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Undergraduates as behavioral technicians on an adult token economy ward
BEHAVIOR THERAPY (1972)
3,
589-592
Undergraduates as Behavioral Technicians on an Adult Token Economy Ward 1 CLAUDIA A. JOHNSON,2 ROGER C. KATZ, AND SIDNEY GELFAND University df Utah and Salt Lake City Veterans Administration Hospital The training procedure, rationale, and utilization of undergraduate students as behavioral technicians on a token economy program for chronically mentally ill male adult inpatients is described. Included are specific training procedures and duties performed by file students. The conventional team on a psychiatric token economy ward consists of a psychiatrist, a psychologist, a social worker, nurses, and nursing aides. Of these, the aides interact most frequently with patients and it is therefore highly desirable that their interactions be consistent with the goals of the programs. But in practice, most probably because they are minimally trained and frequently overworked due to the large number of patients for whom they are responsible, nursing aides often fail to adhere to the behavior modification treatment programs prescribed (Katz, Johnson, & Gelfand, 1972). While the provision of a monetary bonus contingent upon an increased frequency of reinforcing contacts with the targeted patients can result in a substantial increase in the rate of aide-dispensed reinforcement (Katz et al., 1972), the aides' job description tends to emphasize the maintenance of order and security rather than therapy and it is not always possible to use them to administer treatment programs. Therefore, we decided to investigate the possibility of using volunteers. Various investigators have used volunteer housewives and high school students (e.g., Staats, Minke, Goodwin, & Landeen, 1967), college students (e.g., Davison, 1965; Gelfand, Elton, & Harman, 1971; Ray & Shaw, 1968), and teachers (e.g., Wahler, 1969). However, the majority of these investigators have failed to provide a detailed description of the training procedures used to instruct paraprofessionals in the application 1Appreciation is expressed to Kathy Roberts, Valerie Rees, and Lynn Behm, whose successful performance originally led to the implementation of this program. 2Requests for reprints should be sent to Claudia A. Johnson, Psychology Dept., University of Utah, Salt Lake City, Utah 84112. 589 Copyright © 1972 by Academic Press, Inc. All rights of reproduction in any form reserved.
590
JOHNSON, KATZ, AND GELFAND
of behavior modification techniques and principles. The present paper attempts to remedy this deficit. PROGRAM DESCRIPTION Since manpower and financial resources were limited, it was decided to recruit nearby undergraduate students in psychology. Two professors who required practieum work as part of their eom'ses were informed of the training potential for students available on this particular ward. The university's financial aids officeresponsible for a work-study program was also supplied with a brief description of the ward and duties required, and asked to refer those individuals who expressed interest in working with chronically ill adult mental patients. In this manner, students were recruited from a number of different fields, including psychology. An initial screening interview with the student was conducted by either the ward psychologist or a graduate psychologystudent interning on the ward. The only criteria used for selection were interest in the program and an expression of willingness to learn the techniques. Individual undergraduate students were given a personal orientation to both the ward and the hospital grounds by one of the graduate students, followed by a preliminary discussion of their roles and duties on the ward. They were given a pretest of the material found in Reese's (1966) manual on The Analysis of Human Operant Behavior, supplied with a copy of the manual and asked to read it within 1 week. They were then given a posttest on the same material which was reviewed individually with the supervising graduate student to provide clarification in any area which the student had difficulty understanding. The students were then assigned the first six chapters in Ferster and Perrott's (1968) Behavior Principles and orally quizzed on the programmed text probes in small groups. These quiz sessions, which lasted approximately 1 hr each, provided an opportunity for informal discussion of any material which they felt that they had failed to understand. Students also viewed the four Behavior Theory in Practice films (Reese, 1968). Each student volunteer was assigned to a specific supervising graduate student responsible for about ten patients. The graduate student wrote a program for a selected patient and carefully explained to the volunteer the behavioral procedures and principles involved in its implementation, giving demonstrations of the various operations if necessary. Volunteers were also instructed in data collection procedures and, in some eases, they aided in the preparation of data recording sheets. Frequent reliability cheeks were conducted by the graduate students to assess the accuracy of the volunteer's observations and frequent informal diseussions before and after the training sessions were used to correct any
UINTDERGRADS AS BEHAVIORAL TECHNICIANS
591
shortcomings or problems the volunteers may have had. Again, the principles involved in the various programs were explained in technical terms, and the students and staff discussed and critically compared alternative treatment approaches. EXAMPLES OF TREATMENT PROGRAMS Target patients were selected from a 32-bed ward at the Salt Lake City Veterans Hospital. Each patient had received a diagnosis of schizophrenia, and many of them displayed behavioral problems that had not been successfully modified through the use of the regular ward token economy. Programs conducted by the volunteers included the development of responsive and spontaneous speech in a nonverbal patient, increasing the volume and intelligibility of speech of an extremely soft-spoken veteran, and the use of successive approximations to encourage veterans to work in the hospital laundry. Other duties performed by the undergraduates consisted of attempting to help a patient to leave the hospital by escorting him to town and requiring him to perform various tasks such as asking directions, purchasing articles, or making telephone calls. One student even practiced in vivo desensitization of a patient with a fear of driving. Several female students acted as social reinforcement dispensers for another patient who was permitted to spend 10-rain chatting with the girls if he met a daily criterion for appropriate behavior. One time-consuming project treated the most unmanageable patient on the ward whose high rate of inappropriate behavior was probably maintained by the intermittent attention received from patients and staff alike. The project involved isolating the patient from staff members and patients, his only social contacts being with the undergraduates and psychology trainees who worked with him from 8 AM until 5 P~. The goals were to decrease mumbling and psychotic talk, and to increase intelligible appropriate speech. Within a 6-weeks' period encouraging improvements in this patient's behavior appeared. The volunteers are presently working with this patient in order to increase his reading, writing, arithmetic, and vocational skills. For example, he is now escorted to the laundry, where he is able to work at simple tasks for a 20-rain period each day. The goal of another project was to change the eating behavior of a patient who, except for his repulsive table manners, was ready to be discharged to a nursing home. Other tasks have included reinforcing patients for engaging in various ward activities and collecting data on specific target behaviors in the previously described programs.
592
JOHNSON, KATZ, AND GELFAND
IMPLICATIONS The advantages of such a p r o g r a m are many. Patients benefit b y the more intensive attention and more systematic treatment p r o g r a m m i n g which in most cases results in dramatic i m p r o v e m e n t or even discharge, and several long-term patients have been successfully relocated in the community. Financially, the institution expends a minimal amount (2070 of salary paid w o r k - s t u d y students and nothing for volunteers) to receive m u c h needed ancillary manpower. The nursing staff is able to concentrate on the general ward p r o g r a m with resultant greater effectiveness, and morale is improved since the students take over m a n y of the more difficult patients and are able to produce some significant changes. The extra m a n p o w e r also enables the staff to undertake additional research projects. Students receive experience in their fields of interest and have an opportunity to observe and to sample various professional roles. The combination of reading and discussion of theory with practice appears to lead to greater learning and appreciation of the therapeutic value of the treatment procedures. After some initial minor apprehensions about working with psychotic inpatients, the students express enthusiasm about the ward and their duties. REFERENCES DAWSON, G. C. The training of undergraduates as social reinforcers for autistic children. In L. P. Ullmann & L. Krasner (Eds.), Case Studies in Behavior Modification. New York: Holt, Rinehart & Winston, 1965. Pp. 146-148. FERSTER, C. B., & PERROTT, M. C. Behavior Principles. New York: AppletonCentury-Crofts, 1968. GELFAND, D. M., EnTON, R., & ItAR~ON, R. A video feedback training method to teach behavior modification skills to nonprofessionals. Paper presented at Western Psychological Association Convention, San Francisco, April, 1971. KATZ, R. C., JO~XNSON,C. A., & GELVAND,S. Modifying the dispensing of reinforcers: Some implications for behavior modification with hospitalized patients. Behavior Therapy, 1972, 3, 579-583. PATTERSON, G. R., BAY, R. S., & S~AW, D. A. Direct intervention in families of deviant children. Oregon Research Institute Bulletin, 1968, 1-60. REESE, E. P. The analysis of human operant behavior. Dubuque, Iowa: Wm. C. Brown, 1966. Rw~sE, E. P. Behavior theory in practice. Filmed by Charter Oak Studios, Produced by Appleton-Century-Crofts, 1965. ST~TS, A. W., MINKE, K. A., GOODWIN, W., & LAND~EN, J. Cognitive :behavior modification: "Motivated learning" reading treatment with subprofessional therapy-technicians. Behaviour Research and Therapy, 1967, 5, 283-299. WA~LEn, R. G. Setting genera]ity: Some specific and general effects of child behavior therapy. Iournal of Applied Behavior Analysis, 1969, 2, 239-246.
3,
589-592
Undergraduates as Behavioral Technicians on an Adult Token Economy Ward 1 CLAUDIA A. JOHNSON,2 ROGER C. KATZ, AND SIDNEY GELFAND University df Utah and Salt Lake City Veterans Administration Hospital The training procedure, rationale, and utilization of undergraduate students as behavioral technicians on a token economy program for chronically mentally ill male adult inpatients is described. Included are specific training procedures and duties performed by file students. The conventional team on a psychiatric token economy ward consists of a psychiatrist, a psychologist, a social worker, nurses, and nursing aides. Of these, the aides interact most frequently with patients and it is therefore highly desirable that their interactions be consistent with the goals of the programs. But in practice, most probably because they are minimally trained and frequently overworked due to the large number of patients for whom they are responsible, nursing aides often fail to adhere to the behavior modification treatment programs prescribed (Katz, Johnson, & Gelfand, 1972). While the provision of a monetary bonus contingent upon an increased frequency of reinforcing contacts with the targeted patients can result in a substantial increase in the rate of aide-dispensed reinforcement (Katz et al., 1972), the aides' job description tends to emphasize the maintenance of order and security rather than therapy and it is not always possible to use them to administer treatment programs. Therefore, we decided to investigate the possibility of using volunteers. Various investigators have used volunteer housewives and high school students (e.g., Staats, Minke, Goodwin, & Landeen, 1967), college students (e.g., Davison, 1965; Gelfand, Elton, & Harman, 1971; Ray & Shaw, 1968), and teachers (e.g., Wahler, 1969). However, the majority of these investigators have failed to provide a detailed description of the training procedures used to instruct paraprofessionals in the application 1Appreciation is expressed to Kathy Roberts, Valerie Rees, and Lynn Behm, whose successful performance originally led to the implementation of this program. 2Requests for reprints should be sent to Claudia A. Johnson, Psychology Dept., University of Utah, Salt Lake City, Utah 84112. 589 Copyright © 1972 by Academic Press, Inc. All rights of reproduction in any form reserved.
590
JOHNSON, KATZ, AND GELFAND
of behavior modification techniques and principles. The present paper attempts to remedy this deficit. PROGRAM DESCRIPTION Since manpower and financial resources were limited, it was decided to recruit nearby undergraduate students in psychology. Two professors who required practieum work as part of their eom'ses were informed of the training potential for students available on this particular ward. The university's financial aids officeresponsible for a work-study program was also supplied with a brief description of the ward and duties required, and asked to refer those individuals who expressed interest in working with chronically ill adult mental patients. In this manner, students were recruited from a number of different fields, including psychology. An initial screening interview with the student was conducted by either the ward psychologist or a graduate psychologystudent interning on the ward. The only criteria used for selection were interest in the program and an expression of willingness to learn the techniques. Individual undergraduate students were given a personal orientation to both the ward and the hospital grounds by one of the graduate students, followed by a preliminary discussion of their roles and duties on the ward. They were given a pretest of the material found in Reese's (1966) manual on The Analysis of Human Operant Behavior, supplied with a copy of the manual and asked to read it within 1 week. They were then given a posttest on the same material which was reviewed individually with the supervising graduate student to provide clarification in any area which the student had difficulty understanding. The students were then assigned the first six chapters in Ferster and Perrott's (1968) Behavior Principles and orally quizzed on the programmed text probes in small groups. These quiz sessions, which lasted approximately 1 hr each, provided an opportunity for informal discussion of any material which they felt that they had failed to understand. Students also viewed the four Behavior Theory in Practice films (Reese, 1968). Each student volunteer was assigned to a specific supervising graduate student responsible for about ten patients. The graduate student wrote a program for a selected patient and carefully explained to the volunteer the behavioral procedures and principles involved in its implementation, giving demonstrations of the various operations if necessary. Volunteers were also instructed in data collection procedures and, in some eases, they aided in the preparation of data recording sheets. Frequent reliability cheeks were conducted by the graduate students to assess the accuracy of the volunteer's observations and frequent informal diseussions before and after the training sessions were used to correct any
UINTDERGRADS AS BEHAVIORAL TECHNICIANS
591
shortcomings or problems the volunteers may have had. Again, the principles involved in the various programs were explained in technical terms, and the students and staff discussed and critically compared alternative treatment approaches. EXAMPLES OF TREATMENT PROGRAMS Target patients were selected from a 32-bed ward at the Salt Lake City Veterans Hospital. Each patient had received a diagnosis of schizophrenia, and many of them displayed behavioral problems that had not been successfully modified through the use of the regular ward token economy. Programs conducted by the volunteers included the development of responsive and spontaneous speech in a nonverbal patient, increasing the volume and intelligibility of speech of an extremely soft-spoken veteran, and the use of successive approximations to encourage veterans to work in the hospital laundry. Other duties performed by the undergraduates consisted of attempting to help a patient to leave the hospital by escorting him to town and requiring him to perform various tasks such as asking directions, purchasing articles, or making telephone calls. One student even practiced in vivo desensitization of a patient with a fear of driving. Several female students acted as social reinforcement dispensers for another patient who was permitted to spend 10-rain chatting with the girls if he met a daily criterion for appropriate behavior. One time-consuming project treated the most unmanageable patient on the ward whose high rate of inappropriate behavior was probably maintained by the intermittent attention received from patients and staff alike. The project involved isolating the patient from staff members and patients, his only social contacts being with the undergraduates and psychology trainees who worked with him from 8 AM until 5 P~. The goals were to decrease mumbling and psychotic talk, and to increase intelligible appropriate speech. Within a 6-weeks' period encouraging improvements in this patient's behavior appeared. The volunteers are presently working with this patient in order to increase his reading, writing, arithmetic, and vocational skills. For example, he is now escorted to the laundry, where he is able to work at simple tasks for a 20-rain period each day. The goal of another project was to change the eating behavior of a patient who, except for his repulsive table manners, was ready to be discharged to a nursing home. Other tasks have included reinforcing patients for engaging in various ward activities and collecting data on specific target behaviors in the previously described programs.
592
JOHNSON, KATZ, AND GELFAND
IMPLICATIONS The advantages of such a p r o g r a m are many. Patients benefit b y the more intensive attention and more systematic treatment p r o g r a m m i n g which in most cases results in dramatic i m p r o v e m e n t or even discharge, and several long-term patients have been successfully relocated in the community. Financially, the institution expends a minimal amount (2070 of salary paid w o r k - s t u d y students and nothing for volunteers) to receive m u c h needed ancillary manpower. The nursing staff is able to concentrate on the general ward p r o g r a m with resultant greater effectiveness, and morale is improved since the students take over m a n y of the more difficult patients and are able to produce some significant changes. The extra m a n p o w e r also enables the staff to undertake additional research projects. Students receive experience in their fields of interest and have an opportunity to observe and to sample various professional roles. The combination of reading and discussion of theory with practice appears to lead to greater learning and appreciation of the therapeutic value of the treatment procedures. After some initial minor apprehensions about working with psychotic inpatients, the students express enthusiasm about the ward and their duties. REFERENCES DAWSON, G. C. The training of undergraduates as social reinforcers for autistic children. In L. P. Ullmann & L. Krasner (Eds.), Case Studies in Behavior Modification. New York: Holt, Rinehart & Winston, 1965. Pp. 146-148. FERSTER, C. B., & PERROTT, M. C. Behavior Principles. New York: AppletonCentury-Crofts, 1968. GELFAND, D. M., EnTON, R., & ItAR~ON, R. A video feedback training method to teach behavior modification skills to nonprofessionals. Paper presented at Western Psychological Association Convention, San Francisco, April, 1971. KATZ, R. C., JO~XNSON,C. A., & GELVAND,S. Modifying the dispensing of reinforcers: Some implications for behavior modification with hospitalized patients. Behavior Therapy, 1972, 3, 579-583. PATTERSON, G. R., BAY, R. S., & S~AW, D. A. Direct intervention in families of deviant children. Oregon Research Institute Bulletin, 1968, 1-60. REESE, E. P. The analysis of human operant behavior. Dubuque, Iowa: Wm. C. Brown, 1966. Rw~sE, E. P. Behavior theory in practice. Filmed by Charter Oak Studios, Produced by Appleton-Century-Crofts, 1965. ST~TS, A. W., MINKE, K. A., GOODWIN, W., & LAND~EN, J. Cognitive :behavior modification: "Motivated learning" reading treatment with subprofessional therapy-technicians. Behaviour Research and Therapy, 1967, 5, 283-299. WA~LEn, R. G. Setting genera]ity: Some specific and general effects of child behavior therapy. Iournal of Applied Behavior Analysis, 1969, 2, 239-246.