewards and punishments. Psychotropic medication was used as an adjunct to therapy. Sign&ant improvement was obtained ia all three patients within a relatively short time and in two cases the improvement has been maintained six months after summary--Three
discharge. IN RECENTyears there has been increasing interest in the application of principles of learning to psychotherapeutic endeavours (e.g. reviews by Eysenck, 1960; Wolpe, 1958). Procedures such as desensitization (Clark, 1963; Meyer, 1957; Rachman, 1959; Wolpe, 1958, 1961), aversion therapy (Clark, 1963; Freund, 1960; Raymond, 1956; Wolpe, 1960), operant conditioning (Ayllon and Hat&ton, 1962; Ayllon, 1963; Lindsley, 1956; Rickard and Dignam, 1960) and negative practice (Yates, 1958) have been attempted with a wide variety of patient types. Most effort, however, has been devoted to those patients demonstrating neurotic difficulties, particularly monosymptomatic neurosis such as phobia. Such techniques have appeared quite promising (Rachman, 1961) and in the case of phobic disorders, desensitization appears to be the treatment of choice (Lazarus, 1960, 1961). Less evidence is available with regard to the efficiency of such procedures when applied to hospitalized psychiatric patients who have demonstrated long standing psychotic difficulties. Work with this particular patient sample has typically employed operant conditioning techniques and has been limited either to modifying behaviour for ward management purposes (Ayllon, 1960; Ring et al., 1960) or has not been demonstrated to be of “significant” value to the patient (Bryan and Lichtenstein, 1963; Rickard and Dignam, 1960). It is the purpose of this paper to present the history and management (by direct manipulation of social rewards and punishments) of three patients diagnosed as schizophrenic reaction, chronic paranoid type. Ca>e 1.
R. R.
A 32-year-old married insurance sales manager who was admitted complaining of hallucinations, ideas of reference with regards to television and newspaper articles and paranoid delusions. He was convinced that his life was intimately bound up with his own insurance policies and by omitting a payment on his insurance premium he had lost part of himself. He had shown evidence of decreased work efficiency and began to drink heaviiy. His appetite and sleeping habits were poor. His wife reported increasing abruptness and irritability in his treatment of her and the two children. Mental status examination on admission showed him to be reserved, sonewhat withdrawn and suspicious. He showed very little evidence of anxiety, affect being moderately flattened. Speech was not always 1
2
TRUDY KENNEDY
coherent. He had a well delineated delusional system centering around various aspects of life insurance. His ideation was grandiose and persecutory. He was above average intelligence and was well orientated to time, place and person. Psychological testing confirmed the clinical diagnosis of schizophrenic reaction, chronic, paranoid type. This patient was seen for half-an-hour interviews on a three times a week basis. He was started on psychotropic medications, 300 mg chlorpromazine daily, which was later reduced to 100 mg daily. The first interviews were primarily to obtain an adequate factual history and to attempt to gain the confidence of the patient. The therapist gave no indication of consistent approval or disapproval of any statements made by the patient. During the second week of treatment, each frankly delusional statement was objected to by the therapist, using both verbal and non-verbal (i.e. facial expression) cues of disapproval. Facts known to the therapist were brought forward as objections to delusional statements. The therapist insisted that the patient speak of problems concerning his job and family relationships and by so doing he gained the attention and presumable approval of the therapist. A gradual change in his speech content developed and each demonstration of change to a more reality orientated approach to problems was strongly reinforced both by the therapist’s attitude and by direct expression of approval. This attitude was continued in the general ward routine by the nursing staff, who verbalized their approval and appreciation of his modified speech and behaviour. He was elected ward president and this in itself was a reinforcement of his changed behaviour. Towards the end of his stay in the hospital he was able to continue studying for his examinations as a chartered life underwriter. Such studying was reinforced by permitting him to remain in his room. Since leaving the hospital, he has been seen at monthly intervals by another therapist. His first foliow-up assessment was conducted eight weeks after his discharge. At this time he was working full-time and his wife stated that he was more tolerant of her and the children. Sessions since then have been fifteen minutes in duration and entirely devoted to discussion of practical matters concerning his job and home life. He does not bring forward any delusional ideas and is functioning well in a responsible job as an insurance sales manager, with six to eight men working in subordinate positions. His stay in the hospital was less than three months. Case 2. P.R. A 35year-old female, twice divorced, ex-high school teacher was admitted complaining that an FBI investigation was held two and one-half years previously, following her application for a job with the Federal government, and she was blacklisted. As a result of this, there had been total disruption of her social, personal and professional life. She had always had difficulty in interpersonal relationships, both in her work and with her family. Having been a school teacher for eight and a half years, she applied for a job with the Federal government as a social director. Following her failure to obtain employment she developed a persecutory delusional system centering around the FBI and consequently had not worked for two and a half years apart from casual jobs as, for example, a waitress. She remained at home with her aging parents. She had withdrawn completely from all social contacts and was concerned almost entirely with a campaign to have herself cleared by the FBI and with a number of bizarre food fads. Mental status examination on admission showed a rather masculine aggressive woman. She was intensely suspicious and hostile. Her speech was spontaneous and very discursive. Her mood was tense and irritable. She showed a number of obsessional traits, including a continual demand for definition of words. She demonstrated a systematized delusional system concerning the influence of the FBI on her life.
TREATMENT OF CHRONIC SCHIZOPHRENIA BY BEHAVIOUR THERAPY:
CASE REPORTS
3
She stated that she would never be able to work again until they had cleared her. She appeared to be of above average intelligence and was orientated in time, place and person. She showed no insight into her condition. Psychological testing indicated an extremely paranoid individual with slight loosening of associations and poor reality testing. The only aspect of herself that she deemed worthwhile appeared to lie in intellectual pursuits and abilities. The course of treatment with this patient was similar to Case 1. She was given chlorpromazine up to 600 mg daily which was reduced within a month to a maintenance dose of 100 mg daily, and was seen for half-an-hour intervals three times a week. Therapy sessions were directed entirely to such subjects as how to behave with other people, her profession and her relationships with her family. The subject of persecution by the FBI was strongly negatively reinforced by withdrawal of the therapist’s attention and sometimes “punished” by verbal means, whereas discussions of the “approved” topics were positively reinforced by expressions of interest and offers of help. She found considerable difficulty in following ward routine, demanding definitions of words and reasons for the simplest rules. This latter behaviour was modified by giving her a printed list of the do’s and don’ts to carry about, which she then followed implicitly. Both the therapist and the ward milieu were used as social reinforcing agents through their verbalizations of approval when the patient acted in a normative manner. As the patient improved slightly, she was appointed ward librarian and was able to use her abilities to catalogue and in her professional list making. A marked change ili her behaviour on the ward was noted after some weeks of this treatment. From an extremely hostile, argumentative, aggressive woman, disliked by the other patients, she became very helpful and had a great feeling of responsibility to the ward. This changed behaviour was strongly encouraged by both the nursing staff and the therapist and also by the changed attitudes of the other patients who began to confide in her. As her adjustment to ward routine continued she became ward representative on the inter-ward council and was able to perform well in jobs inside the hospital. After a two-month stay, the patient obtained a teaching position in a school for physically handicapped children and began a special college course for this type of teaching. Each step of her preparation for obtaining this job and for entering college was discussed with the therapist whose approval was made obvious. Her first follow-up assessment was four weeks after discharge. At this point she was attending regular classes and maintaining good grades. She was looking forward to the beginning of the semester, when her job would begin. Socially, she was now on good terms with her sister and her sister’s family and was living with her parents. There was no extension of social contacts outside her immediate family. Since then she has been seen for 15 min periods at monthly intervals and has been able to maintain her improvement, continuing to teach successfully. Case 3. D. R. The patient was a 2%year-old sjngle woman, previously diagnosed as schizophrenic reaction, chronic, paranoid type. In the autumn of 1959, the patient became delusional, had ideas of persecution and was hospitalized for 21 months. Following this she was able to return to work for a one-year period as a cosmetic demonstrator. During this period she received weekly outpatient psychiatric care. In November 1961, she again developed a similar delusional system, was again hospitalized and received 13 electroshock treatments without improvement. She was almost continuously hospitalized until January 1963. After June 1962, she was treated by a variety of means, including 50 insulin comas, the last
4
TRUDY
KENNEDY
nine of which were combined with ECT. She also received large doses of Thorazine and Stelazine and an attempt at insight therapy was made, all without appreciable response. The last five months prior to her readmission here as a day patient, were spent in a State hospital where treatment was by means of Prolixin 7.5 mg daily and supportive interviews once a month. In her recent admission, she was pleasant and tidy in appearance. She was actively hallucinating, continually breaking off her conversation to reply to unseen threatening voices whichashe heard. Her persecutory delusional system was centered upon the idea of a contraption in her teeth which audibly transmitted her thoughts. As a result she was convinced of her importance to the government in space research. She was of average intelligence and well orientated in time, place and person. She was almost completely withdrawn from social contacts since she was frightened of people receiving her thoughts. Her only significant contact was an extremely malignant symbiotic relationship with her father. Psychological evaluation indicated that her delusional system was quite fixed and inflexible and that her paranoid ideation was of long standing. As can be seen from the history this patient has had every variety of treatment without any sign&ant improvement and had been unable to make even an attempt at working for the last three years. It appears that on return to state hospitalization in June 1962, she had been discouraged from talking about her delusions and had been told that she must learn to “live with her voices”. This kind of treatment was continued on her return as a day patient here. She was encouraged to travel to and from the hospital by public transport. Delusional speech was strongly negatively reinforced with expressions of disbelief and at times completely ignored by the therapist. She was seen for frequent short interviews, in the surrounding campus and nearby shopping centre. Whenever possible, interviews took place outside the hospital. Since her main difficulties centered around communication with other people, the fact that she was able to speak to her therapist in public places rather than in the shelter of the hospital, acted as a direct reinforcer. Evidence of her delusional voices not being heard by other people was constantly pointed out in these situations and any contacts she ma&, for example, in various shops, were strongly reinforced by approval given to her by the therapist. She was actively encouraged to inquire about prices and to buy small articles, such as soap, cigarettes, which had always previously been done by her parents. When she was reluctant to do this it was insisted upon by the therapist whose attitude became extremely negative if she failed to carry through these suggestions. Eventually she was able to find and maintain a part time job where she helped out five hours daily selling ice cream. This was the first time she had worked in three years. She maintained this job for three months and expressed the opinion that she was happy and found it the most satisfying aspect of her life. Considerable resistance was found on the part of the patient’s father to even her minimal improvement and some two months after final discharge, the patient required readmission to a state hospital. DISCUSSION This paper presents the treatment of three chronic schizophrenic patients by means of direct and intentional manipulation of rewards and punishments. Behaviour judged by the therapist to be socially appropriate within the limited environment was rewarded by increased attention by therapist and nursing personnel, while inappropriate behaviour was met with punishment and the withdrawal of social approval. Behaviour that was desired by the therapist on the part of the patient was explicitly stated and directly taught. The
TRRATMENTOF CHRONlC SCHIZOPHRENIABY BEHAVIOURTHERAPY: CASE REPORTS
5
therapist made no attempt to produce the so called “repressed” ideations or affects and ignored developmental history within the therapeutic context. It is therefore apparent that the method of treatment employed differed from the usual techniques insofar as behaviour desired was directly reinforced and time was not spent in the search for hypothetical mediating responses. Unlike previously reported studies of behaviour therapy with chronic psychotic patients (Ayllon, 1963; Lindsley 1956, 1960), the goal of treatment was that of social rehabilitation. It should be noted that these gaals were achieved with considerable rapidity. It is rather unlikely that the average length of hospitalization for a chronically psychotic patient receiving orthodox treatment is only three months. In the three cases treated by operant conditioning methods, all three were discharged within three months, two were employed while still under hospital care, and two have maintained their social adjustment six months after discharge. While it is impossible to be certain, it does seem reasonable to assume that such gross bchavioural changes on the part of these very disturbed patients can be attributed to the approach adopted. Furthermore, if this is so, then it is apparent that bchaviour therapy of the operant conditioning type, may be a potent tool in the treatment of hospitalized psychotic patients. A further note seems necessary. The ethical problem posed to individuals engaged in psychotherapy has been explored by Rieff (1959), London (1963) and Szasz (1961) and those problems specific to the behaviour therapist have been indicated by London and Krasner (1961). In the treatment of these three cases, behavioural changes were sought only in the context of social rehabilitation. It must be emphasized that no attempts were made to aher moral or ethical attitudes. Acknowledgments-This research project was supported by a Travel Grant from the Astor Foundation. Thanks are due to Jlums H. BRYANfor his critical reading of the manuscript.
REFERENCES AYLLON T. (1960) Some
Behavioral
Problems
Associated
with Euting in Chronic
Schizophrenic
Patients.
Read at‘an A.P.A. meeting, Chicago. A~LLON T. (1963) Intensive treatment of _ nsvchotic behaviour by stimulus satiation and food reinforcement. _ Behav. ‘Res. ?her. 1, 53-61.
AYLLONT. and HAUGHT~NE. (1962) Control of the behavior of schizophrenic patients by food. J. exp. analyt. Behav. 5, 343-352. BRYANJ. H. and LICMZN~XEIN E. (1963) Failure to verbally condition socially desirable speech. Psychol. Repts. (Ill press). CLARKD. F. (1963) The treatment of monosymptomatic phobia by systematic desensitization. Behav. Res. Ther. 1, 63-68. EYSENCKH. J. (1960) Behaviour
Therapy and the Neuroses. Pergamon Press, Oxford. F~EIJNDK. (1960) Problems in the treatment of homosexuality, in Behaviour Therapy and the Neuroses (Ed. H. J. Eysenck). Pergamon Press, oxford. KIN0 G. F., ARMTAGES. and TILTONJ. (1960) A therapeutic approach to schizophrenics of extreme pathology. 1. abnorm. (sot.) Psychol. 61, 276-286. KRMNER L. (1961) Behavior Control and Social Responsibility. Paper presented at W.P.A. meeting, Seattle. LAZARUSA. A. (1960) The elimination of children’s phobias by deconditioning, in Behaviour Therapy and the Neuroses (Ed. H. J. Eysenck). Pergamon Press, Oxford. LAZARUSA. A. (1961) Group therapy of phobic disorders by systematic desensitization. J. abnorm. (sot.) Psychol.
63,504-510.
LRJDSLEY0. R. (1956) Gperant conditioning methods applied to research in chronic schizophrenia. Psych&. Res. Rep. 5, 118-139.
6
TRUDY
KENNEDY
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