Reinforcement therapy

okay put your sound to the level of this voice it will match the level of sound in the film you are about to see this is the Neuropsychiatric Institute on the campus of the University of California at Los Angeles here Dr James Simmons a psychiatrist is studying the way in which learning affects the behavior of autistic emotionally disturbed or mentally get interested in investigating reinforcement therapy it's been increasingly clear in the field of Psychiatry that there are a large number of individuals who don't respond favorably to traditional therapeutic approaches these groups include for example the schizophrenic child the mentally child and adult and the chronically regressed schizophrenic adult consequently it's been necessary to look in other areas for the types of treatment approaches that might prove effective for this group why do you think traditional techniques haven't done so well with these patients in part it probably is because the individuals who have to care for all of these patients have been trained in such a way to view sick Behavior as the thing which they have to take care of and in many instances the destructive Behavior the bizarre speech and so on like that are actually reinforced by the environment and you could say that the hospital itself supports the sick Behavior well how would you go about changing sick Behavior if behavior is really partly a result of what the environment expects it's not too difficult to conceive of an environment so structured that the expectations of the patients are more directed toward normal behaviors towards socially acceptable behaviors and this is the basis of this particular approach and your approach is based on learning theory isn't it yes if it is true that part of treatment is learning new behaviors then one could use a learning theory approach to this problem and if you were to use a learning theory approach it would then be well to utilize what is current acceptable learning theory which is has to do with reinforcement Theory and thus use a reinforcement therapy or operant conditioning type of therapy this happens to be the area of expertise of Dr Ivar lovas who is the director of the project on treatment of childhood schizophrenia is the application of learning theory something new here Dr lovas No research on the principles of learning has taken place in every major American University for or 50 or more years so that the principles of learning are relatively well understood and we have this advantage of being Guided by a set of principles that has some clarity the application of learning principles law for treatment and for educational mentally children that is rather new it's uh only a few years ago that Dr ion Dr Ted Ion at an estate initiated a program based on reinforcement theory for a treatment of abnormal behavior since then [Music] we've had a number of programs all over the country but they still have the quality of of of inquiry and equality research Associated rhythm what is this research told us about Behavior well in the most General sense I would say that behavior which leads to a reward or determination of stress or discomfort those behaviors are strengthened behaviors which results in no reward at all or discomfort those behaviors are weakened so when we structure a treatment program along these lines what we have done is to actively reward Behavior which we judge to be uh socially appropriate and we have not rewarded and here at NPI we have explored actual discomfort for the patient if he engaged in Pro in behaviors which we judge to be socially inappropriate doesn't this mean that you're asking a patient to take on a large responsibility it does and we feel quite strongly that that without this responsibility without the person experiencing the consequences of his behavior his behavior would in fact disintegrate and solve with the functioning of the group in which he exists as to the patients accepting responsibility how does this affect the method of treatment well the most important aspect of the treatment I think would be to Define what Behavior it is that you want the patient to be responsible for and then secondly what the consequences are that you invoke for those behaviors a treatment becomes then the structuring of a special environment a special Society what will we see here at UCLA well here you will see the program that we initiated uh with four uh the four first children that we took into treatment uh they are very sick children profoundly Disturbed and those children who had been in treatment by the time we saw them have not improved with with that treatment Pamela was nine she was extremely psychotic do you like my shirt there what is that is that my stomach the speech was entirely echolic she showed no interest in her environment but repeated over and over the bizarre behavior so characteristic of autism Ricky was seven and rejected our attempts to show him affection like Pam evil psycholelic what's your name what's your name how old are you Ricky Billy got no comfort from people he actively fought them off he was six and he had never talked Billy had violent tantrums and often injured himself like Billy Chuck was mute at the age of six he still didn't know how to play spent most of his time rocking [Music] these children were so unresponsive to people we couldn't use social or verbal approval as a reward but since they were all good eaters we could use the primary Award of food starting at the simplest level we had to teach him to play with each other to respond to affection and how to talk the job became one of creating a total environment in which a children could learn in this film we will consider only the program for teaching the children to speak however that program demonstrates quite well how the principles of learning can be applied in the teaching on your behaviors we proceed to teach language in a step-by-step fashion first we ask the children to imitate sounds which others make then we teach them to crawl objects by name then to ask for things and gradually then in a step-by-step manner we approach the teaching or conversational speech um Chucky couldn't imitate the sound so we had to help him we did this by closing his lips good Chucky just as soon as he showed the desired Behavior he got his reward it is crucial to give the reward immediately um notice that we help him less now the hand is only on his chin good good Chucky that's good good boy um [Music] we don't close his lips anymore we always remove our direct help as soon as possible when the child behaves on his own he learns the most Chucky bet that wasn't close enough if we had rewarded him that time we would have taught him the wrong thing we will try again and see if we can't get a closer approximation there Jackie Chucky look at my mouth my mouth bad that's right I want you to look at my mouth Ben that's right Chucky Chucky look at me look at my mouth bet that was close enough so we rewarded him this time good that's pretty good [Music] mama foreign see how inconsistent Chuck's performance is Behavior you have just started to build will be weak and you should expect many errors in the beginning mama good Mama good boy that's good talking that's very good Billy we Bill e Billy [Music] no Billy bill look at me Billy Billy the word Billy was too difficult to get when any behavior is too complex we have to break it down into its parts and put it back together later on let's do this no well Kelly good y good [Applause] Philly good Billy good wow good boy with continuation of training imitative Behavior becomes strong and more consistent really good done baby good ball oh good [Applause] boy good after months of treatment Billy can repeat words but he doesn't know what they mean baby good the children don't know when to use words or how to use them they cannot yet describe the world which they are beginning to enjoy but they have to learn to tell us about that world so our next step is to teach them what things are called what is it Chucky bet [Music] big good what is this good that's right very good very good what is this Chucky juice good what is this good boy what is it Chucky toast good very good that's a boy my boy what's this what is this wait corn good very good a a good good egg good very good delete what is this all right good what's this here right what's this nose what's this what is this mouth good good it I I am good what what good I want I am good very good that's a good boy very good corn corn good I want corn very good good boy what what okay now we teach them to ask for what they want yeah what do you want what do you want uh I I oh okay [Music] okay now what do you want all right that was good talking do you want me to chase you yes ask me okay on your mark okay yeah go Pamela what's your name foreign what's your name was mine ham and Ricky were echolalic they already imitated but far too much so our first step with them is to teach them when not to imitate or Echo by ignoring or disapproving of this incorrect Behavior at the same time we teach them to answer correctly for example by telling us their names look at me Panda what's your name no yeah what's your name good what's your name what's your name Pamela right what's your name yeah what's your name what's your name no what's your name Noah what's your name what's your name good what's your name good what's your name what's my name name no Dr Rubin what's my name Ricky look at me that's right [Applause] Pamela has already learned to identify colors in this case yellow but here she manifests once again her bizarre symptoms what color is his pants what color is it look at this [Applause] what color is it Pam what color is it Pam look at the cream what color is it Santa further learning is to take place we cannot permit this Behavior to continue look at it what code is it very good Pam what color is that Pam no what color is this Pam yellow very good Pamela Pamela put the block on top of the box we have to teach them things other than the names of objects they have to learn the meaning of relational terms for example on top of beside and inside put the block beside the Box see beside the Box put the blocks beside the Box no Pamela put the block look at the Block Pamela Pam look at the Block put the block on top of the box let's see this is a block okay now you do it Pamela Pamela stop it pick up the block and put it on top of the box on top good what am I wearing Pamela what am I wearing they have to learn the meaning of I you and he and what is mine yours and his blue sweater that's right wearing the red I am that's right what are you wearing Ricky I'm wearing clothes what clothes what kind of clothes no shirt yeah your parents yeah can you show us black white time if you had your eyes that's right that's right him well who sleeps in Ricky's bed Ricky does that's right good girl who comes to see you on Tuesday and Thursday mom and daddy that's right tell me about breakfast I have toast Angela they have to learn to remember and tell us what they remember that's good why don't you put ketchup on my egg eggs good girl hello Pamela hello how are you Pamela I'm fine it's very good the children understand some words now and so we start to teach them to converse with us notice the mechanical robot-like quality of these early conversations also notice that we have made it easy enough for them to be rewarded Diane Pamela Ricky what's your name that's good and it'd be good where do you go to school you'll see all right that's good ask me where I go to school say where let's go to school UCLA that's good Ricky very good that's good read this and do what it says Rick now that the children know what some words mean they can be taught to answer factual questions here Ricky looks forward to giving the right answer we don't have to use food as a reward anymore our approval has become important to the children Are you standing on the chair yes that's good are you sitting are you sitting on the chair no are you standing beside the chair Are you standing on top of the dresser no are you standing on top of the chair yes [Music] ask me some questions at the circle panel but the red circle very good Pam that's a good girl Tammy that's very good look at me it's my girl Ricky ask me some questions about the things yes after a while asking questions becomes fairly easy [Music] [Music] [Applause] yes good boy that's good I love you tons and tons now that many of the parts of speech are there the children can begin to talk with us and tell us what they experience look at it look like that's right what else did the Train Say that's right what do they wear on their feet it's one thing that's right which they wear on their backs good what's inside the Aqua Lung compressor good where do they go hey look at me where do they go swimming in the lake that's right what do they do underneath the light hey skin Bibles that's right what do they look for the footballer treasured that's right underneath the ocean right this is how Ricky was a year ago look at him now he has begun to respond to affection and to enjoy some of the things that other children do by teaching these children new behaviors we have brought them step by step towards a more rewarding existence they still have a long way to go but now that they can communicate with people other forms of treatment can be used to help them [Music] Rainier School in Buckley Washington is a residential school for the mentally in this setting a research program is going on which aims to teach children academic subjects using the reinforcement principles and behavior modification you've just seen applied to psychotic children the program was initiated by Dr Sydney Bijou a psychologist with a research staff consisting of Dr Jay bernbrower whom you see here Mr John Kidder and Miss Cecilia take Dr Byrne Brower what do most of our institutions do to teach the mentally most institutions have a fairly large educational program which has run along traditional classroom techniques with some variations designed for the unfortunately the success of these programs has not been what most people would hope for how did you approach teaching mentally children in designing a teaching program for the child first of all I would and we did discount the traditional preconceptions of what a child can and cannot do or what he can learn or cannot learn what we teach are pretty ordinary things Reading Writing arithmetic at the primary level what's different about the way you teach these things the two major characteristics of the teaching program are first that we treat each child as an individual and prepare instruction for him in stepwise fashion that will take him at PACE that he can absorb and secondly we use reinforcers that are meaningful to the child and we dispense them meaningfully we use candy toys and other goodies that most children like to get these however they have to earn marks these are tokens for achievement the children really look forward to their classes inside they quickly get ready to start the day's work the advanced group Begins by picking up folders containing a series of lessons to be completed during the session since the lessons are individually designed each child can work at his own speed each of them keeps a daily log of his work first writing his name on it and then setting his watch by the wall clock incidentally the children are very proud of their watches which they have earned by learning to tell time now each child demonstrates and maintains his ability to read a clock by writing his exact starting time on the daily log sheet Ron is working with a stimulus presenting device which allows us to present new words to him in a systematic way this is the site vocabulary part of the reading program for each correct response he gets immediate reinforcement from his teacher he has a very good attention span now and makes few mistakes one of the boys whose IQ is only 45 is learning six new words a day with this procedure Mary is a child and the youngest in our program she is doing a picture phrase exercise to maintain the vocabulary she has learned in the site vocabulary program we are pleased to see Mary working steadily on her own over a period of several months she has been taught to do so since children in the beginning group are only assigned one task at a time the teacher will look over Mary's work as soon as she is finished and give her marks for correct responses Mary knows that she can exchange a page of these marks for a reward after the class is over Jimmy is learning to follow written directions he is a step ahead of Mary in reading skills during each site vocabulary session Jimmy learns two new words and here puts them to use in a practical way this is truly meaningful reading his concentration on his work is remarkable for a boy who can't keep his mind on anything for too long outside the classroom four green cars and two roof foreign is wrestling with arithmetic before he entered the program it was extremely difficult for him but because we encouraged him to use his environment including his fingers he can now do addition and subtraction very well this is Lee one of our Advanced students he has progressed to the point where he can study site vocabulary entirely on his own this stimulus presenting device is considerably more sophisticated than the one Ron was using earlier he is big butts but she is little drink all the milk drink all the milk thank you at the end of the school day all of the work is marked okay Lee ready three yeah give me the page [Applause] okay you you all ready to train yeah let me have a page well what do you see in there I think I'll have my job and they take together see ya bye you wanna break your tree got a full page today good girl what would you like it looks good okay that's fine see you tomorrow okay the rewards of learning can be enjoyed by anyone staff is just as pleased with Mary's progress as she is with her candy at Patton State Hospital in California San Bernardino Valley a reinforcement Therapy Program has been set up to help long-term chronic psychotic patients it is patterned on the Pioneer work of Dr Ted ion the first to apply reinforcement Theory to the treatment of mental illness Dr Otto gericki superintendent and medical director of Patton was instrumental in getting the program underway as Dr Simmons said earlier one of the problems facing the staff of any mental hospital is the sizeable group of patients who don't seem to respond to any of the various forms of therapy the hospital has to offer here is Patton some of these treatment failures as we call them have been in the hospital anywhere from six months to 30 years what led you to try reinforcement therapy with these patients yes we thought that this type of therapy has two obvious advantages first of all it deals with a patient's immediate problem the behavior which causes the community to reject him secondly the principles of reinforcement therapy are relatively easily learned by the nurses and technicians who must Supply them daily on the ward reinforcement therapy does require special training for Ward Personnel doesn't the doctor yes it does but it's practical aspects are relatively easy to grasp compared to the traditional psychodynamic techniques Dr Hal Shafer one of our research psychologists gives a six-month course in reinforcement therapy techniques for nurses and technicians we find that after completing the course these people can make a significant contribution to the patient's improvements one of the people now working with reinforcement techniques is Nurse Debbie Farish who supervises women's unit 10. I've been working at this hospital for 11 years in psychiatric nursing and in the past I've found that our program we thought through a good program but there's been something missing we try to do everything for the patients they had no part in their own treatment I think the patients know that we care about them we don't tolerate inappropriate behavior we try to help them change his behavior and try to guide them but they soon find out that this is a chance for them to get up and get out of the hospital and many of them had given up hopes of leaving the hospital foreign [Music] most of our patients have been in the hospital for several years but now that we are rewarding them for improving their behavior we are seeing some real changes instead of sitting off in a corner somewhere or pacing up and down all day like they used to some of our patients help out with the ward work course Improvement in behavior is not unique to our program the essential thing is our systematic use of reinforcement principles to bring out and reinforce appropriate behavior there are many types of behavior which these patients will have to learn if they are to live successfully outside the hospital as part of our program improved behavior is rewarded with property we call them tokens and the patients use them as money to pay for their room and board as well as for the various Ward privileges some appropriate behavior is rewarded immediately but patients also get some of the tokens they have earned at a regular pay call because we encourage the patients to think for themselves they are asked to explain what they have done to earn their pay and I told um I'm glad I've come right that I that I lost my calm and you get paid for socializing yeah see you overpaid me I did yeah how much did I will pay you well let's see I get 119 and you gave me 112. [Applause] this patient was deliberately overpaid she'll get to keep the extra tokens as a reward for figuring it out will that help you out any sure some patients spend their tokens at our vanity shop they enjoyed their beauty treatment and later they will be rewarded for looking nice this helps them to learn that keeping neat and attractive is a good thing everyone pays to go into the dining room at meal time and they are seated according to their progress in acquiring acceptable social behavior some eat at comfortable tables with tablecloths and flowers others have to accept much less elegant conditions until they earn the right to eat at a better table two tokens Consultants well where are we I don't know well I can't let you have lunch without children by two tokens I don't have two of them yes they do have terrified for lunch it has whipped cream on it or give me some two tokens valet let me in there how much do you price unless you pay for your male two two four you better get one oh come online go on Ali sit down I'll have to charge you for that I charge you for everything you hit me I have notches open well why don't you go get some cookies have you sat around all morning not not done anything during talking yes well that's too bad you'll have to go about your lunch [Music] and I'm not kidding play around that's it come on get it going this is the other way reverse it these patients are watching Jacqueline Lane's daily exercise show get the exercise along with the program they get reinforced immediately especially if they're overweight there's Ellie she's making sure she won't miss her supper too [Music] I waste in this time stand tall [Music] hi Ellie [Applause] do you know what that's for no well it looks to me like you're reading a patient who takes an interest in what's going on in the world will have an easier time when she leaves the hospital you don't have enough tokens to earn the bed tonight okay [Music] this patient hasn't earned enough tokens for our bed and the only bed she can have for free is a cot right now she's a little stubborn and Confused the nurse will explain and re-explain until she understands well it's not your sister you can't sleep on the bed okay but you can't have the bag too we found in the past in this program that no patient has to sleep for any more than one or two days on a cuts under those conditions because the tokens then require their value and the patient learns that it's very easy to earn them and does so [Applause] work this afternoon or you're supposed to be at work yeah you better get up and go you have to pay three tokens if you stay on the bed oh what you gonna do okay thank you cigarettes are a powerful reinforcer patience Must Learn by them some patients work very hard on their behavior to earn the use of our smoking room [Music] this is one of our social learning groups where we get together and talk with patients their verbal behavior during these sessions give us a good clue to their progress a patient doesn't get a token just for talking about her problems she's rewarded only when she says something that shows she's actually trying to deal with them perhaps it would help the people know you a little better if you told us a little bit about yourself this morning but my family had more knowledge they would understand it better break a leg a medical doctor see that gets well but if you have a mental breakdown you yourself are the one that needs to help yourself more than anyone else well in about two weeks I'm going to a family care home in San Bernardino and there will be four girls at this family care home and they have a swimming pool and we'll let the patients use the pool and after I get acquainted with the home and the family caretakers I plan to get work it's a little early to say what a research project like this will mean in terms of the rest of our hospital or else we'll get along in the community still we have seen that behavior can be changed by the better through our reinforcement program and we are planning to keep on looking for ways to improve it [Music] is [Music] foreign [Music]