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This is to certify that the

thesis entitled
THE EFFECTS OF SELF-REINFORCEMENT

ON MEDICAL REHABILITATION
PATIENT BEHAVIORS

presented by
Edward J. De Vries

has been accepted towards fulfillment
of the requirements for

.___Eh‘JL_degree in _C_ans_eLi_nq_

 

hdaj fessor

Date April 30, 1976

0-7639

 

 

Pu ABSTRACT
THE EFFECTS OF SELF-REINFORCEMENT

ON MEDICAL REHABILITATION
PATIENT BEHAVIORS

By
Edward J. De Vries

This study attempted to assess the effects of self-directed
behavior change on medical rehabilitation in-patients' behaviors.
The treatments of self-monitoring (SM) and Self-reinforcement (SR)
were appled to three unique behaviors of each of three patients
residing in a 72 bed medical rehabilitation treatment center
in a midwestern city. The four hypotheses tested in this inten-
sive case study (N=1) multiple baseline time series design were
as follows: 1.) The implementation of a SM technique for se-
lected patient behaviors will significantly change the occur-
rence pattern of behaviors in the desired direction over a
pre-treatment baseline period (B); 2.) The implementation of
a SR technique for selected patient behaviors will change the
occurrence pattern of behaviors in the desired direction over
the B period; 3.) The implementation of a SR technique will
significantly change the occurrence pattern of selected behaviors
in the desired direction over a SM period; 4.) As a result
of the SM and SR interventions the pattern of occurrence of
selected behaviors during the post-treatment extinction (E)
period will be improved over the B period.

The results of the study showed no consistent support
for any of the hypotheses. An analysis of the overall process
however, indicated that those behaviors which obtained rein-

forcement from the behavior itself showed improvement under

Edward J. De Vries

the SM treatment. Those behaviors which did not obtain re-
inforcement from the behavior itself showed improvement in
the SR phase. Further analysis showed that the meaningfulness
of the behavior, the potency of the self-administered rein-
forcers and the patient's attitude toward the research project
itself seemed to influence the outcome of the study. Finally,
a consideration of the study in terms of how it was presented
to the patients, as a research project as opposed to a treat-
ment program, seemed to provide some further support for the
treatment effect under hypothesis 4. In that hypothesis the
post-treatment (E) behavior occurrence pattern was to be sig-
nificantly better than the pre-treatment baseline (B) condition.
In that the researcher suggested that the patients no longer
needed to monitor or reinforce the selected behavior during
this E phase, a reversal of sorts was expected. The pattern
of behavior changed dramatically after the SR period to a level
similar to the B in many cases. This would seem to confirm the
benefit of this type of program as much as a positive change
at the outset of the program, the SM period, which in some
cases did occur.

The implications of this study would seem to indicate
that the application of self-control strategies in a medical
rehabilitation setting may be a valid consideration for the
treatment oriented staff members. Care must be exercised in
training patients and staff in the understanding and implement-
ation of self-control stategies. The staff needs to be aware

of the need to develop a supportive environment for patient

Edward J. De Vries

attempts at self-control, particularly for those patients

who perceive they are dependent upon external reinforcement
(external locus of control). The benefits seen for initiation
of this type of treatment program include increased patient
activity time outside of regularly scheduled therapy periods,
possible reduction in length of stay, possible reduction in
treatment cost. The benefits to the staff are seen as increased
time for work with the more severely disabled, increased feed-
back from the patient on off-therapy hour activity and an in-
creased opportunity to assess progress in individual patients

on specific behaviors.

THE EFFECTS OF SELF-REINFORCEMENT
ON MEDICAL REHABILITATION
PATIENT BEHAVIORS

By
as) .
Edward J. De Vries

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
fOr the degree of

DOCTOR OF PHILOSOPHY
Department of Counseling, Personnel Services,

and Educational Psychology

1976

ACKNOWLEDGMENTS

I wish to acknowledge the assistance and cooperation of
many persons without whose help this learning experience
would have been impossible. It was only because of their
cooperation that a project of this nature could be planned,
implemented, and described.

I wish to first acknowledge Dr. Richard Johnson whose
leadership and guidance in the planning and evaluation of
this research was most crucial. Likewise I wish to express
my appreciation to the members of my dissertation committee.
I wish to acknowledge Dr. James Engelkes for his suggestions
and interest in the study itself; Dr. Betty Giuliani for
her time spent in developing the design and assistance with
the analysis; to Dr. John Schneider for his personal support
and assistance over the occasional hurdles and his invaluable
aid in instrumentation; and finally to Dr. Bert Stofflemayr
for his accurate perceptions of the rehabilitation process
and for keeping the perspective of the meaningfulness of
this type of study for rehabilitation programs.

This study, of course, could never have been completed
without the consent of Dr. George Fahlund, Executive Director
of Mary Free Bed Hospital and Rehabilitation Center in
Grand Rapids. Furthermore, I deeply appreciated the great
deal of personal interest in the study shown by each of the
department heads at Mary Free Bed who took many hours of their

time in planning assistnace. Finally, a word of thanks is

ii

due to the many physical and occupational therapists, nursing
staff personnel, and social service and psychology department
persons who took time in their busy schedules to attend meetings,
patient conferences, complete additional forms, and on occasion
to live with seemingly omnipresent observers looking over

their shoulders for the 10 weeks of the study.

A word of thanks is most certainly due also the three
patients, Sue Bob, and Doug. Without their cooperation and
willingness to subject themselves to new experiences and the
intense scrutiny of external observers over the 54 day period
this study would not have been possible. Their unique person-
alities and overall cooperative nature made believers of each
of us involved in the study about the value of every individual
to every other individual.

In terms of the external observations required, I cannot
thank Doug Frens and Lois Kuipers enough for their dedication
and interest in the study. Their stability of performance
and daily attendance to the study details made the entire
experience possible over the 10 weeks.

Conducting the experiment was one major effort, but
describing the study was quite another. To assist in this
detail I must thank Nancy Gendell whose sharp but poignant
criticism of my writing style makes the transcript intelli-
gible to the unknowing reader. I also owe a considerable
amount of thanks to Renee Follett who in the cold winter
months rose early many mornings to type the dissertation

in the accurate style in which it is presented. And, a word

iii

of appreciation is due Dave Vidio for his persistant efforts
on the behavioral graphs.

Finally, but most importantly, I wish to express my
most heartfelt thanks to my wife, Joan, whose psychological
and emotional support of this entire project was essential
to the attainment of this personal goal. The countless hours
she spent working, and the sage advice she provided as an
experienced nurse and a concerned wife, in order to help me
reach this goal are never to be forgotten. Finally, a word
of thanks is due my children, Amy and Gregory, whose unique
personalities exhibited during the study and its analysis
provided a welcome diversion from the scientific rigors of

such an experience.

iv

Chapter

TABLE OF CONTENTS

The Problem .

Introduction . . . . . . . . . .
Stigma of the Disabled .

Role of Rehabilitation .

Purpose .

Questions to be Addressed .
The Need for Rehabilitation Research .
Theory . . .

Self- Directed Behavior .

Self— Control Defined . .
Principles of Self— Control . . .
Self- Vs. Other- Controlled Behavior .

Overview . . . . . . . .

A Review of Literature

Self- Reinforcement .
Self— -Monitoring

Behavior Modification and Rehabilitation :

Design .

Case Study Approach . . .
Multiple Baseline Time Series .

Analysis

Instrumentation . . .
Relation of Self— Control and Locus
of Control

Methods and Procedures

Hypotheses
Design .
Sample .

64
65
68

Chapter
III.

IV.

Methods and Procedures (cont.)

Procedures . . . . . . .

Pre-Study Sequence

Patient Selection .

Patient Conference .

Elaboration of the Behaviors Chosen and
Monitoring Techniques

Self-Monitoring Technique .
Self-Reinforcement Period .

Additional Data Collected
Analysis . . . . . . . .

Statistical Analysis of the Data

General Findings

Hypothesis 1
Hypothesis 2
Hypothesis 3
Hypothesis 4

Comparison of Self— Monitoring and

External Monitoring . .

Summary of Statistical Findings
Descriptive Analysis of the Study .

Within-Behavior Analysis .

Sue: Behavior 1 (Travel Time and
Accident ) . .

Sue: Behavior 2 (OT Activity)

Sue: Behavior 3 (Range of Motion)
Sue: Across- Behavior Assessment

Bob: Behavior 1 (Resistance Exercises)

Bob: Behavior 2 (Range of Motion).
Bob: Behavior 3 (OT Inactivity Time)
Bob: Across-Behavior Summary .

Doug: Behavior 1 (Range of Motion
Doug: Behavior 2 and 2a (Travel Time
and Pushes) .

Doug: Behavior 3 (OT Activity Time)
Doug: Across- Behavior Summary

Personal Data Analysis

vi

Page

73

73
74
75

80
86
88

91
92

95
98
98

101
103

107
110

113
113

113
115
117
118
119
120
121
124
124

125
127
129

129

Chapter Page

VI. Summary, Discussion, and Implications . . . . 134

Summary of Results . . . . . . . . . . . . 136

Discussion . . . . . . . . . . . 137

Limitations of the Study . . . . . . . . 142

Implications for Future Studies . . . . . 145

In Retrospect . . . . . . . . . . . . . . 148

References . . . . . . . . . . . . . . . . . . . . . 150
Appendix

A. Figures . . . . . . . . . . . . . . . . . 159

B. Forms Used . . . . . . . . . . . . . . . 170

C. Instruments . . . . . . . . . . . . . . . 173

vii

Table

4-1.

4-5.

4-6.

5-1.

5-2.

LIST OF TABLES

Page

Statistical Probability of SM>B for each

behavior using all B period data points . . 97
Statistical Probability of SR>B for each

behavior using all B period data points . . 100
Statistical probability of SR>SM for each

behavior . . . . . . . . . . . . . . . 102
Statistical probability of E )8 for each

behavior using all the data points for

B and B periods . . . . . . . . . . . . . . 104
Summary of mean values obtained across

phases 106
Correlation of Self-Observation and

External Observation . . . . . . . . . . . 107
Comparative Scores of the 3 patients on

each of 3 tests administered . . . . . . . 131
Average Staff Rating of Patient Activity

Level . . . . . . . . . . . . . . 131

viii

Figures

3-1.

3-2.

A-3.

A-4.

A-S.

A-6.

A-7.

A-9.

A-lO.

A-ll.

LIST OF FIGURES

Multiple baseline design applied to 3
behaviors for each patient . .

Multiple baseline design as applied to the
selected behaviors of the 3 patients

Summary of Sue's Goals, Monitored Behaviors
and Self-Reward Contract

Summary of Bob's Goals, Monitored Behaviors
and Self-Reward Contract . . . . . .

Summary of Doug's Goals, Monitored Behaviors
and Self-Reward Contract

Travel time from nursing unit to OT (Sue--
Behavior 1) . . . . . . . . . . . . .

Number of objects struck enroute to therapy
(Sue--Behavior la)

Number of minutes in OT activity in room
(Sue-~Behavior 2)

Number of range of motion exercises (Sue--
Behavior 3) . . . . . . . . . . . . .

Number of resistance exercises (Bob-- Behav-
ior 1)

Number of range of motion exercises (Bob--
Behavior 2). .

Percentage of time active in OT (Bob--Behav-
ior 3) . . . . . . . . . . . . . . . .

Number of range of motion exercises (Doug--
Behavior 1). . . . . . .

Travel time from CT to elevator (Doug--
Behavior 2) . . . . . . . . . .

Number of pushes of wheelchair (Doug--
Behavior 2a) . . . . . . . . .

Percentage of time active in OT (Doug--
Behavior 3) . . . . .

ix

Page

66

67

76

77

78

159

160

161

162

163

164

165

166

167

168

169

Chapter I

The Problem

 

Introduction

 

Throughout the centuries of recorded human history, mankind
has been seen as the dominant species on the earth. From the
earliest times humans have sought to control their environment
and each other. They have conquered nations, founded religions,
discovered and rediscovered basic scientific principles, walked
on the moon, and transplanted human organs. As long as they
have written or printed, people have extolled themselves and
each other for their feats of brilliance in science, religion,
art, philosophy, medicine, sports, and politics. Names like
Marian Anderson, Galileo, Einstein, Mozart, Babe Ruth, Mead,
Edison, Hammarskjold, Indira Gandhi, St. Augustine, abound
in history to record the superachievements of human beings.

But almost as long as the chronicles of the great persons
of history are the lengthy annals depicting the misfortune and
inhumane treatment of those, who for a variety of reasons,
lack the physical or mental capability for competing in certain
aspects of their society. The countless myths and actual
events written about the disabled human leave the average
reader confused, mystified, and shocked. The stories of
emotionally disturbed children locked in windowless rooms,
of lepers banned from the city, of the retarded and emotionally
disturbed crammed into bedlams, physically disabled children
abandoned, of the deaf and blind being labelled retarded,

I

of epileptics being condemned as "possessed" by evil spirits,
make healthy individuals squirm as they realize the extent
of people's inhumanity to each other. In nearly all cases,
these shunned persons are perceived by their society to be
lacking a segment of "human-ness" and, therefore, they may,
with impunity, be isolated or ignored.

Stigma of the Disabled

 

Although the number of overt acts of rejection or
abandonment have been somewhat curtailed in the recent decades
because of increased awareness and knowledge and, because
of legislation, studies of attitudes about the disabled show that
there is still a stigma attached to those who have an observable
physical or mental deviation from the norm. Barker (1948)
was an early promoter of the idea that the disabled, like the
culturally outnumbered, are considered a minority and are,
therefore, stereotyped in their role as are the other minorities.
Beatrice Wright (1964), a leader in the field of equality for
all, identified a variety of specific situations wherein the
non-disabled view the disabled as completely lacking the ability
to fit into any segment of society. English (1971) defined
stigma as an attribute which dehumanizes the individual, main-
taining that it is the way a so-called normal person views
others who are different than himself. This seems to put the
responsibility for stigmatizing on the "normal" population.

This stigmatizing process often leads to the segregation
of the disabled person. For example, special education
classrooms are part of a nationally legislated procedure to

provide adequate education to all persons regardless of physical

 

.-

 

 

 

3

or mental ability. Sharland Trotter (1974) summarized a re-
port written by Nicholas Hobbs. a psychologist at Vanderbilt
University. His lengthy report discredited this process of
educational labeling, indicating it often creates a gulf be-
tween the able-bodied and disabled by building and perpetuating
social barriers, depersonalized customs, and restricted
opportunities.

Another significant way the stigma is enforced is by a
variety of civil laws passed "to protect society" from poten-
tial interaction with the disabled. These laws include
restrictions on the disabled with respect to driving, voting,
marrying, or working. Revisions in these laws, along with
major changes in building construction codes, mass transpor-
tation policies and techniques, employment compensation
incentives, and other socially controlling regulations, will
help the disabled, but they may still be seen as "second class"
citizens. As English indicated, "Stigma exists in the lives
of most disabled persons, and generally it represents the
most salient and frustrating problem to be overcome in
rehabilitation" (1971, p. 2).

Role of Rehabilitation

 

In the midst of this clash between the production-minded,
impersonal and health—oriented society and the personal ambi-
tion of the physically disabled individual lies the medical
rehabilitation program of our country. For those who have
the capacity to relearn lost physical functions or who will
benefit from learning new physical coping behaviors over an

extended period of time, the medical rehabilitation treatment

4

concept is essential. The task of the medical rehabilitation
staff is to assist the physically disabled to overcome their
psychological and physical limitations by teaching them new
coping behaviors as well as reteaching old adaptive behaviors
(Fordyce, 1967). The goal of rehabilitation programs is to
assist disabled persons to become productive and complete indi-
viduals and thereby restore their sense of first class citizenship.

From the patient's perspective, the entire rehabilitation
process is often a long and arduous one. For most it is a
physical struggle with injured nerve pathways, atrophied
muscles, lost limbs, or malfunctioning sensory modalities, as
they attempt to regain a sense of "self-dignity and worth"
(Raninowitz and Mitsos, 1964). It is psychological combat
between weakened bodies and a cultural value system that re-
wards healthy nondisfigured bodies and unimpaired functioning.
It is an intense relationship with trained professionals which
attempts at all costs to re-establish the disabled individual
into a familiar environment. It is, then, the "interwoven
fabric of value judgments, mutual expectations, and effective
bondsthat creates the design of the rehabilitation picture"
(Rabinowitz and Mitsos, 1964, p. 3).

This dissertation proceeds from the personal observations
provided by Goldiamond (1973). Based on his determination
that a medical rehabilitation treatment program can be best
effected through the application of a self-controlled contin—
gency management program, the idea for this study was germinated.
Because of his observation that those individuals who were

able to maintain a relatively normal life style even though

5
confined to a medical rehabilitation center were the patients
who made the greatest gains in treatment, the earlier observa—
tion regarding the need for most individuals to be productive
and self-enhancing seems supported. Therefore, it seemed
meaningful to develop a research study to empirically test
the effects of a self-controlled behavior modification program
on medical rehabilitation patient behaviors. The meaningful-
ness of this study is seen primarily for the thousands of
patients who daily are confined to sterile, rigid and often
impersonal institutions wherein all characteristics of a
previous enjoyable life-style are non-existent and where
personal controls are unrewarded.
Purpose

It has been noted by Rabinowitz and Mitsos (1964) and
Rothschild (1970) that the process of rehabilitation is often
a psychologically demanding one. The rehabilitation patient
must of necessity work through the psychological impact
created by the limitation of the disability. This readjustment
is further complicated by the fact that the patient is in a
strange environment. .It has been mentioned that this environ-
ment often includes authoritarian roles, physical confinement,
and an estrangement from all normal social activities, and
often becomes, in effect, a dependency producing system.

In a most thought provoking study, Willems (1972), through
an extensive review of patient activity levels, found that the
patients' independent behavior activity was directly correlated
with their freedom of activity. He found that behavior

occurring inthe cafeteria and hallways was significantly more

 

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6
independent than those which occured within treatment areas
of the rehabilitation center. He simply raised the question
in his report about the goals of the treatment programming in
the rehabilitation center.

Ronco (1972), in discussing the theory of architectural
planning for hospitals, considered the psychological impact
the hospital setting has on patient behaviors, noted the
effects of physical and psychological confinement along with
the lack of privacy and familiar support systems. He remarked
that although the lack of clocks, calenders, familiar furniture
may be minor items, their collective absence is a major factor
to consider when assessing patient behaviors. In effect, he
said, the patient is seen as being under the "complete control
of the system" with disruption of familiar behavior patterns
and the lack of autonomy being the ultimate result.

Rothschild (1970) also discussed the concept of the
patient's dependency on medical professionals. She indicated
that one of the basic assumptions in the role of the sick
person is the willingness to follow essential medical direction.
She does indicate, however, that once the patient's physical
condition has stabilized, their participation becomes essential
in planning their rehabilitation program. According to
Rothschild, "It is always assumed that disabled people .
are interested and willing to master their environment and go
on struggling with life and meeting its requirements" (p. 76).
Although this may be the ideal, it seems apparent from the
the literature that patient's input is often neglected, personal
ideas for independence conveniently displaced by administrative

regulations.

7

Schontz (1975) took up this matter of patients' rights in
the introduction to his book on the psychological aspects of
illness and disability. He perceived the role of the patient
to be one of an active participant, staff and patient working
cooperatively. It was his belief that in the rehabilitation
of an individual, the individual should be considered as an
"indivisible whole". He felt that the patient should be the
"peer of those who treat him, not their subordinate" (p. VI),
and advised that patients not only have the right to make
decisions relative to their own programs, but they also have
a right to be heard and to defend themselves against decisions
which are made by the institution in which they are kept.

The intent of the study reported here was to attempt through
the technique of self-controlled behavior, to assist patients
to assume more responsibility for their behaviors while they
are inpatients in a medical rehabilitation center. The need
for self-control has been seen as an essential ingredient in
the rehabilitation program for most physically disabled. The
opportunity to practice the skill of behavioral control while
an inpatient is viewed as a primary step to the later mastery
of the social reintegration phase where the self-control will
be a crucial element in successful readmission to traditional
social roles. Teaching the patients that they can and do
have control of certain contingencies and behaviors even in a
seemingly dependency-producing environment may prove to be an
invaluable resource to those who dislike the routines and

impersonal nature of their present life style. The capacity

8

to control themselves and the reinforcements in their present
environment may be the essential ingredient in their treat—
ment program which keeps them from becoming "lackadaisical"
as Goldiamond (1973) suggested.

The value of this self-control concept is seen as having
a practical side as well. Since patients are generally in
treatment for 2 to 3 hours per day, much of their time in a
treatment center is spent waiting for the next appointment
time. If this waiting period could be changed from a time of
inactivity to one of self-initiated and self-controlled thera—
peutic activity the potential for increasing staff reinforce-
ment as well as self-perceived progress seems greater. In
addition, the potential for a shorter treatment program seems
possible.

Questions to be Addressed

 

Among the possible questions which a study of this nature
provides, the following are to be considered. They are stated
here in a rather general way, but will be restated later in
a testable manner.

The concerns in this study relate to the patient's ability
to take some personal responsibility for increasing their
tolerance for physical activity, for managing some aspects
of their rehabilitation activity. Since rehabilitation patients
are usually seen as being acted upon rather than acting, being
directed as opposed to being directive, being told vs. telling,
the principles of self-managed behavior and the patient's
rights seem to be in direct opposition to what actually is
happening. But in the realization that patients engage in

certain activities over which they do and should have control,

 

 

9
whether implied or expressed, there may be some opportunity
to test the theory of self-directive behavior in a medical
rehabilitation center.

For this reason, then, the study concentrated on two
primary questions: Does the active self-monitoring of a
selected behavior cause a change in the occurrence pattern of
that behavior? And, does the application of self-reinforcement
of selected behaviors cause a change in the behaviors more
than that noticed during either the self-monitoring or a no-
treatment phase of that behavior? These questions were the
focus of this study.

The Need for Rehabilitation Research

 

J. V. Basmajian (1975), a noted physician researcher at
Emory Rehabilitation Research Institute, in a recent address
to the graduating class of physical therapists at the University
of Alabama, challenged that group of newly graduated professionals
to become active researchers in their new appointments. He
discussed the need for continued research in the existing
therapeutic procedures, new drugs, and novel treatment ap-
proaches, bioengineering for the physically disabled and
exploratory work on neuromuscular function. His criticism of
the present status of the medical rehabilitation field is that
it is based on "intensive relationships" and not on the logic
and support of a scientific principle. He maintained that
"rehabilitation activities often respond slowly and obliquely
to scientific progress because they have no base of science

that is uniquely their own" (p. 607).

10

James McDaniel (1969) reflected a similar attitude re-
garding the lack of scientific unity in the field of rehabili-
tation medicine. In his work on the relationship between
physical disability and human behavior, McDaniel commented on
the "paucity of hard data" which efficiently relates the
effects of a particular injury or disability to probable out-
come behaviors for the individual. He claimed that although
there is information available, it is usually scattered in
the widely diverse areas corresponding to the services offered
in a comprehensive treatment facility. In other words, re-
search findings are available in speech pathology, physical
and occupational therapy, medicine, vocational rehabilitation,
and social work, but there is little interdisciplinary re-
search which will benefit all at the same time. McDaniel
believed that the behavioral science field, because of its
commonality across these disciplines, should become the
"prime interface" between the groups.

Fordyce (1971) also noted the relative absence of an
effective data base in rehabilitation services, particularly
the lack of data concentrating on contingency management in
rehabilitation. It was his feeling, as stated earlier, that
rehabilitation is a behavioral science. Success or failure
of the medical rehabilitation program can best be judged by
observing the patient's behavior. Application, then, of
proven learning theory principles to individual treatment
programs should provide a necessary input into rehabilitation

literature.

11

Friedlander (1974) discussed the need for further re-
search in learning and conditioning in the field of rehabili-
tation. He observed that there is little application of
research in learning and conditioning to rehabilitation work
with the disabled. It was his feeling that the reason for the
lack of such applications is because both fields are fairly
new and relatively little work has been done with the disabled.
His requirements for research in the area include practicality
and applicability for existing personnel as opposed to the need
to add newly trained staff in order to provide service. In
addition, it must be simple enough for those trained in other
areas to use, it must deomonstrate cost effectiveness, and it
must have relationship to the entire issue of accountability
in the rehabilitation center. He attributed some of the
resistance to utilization of research to rehabilitation per-
sonnel who are afraid of being displaced by new research
findings which perhaps assist the patients more than the in-
tensive relationships characteristic of rehabilitation work.
For that reason he advocated that research must be implemented
through the staff in order to avoid further resistance.

Perhaps part of the reason for the apparent lack of re-
search in the field of medical rehabilitation is best explained
by Reppucci and Saunders (1974). They described a variety of
potential problems related to the introduction of behaviorally
oriented social innovation programs into the natural environ-
ment. Of particular importance to the idea of conducting

research of a behavioral nature in a medical rehabilitation

 

 

‘A.

 

12
setting, are the problems associated with institutional con-
straints, the limited resources of staff, time, and funds,
the inflexibility necessitated by research designs, and the
frequent scientifically stifling compromises between research
principles and the daily operation of the facility. Considering
these potential roadblocks to conducting applied research in
the field setting, it becomes understandable how scientific
progress might be slowed. Wright (1972), in listing the
principles for rehabilitation psychology, offered a variety
of ideological alternatives for the practitioner. She noted
that basic research must be of a practical nature, that any
research to be conducted with a rehabilitation population should
be geared primarily to "problem resolutions". This issue of
practicality provides a very significant input in a time of
economic inflation. With the spiralling cost of living, there
is a corresponding rise in health care costs. Unfortunately,
private insurance packages, state-supported medicare and medi-
caid benefits and personal finances are inadequate to meet
these increased costs. A recent executive order by the
Governor of the State of Michigan (1975), made in an attempt
to control state finances, indicated that a variety of medical
services previously paid for under the medical assistance pro-
grams will no longer be covered. Such services as occupational
therapy and speech therapy, dental services, hearing services,
vision services, and restricted psychiatric inpatient services
have been arbitrarily removed from the possible payment list.
Such massive curtailment of funding for the medical rehabili-

tation process not only creates tension in the employment

13
market, but must also force a reevaluation of the methods and
types of services the health care professions provide. In
this context, Wright's comments are most appropriate. New
and innovative research must be conducted in such a manner
that it leads to problem resolution both on a personal and
programatic level.

The need for research of this nature, therefore, seems
rather clear. The cost effectiveness of any treatment pro-
gram and the direct observable benefit to the individual
patient for any specific treatment demands a research attitude.
The lack of systematic application of established principles
of behavioral management in a setting where specific behaviors
are being constantly refined seems almost ludicrous. The need
to provide a treatment system which enhances the time effec-
tiveness of the professional, which increases the productivity
of the patient time, and which promotes increased rehabilita-
tion behavior provides the rationale why this study was done.
Theory

The principles of learning theory are extremely broad
and a great deal has been written about them. Of particular
importance to this study, however, are selected principles
from learning theory in particular operant behavior and con-
tingency management. In addition, there is a recent advance
in the field of behavior science called self-controlled
{ behavior modification. This concept is set in opposition to
the more traditional behavior modification approaches which

depend on "other-controlled" or externally controlled

14
programs of behavior management. The theory of self-directed
or self-controlled behavior is the basic concept to be con-
sidered as background for the study.

It is essential that we include a brief overview of the
entire concept of learning theory before proceeding with an
elaboration of the above tOpic areas, however. Learning
theory is one perception of personality development which con-
centrates on specific behavioral developments, as opposed to
the nontangible constructs, theoretical constructs, or other
nonobservable effects, as being responsible for personality
development. Simply described, learning theory claims that
a personality is developed because of a series of reinforcing
or punishing consequences of behavior. The reinforced be-
haviors have an increasing probability of recurrence, while
those behaviors which result in aversive consequences of
punishment decrease in the probability of recurring. Through
several periods of reinforcement or punishment of this type,
the person's predictable behavioral pattern is formed. Through
this process, the individual develops sequences of behavior
which promote individual growth. In addition, antecedent cues
or situations occuring just prior to a reinforced or punished
behavior become related totfluaprediction of the recurrence
of the behavior. The ability to recognize cues and to under-
stand consequences of behavior forms a basis upon which be-
havioral control is predicted. Within this broad concept
of learning theory are countless principles, techniques,

and definitions.

.d-
n.

u

1.!

34A

 
 

 

15

One of these important principles is that of Operant
behavior. Skinner (1953) defined operant behavior as "behavior
that has an effect on the surrounding world" (p. 59). In other
words, operant behavior is a physical response to a stimulus
or cue in the environment which causes a measurable effect on
that environment. Skinner noted that persons are constantly
interacting with the environment. Each activity which the
person finds rewarded by the environment will increase in the
probability of its recurrence; those which meet with some sort
of punishment will, through conditioning, decrease in their
probability of recurrence.

In the field of rehabilitation, operant behaviors are
foremost in importance. Learning the use of new prostheses,
relearning the use of injured limbs, and reestablishing nerve
pathways by repetitive physical activity are all examples of
operant behavior. Those activities which are reinforced by
accomplishment soon become part of the behavioral repertoire
of the patient. Those activities that result in pain, embar-
rasment or failure generally are not individually pursued by
the patient because they are punishing in their consequences.
The goal of rehabilitation therapies might be restated in
operant terms as follows: Rehabilitation is the reshaping of
patient behaviors which will ultimately lead to a successful
effect upon the environment where successful effect means
that the patient approaches the premorbid acceptable level

of such a behavior.

 

 

.4.

 

 

16

Contingency management is also an important concept in

 

this particular study. Contingency management is related to
the concept of operant behaviors. Contingency management is
the control of the various stimuli or reinforcements which
affects the probability of recurrence of a selected behavior.
By controlling the situation or the specific rewards which
ususally serve to produce or maintain the behavior, the be-
havior itself can be controlled.' In the rehabilitation setting
the prospects for contingency management are varied. Specific
patient behaviors occur only in selected areas of the hospital.
As Willems (1972) pointed out, patients engaged in a certain
level of behavior in their rooms but evidenced considerably
different levels of that behavior in therapy. Patients
generally never sleep outside of their own room and may never
exercise themselves when in their own room. In another situa-
tion, the patient may try feeding himself in the therapy

area, but may demand to be fed when in his own room. Hence

we see that the environment may serve as a cue for specific
behaviors.

We also find reinforcement or punishment for certain
behaviors being provided by the staff, family, or other
patients. Patients who are talked to by therapists while
performing therapy activities may feel reinforced. Staff
may criticize patients for other behaviors, the criticism
serving as a punishment and deterrent to further behaviors
of that nature. Patients may also receive a great deal of

intrinsic pleasure by performing certain behaviors, such as

l7

learning to feed themselves again or moving previously paralyzed
muscles. They may feel considerable embarrasment over reshaping
bladder and bowel functions which before were quite standard.

The variety of contingencies which can be expected to be
brought to bear on a patient in a rehabilitation center are
varied. The successful management of these contingencies is,
therefore, important to the efficient rehabilitation of the
patient. Contingency management is an extremely important
variable to the successful implementation of any Operant
behavior modification program.

Self-Directed Behavior

 

Within the behavior modification field an increasing
amount of consideration has recently been given to the pos-
sibility of a self-directed program of behavior change. The
alternate terms self—directed, self-controlled, self-regulated,
self-managed behavior change all refer essentially to the
same concept, 'UD the principle that man has the capacity to
control his own destiny. The variety of approaches to the
principles of self-control will be discussed later. Now,
however, the concepts of self-controlled behavior and the
essential ingredients contained therein must be identified.

Self-Control Defined

 

Skinner (1953), in one of the original writings on the
topic of behavioral self-control, envisioned it as "the
reinforcement of those behaviors which make punished behavior
less probable" (pp. 3-30). Skinner called this process the
"self-determination of conduct". When the punishing effects

of certain behavior are reduced, the behavior doing the

 

 

ll:

‘0

‘M

18

reducing is rewarded. When that behavior is rewarded, its
probability increases and the individual then is seen as
controlling himself. Skinner listed a variety of techniques
wherein self-control is obtained. These include acts like
the use of drugs, punishment, operant conditioning, distrac-
tion, aversive stimulation. He advocated the use of these
techniques by the individual just as they would be applied
in any externally controlled behavior modification program.

Perhaps the most complete review of self-controlled
behavior theory and application to date is that of Mahoney
and Thoreson (1974). They agreed with the basic principle
that behavior is controlled either by antecedents and/or
cues to behavior. If a person wishes to change a given behavior,
he must recognize both the typical consequences of the behavior
as well as the cues for that behavior. They indicate that
research has verified that for self-control to be effective,
at least one of three elements must be present--self—observation,
environmental planning, or behavioral programming.

The concept of self-observation allows a variety of
technical alternatives including the use of graphs and charts
or any other systematic record of behavior. The use of any
form of immediate feedback device by which the individual can
judge progress is recommended. Self-observation is simply
the routine, accurate reporting of the activity level of a
behavior that a person does for himself. Environmental
planning, according to Mahoney and Thoreson, involves "changing
the environment so that either the cues that precede the be-

havior or the consequences that follow it are changed" (p. 23).

19
This may necessitate avoiding situations which elicit the be-
havior or avoiding those situations in which a choice is
allowable. The final recommended procedure is behavioral
programming. This last recommendation involves altering the
consequences of a behavior in such a way that the frequency
of that behavior is changed. A variety of techniques can be
used, including positive self-reinforcement, self-punishment,
or any internal or external consequence which will change the
frequency of the behavior.

Goldfried and Merbaum (1973) perceived self-control to
be a personal decision-making process. They saw self-control
as a result of conscious deliberation of the options for
behavior and the selection of those actions which accommodate
the goals the person has chosen for himself. They indicated
that the areas of human behavior which can be self-controlled
include maladaptive physiological or instrumental behaviors.
The physiological behaviors, they explained, are best controlled
by self-administered aversive conditioning, auto-suggestion,
or relaxation. They recommended that the instrumental or more
overt behaviors be controlled by covert conditioning or self-
reinforcement techniques. It was their observation that the
literature on self-control seemingly concentrates on weight
control and smoking habits, although they noted a few reports
of marital problem solving and study habit remediation with
the self-control concepts.

In a somewhat more theoretical evaluation of the topic
of self-control, Klausner (1965) provided considerable input.

He considered self-control to be the freedom from external

20

social dictates or the internalizing of authoritarian dictates.
According to Klausner, self-control is the ability to control
the environment and its impact. He indicated, however, that
self-control is not so much total control of self but rather
the control of selected aspects of the self. In a review of
290 articles on the topic, Klausner catagorized self-control
programs into control of overt performance, physical and
psychological drive control, intellectual or cognitive thought
control, and control of affect. He also devised the recom-
mended methods of controlling techniques between direct and
indirect control. Indirect control is the control of segments
of a larger complex of behavior until the entire complex can
be controlled directly at the outset. He conceptualized the
controlling methods in four distinct ways. Efforts of synergy
are the skills of controlling the environment and hence the
individual himself. Efforts of conquest are the skills
necessary for the facilitation or inhibition of drives. Efforts
of harmony are those skills needed for controlling the be-
haviors to correspond with physical constitution and personality.
Finally, a fourth level of controlling behavior is that type
of self-control skill which is used to overcome threats to
one's self while acting in a desired manner to achieve certain
goals. This level Klausner labelled the effort to transcend.

Cautella (1969) described self-control in a manner simi-
lar to that of Skinner. He saw self-control as a response
repertiore in which "the individual can make responses to
increase or decrease a response probability that is perceived

as injurious to the individual himself or to others" (p. 324).

21
He endorsed the concept of self-control because he felt the
individual is more apt to maintain a level of new behavior if
he is responsible for that change. Cautella described the method
of self-control within an operant framework, which utilizes
reinforcement and punishment, or reciprocal inhibition which
utilizes the processes of relaxation, thought stopping, or
covert sensitization.

Goldiamond (1965) described self-control as a functional
relationship between man and his immediate environment. The
environment he generally refers to provides the reinforcement
for selective behaviors. These reinforcers he also called
"critical consequences" for behavior (1974). By analyzing and
controlling the environmental reinforcers for a given behavior,
the person is able to control his own behavior. Hence a basic
understanding of man's relation to his environment is important.

Kanfer and Phillips (1969) considered the self-control
process from a therapeutic standpoint and called it instigation
therapy. They defined instigation therapy as a technique by
which the individual

utilizes specific suggestions and assigned

tasks in the patient's usual daily environment,

formulated on the basis of the patient's verbal

report of the symtomatic behaviors, their con-

text and their consequences . . .Self—reinforce-

ment by the patient and the natural occurence

of reinforcements contingent upon adequate

patient behaviors in his usual environment are

used to achieve self-control. (p. 474)

They added that self-control is a most effective method of

behavior change since it is accomplished in the stimulus situa-

tions in which the behavior change is desired. The ultimate

22

success of the self-control program rests basically on the
patient's self-reports and adequate reinforcement. We will
discuss the concept of self—reinforcement in more detail later.

Martsen and Feldman (1972) saw the principle of self-
control both as a thought oriented process wherein the indi-
vidual has his mind set on controlling some behavior and as
a specific behavior oriented self-control where the individual
performs some function to control his behavior. Essential to
their concept is a need for clear definition of the behavior
to be controlled as well as an understanding of the person's
attitude, insight, consciousness level. The personal awareness
(consciousness) of the need to control an attitude which per-
suades or reinforces the commitment to change and the insight
to realize how the change will affect the total person is
essential to the self-control strategy.

Rimm and Masters (1974) defined the process of self-
control as replacement of nonproductive behaviors with pro-
ductive behavior. As others have indicated, the importance
of the personal awareness of stimulus situations in the environ-
ment which affect the probability of the desired behavior and
the response consequences to the desired behavior are emphasized.
These authors also felt that alternative or competing behaviors
are essential as are the use of principles of approximation
(or shaping) to the desired behavior, chaining of behaviors,
and the control of the early parts of the chain, and the
importance of self-monitoring.

Finally, Watson and Tharpe (1972) in an instruction book

for behavioral control define self-controlled behavior as the

23

process of "directing the relationships between your environ-
ment and your behavior" (p. 23). They, like all the others,
emphasized the importance of understanding the relationship

of behavior to antecedent cues and consequences. They also
advocated the use of self-monitoring, self-reward, and punish-
ment programs in whatever manner facilitates the occurence

of the appropriate behavior.

Principles of Self-Control

 

From the theories noted above, and for this study, it
appears that self-controlled behavior is, first of all, self;
suggested. Although none of the authors cited specify how the
behavior to be changed is to be identified, most authors im-
plicitly agree with the idea of self-prescription (Bandura,
Grusec, and Menlove, 1967; Bandura and Perloff, 1967). Once
the behavior has been self-suggested, it must be clearly

identified. At this point, a process of self-monitoring must

 

 

begin with an awareness of situational cues which precipitate

 

the behaviors and reinforcingficonsequences which, in turn,

 

increase the probability of the recurrence of similar behaviors.
The primary aspect of the self-controlled behavior is the
ability to manipulate the environment to increase the proba-

bility of the behavior and/or managgment of the consequences

 

of the behavior to facilitate its continuation. Of those
latter concepts, some writers have added further observations
which are essential.

Self— Vs. Other-Controlled Reinforcement

As a strong prOponent of the self-control ideal, Mahoney

(1971) has researched the concepts of self-imposed techniques

24

of reinforcement. His work will be considered in more detail
later. Essential to his theory, however, is his observation
of the value of "self-regulation" versus "other-regulation"
of consequences. He noted that self—imposed regulation is more
effective than externally imposed regulations. He found that
there seems to be little difference between the effectiveness
of apprOpriate uses of positive or negative reinforcement, but
indicated that there is little supportive research on the
application of self-punishment as a means of behavior control.

Bandura (1967b), another leader in the field of self-
controlled behavion indicated that self-regulation of behavior
demands an initial explanation of the acceptable levels of the
target behavior. Once these standards have been adopted, the
person must then "self-administer rewards and punishments
depending upon whether their performance falls short of, matches,
or exceeds their self-prescribed demands" (p. 449). Bandura
also found that those persons who desire to regulate their
own behavior generally tend to maintain relatively high stan-
dards for themselves. He noted that the most important attri-
bute of such a self-rewarding contract is its capacity "to
maintain effortful behavior over time" (1967a, p. 112).

Kanfer and Duerfeldt (1967) compared the varying effects of
self-control as opposed to other controlled reinforcement.
They found, in a three phase experiment, that the process of
self-reinforcement has longer lasting effects, that self-
reinforced subjects tended to establish performance standards
at levels of previously externally reinforced standards, and
that they maintained a higher performance level when compared

to the behavioral levels of externally reinforced persons.

25

Kanfer (1971) in a later study described the process of
self-control and reinforcement. Speaking fauna forecaster's
viewpoint, he envisioned that the rapid rate of change in life
settings demands that man be aware of the intense personal
interactions he has with his environment. With the possi-
bility of such change, man must be consistently able to adapt.
He felt that this consistency will only be deve10ped
through "self-generated motivations and standards and means
for maintaining" (p. 404) that consistency which.in turn, means
defining contracts in therapy which utilizes the principles
of internal reinforcement.

To further elaborate on reinforcement, Kanfer and Philips
(1969) indicated such reinforcement can consist of self-
evaluations of the person, therapist-related reinforcements
or peOple, objects or reinforcing events in the daily life
of the individual. It is imperative, however, that the rein-
forcement be under the direct control of the person himself
and that it be administered only "when reinforcement is appro-
priate to his own behavior" (Kanfer, Bradley and Martson, 1962).

Kazdin (1973) added further thoughts to support the con-
cept of self-directed reinforcement system. In his writing
he attempted to explain why some externally imposed token
economy reinforcement programs may fail. Among five explana-
tions for a breakdown in effectiveness, Kazdin indicated that
the behavior being rewarded may not be possible for the indi-
vidual, that there may be a lack of understanding about the
relationship between adequate performance and receipt of the

reward, or that there may be a delay in receiving the reward.

26

As a potential solution Kazdin recommended including the
patient in the development and administration of the contin—
gency which is, in effect, the self-control principle which
has been discussed.

In summary, the theoretical principle upon which this
study was based is personally controlled behavior change.
The particular skills of self-delineation of behavior change,
self—established performance standards for the behavior, the
utilization of self-monitoring techniques, and the application
of a self—devised and controlled reinforcement program were
emphasized. This study was applied to a small segment of a
population which has traditionally not been conceived of as
being self-directed, although the professional's expectation
is that these people should become self-directed as a result
of their treatment experience. The rehabilitation patient
may be a prime candidate for the application of the principle
of self-directed behavior change. Originally self-directed,
this individual became instantaneously other-controlled and
powerless as the result of a trauma or illness. Yet, through
retraining, he or she may become maximally self-controlling in
a dependency reinforcing situation.
Overview

The following chapter provides a review of the literature
with respect to the application of behavior modification prin-
ciples in the field of rehabilitation and the utilization of
self-control principles with the rehabilitation patient. The

hypotheses will be formulated and the specific procedures for

27

conducting the study are presented in chapter three. A des-
cription of the study results is presented in chapters four
and five. The final chapter draws together the concepts as
discussed and observed in the study. Based on the study, recom-

mendations for the application of the data to other situations

will be presented.

Chapter II

A Review of Literature

 

Behavior modification is without a doubt one of the most
controversial of the theories of human behavior change, and
it is probably the most widely applied. The growth of knowl-
edge about behavior modification and the research in the field
during the last two decades has created as much excitement and
ambivalence in the area of psychology as did Freud's first
pr0posals about the unconscious. The use of behavior modifi-
cation is praised by many when it works, but has also led to
governmental controls when it created pain and nearly animal-
like experimental conditions (Trotter and Warren, 1974).

The utilization of behavior modification techniques in
controlling institutional populations has provided a large
volume of literature. The application of concepts such as
operant conditioning, covert conditioning, token economies,
systematic desensitization, aversive conditioning, and
punishment have become standard treatment for behavioral
disorders and standard procedures for behavior change pro-
grams in mental health institutions, prisons, schools, and
workshOps. Couch and Allen (1973)supported the idea of applying
behavior modification principles in rehabilitation settings.
They indicate, "Studies promoting the utilization of behavior
modification in rehabilitation settings offered dramatic
proof of its efficacy" (p. 88), and they note that many
researchers see it as THE system of patient control.

As was cited in the first chapter, a new advance in the
field of behavior modification is the process of self-controlled

28

 

s""

.n:

 

.‘

It],

29
behavior. This technique of modifying selected behaviors
demands a self-realization of the cues which surround the
behavior and the reinforcement contingencies which affect
the behavior. In addition, we noted that self-controlled
behavior necessitates the self-establishment of an acceptable
standard for the behavior, self-monitoring, and a self-
controlled reward system. Reviewed here will be that body
of literature which evaluates these specific areas of self-
controlled behavior in terms of its proven effects on behavior.
In addition, the applicability of behavior modification pro-
grams and self-controlled programs as they have been applied
to rehabilitation patients will be reviewed.

Self-Reinforcement

 

A major component within the self-control concept is the
management of reinforcers that will promote or change the de-
sired behavior. Bandura, one of the leaders in the field,
has published, in conjunction with others, several articles
on the topic (Bandura, Grusec, and Menlove, 1967; Bandura and
Perloff, 1967; Bandura and Whalen, 1966). In these articles,
the authors were generally concerned with the combined effects
of role modeling on the self-establishment of reward standards
and the effects of self-reinforcement on the individual. In
a study of 80 children, Bandura and Perloff reported that the
reinforced subjectszusacombined group performed better at a
given task than did non-reinforced group. They noted no
significant difference in the performance of the externally
or self-reinforced children. They did note however, that the

self-reinforced group seemed to establish higher levels of

"'1

0%":
-

.hu

«1.

'v

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'11.

30

performance than was necessary in terms of minimal standards
for reward. Bandura, Grusec, and Menlove discovered that
when children (whether these were the same or different
children is not clear) were exposed to role models, they
tended to establish a standard for their own behavior in
terms of the modelled standards even if the schedule was very
demanding and lower performances possible to obtain the same
reward. The common observation in each research team was the
negative personal effect that the potential for failure had
on the children as well as the undue expectations they often
held for their own performance. Based on this research, it
might be worthwhile, then, in any self-reinforcement program
to be alert to the tendency of persons to be overly demanding
in establishing behavior standards for the amount of reward
obtained.

Hall (1972), in a doctoral dissertation, followed the
lead of Bandura by testing the difference in productivity
resulting from different reinforcement alternative? and per-
sonality characteristics. In his study of 60 subjects, he
attempted to analyze the differences between reinforcment
types, whether external or self, and the subject's perceived
locus of control. He found, as did the earlier authors,
that there were no differences in task production between the
self-reinforced and externally reinforced groups. He also
found that the reinforced groups both performed at a higher
level than a no-reinforcement control group. He further
noted that the generalized expectancy of reinforcement (locus

of control) had no effect on task performance, thereby

31

indicating that the personality trait of perception of the
locus of control of reinforcement produced no difference
between groups.

Kanfer and Duerfeldt (1967), in a three-phase research
design utilizing three groups, also tested the effects of
self-controlled versus other directed reinforcement. Three
groups of subjects were shown geometric designs and asked to
select correct designs based on a pregiven criteria. Two
of the three groups were initially reinforced for responses
without any relationship to correctness; the third group
was not reinforced for any response. The second phase of the
study continued the non-contingent external reward system
for one group, the second group was asked to reward themselves
if they felt they were correct, while the control group con-
tinued on a no-reinforcement program. The final phase of
this study was an extinction phase for all three groups. The
results showed a significant difference in the final phase
behavior with the self-reinforcement group correctly choosing
more designs than the other groups. The evaluation of this
study supports the hypothesis that "training in self-
administered reinforcement enhances performance under
extinction" (p. 244).

In a much different research design, Lovitt and Curtiss
(1969) reported the results of a comparative study on rein-
forcement techniques. In a single case study design of a
twelve-year-old student, the researchers found that self-
administered rewards by the student for correct behavior

prompted a higher performance for a specific classroom behavior

32

than either a teacher-dominated point system or other teacher~
dictated reward. In the repeated measure experimental study,
these findings were reproduced, thereby confirming the hypo-
thesis that self—directed reinforcement program does produce
more of a desired change in a specific behavior than does an
externally devised system.

In another single subject study, Nurnberger and Zimmerman
(1970) applied the concept of self-controlled behavior to
study habits. They found, through the use of self-administered
punishment, that a graduate student significantly changed his
behavior with respect to work on his dissertation. The stu-
dent increased his study behavior when he required the re-
searchers to spend the student's money on social programs
with which the student was in basic disagreement, if his
behavior was below a self-established standard. It is also
surmised by this writer, although not described in the article
itself, that the reinforcement gained by the student for pro-
ductive behavior undoubtedly served to increase his motivation
to continue such goal directed behaviors.

Bolstad and Johnson (1972) provided yet another observa-
tion on the application of self-controlled versus other-
controlled reinforcement in school age children's behavior.

In a well designed study, the researchers used a four-group
design in five classrooms in each of two separate locations
and done over five time periods to test their hypotheses.
The treatments were controlled across time. In addition,
controls were imposed upon the students for reliability of

self-monitoring reports. The authors found, generally, that

33

by reinforcing appropriate in-class behaviors they decreased
disruptive in-class behaviors. They noted no significant
differences between the self-reward and external reward groups
in terms of behavior change. They found further that the
self-rewarded group on occasion tended to reward themselves
more liberally than did the externally reinforced group, an
observation also made by Kanfer and Duerfeldt at the con-
clusion of their study (1967).

It was noted in the previous chapter that the utilization
of behavioral self-control is widely used in weight control
programs. This area of behavioral control strategy seems to
utilize both the principles of stimulus control and self-
reinforcement. The overall results of studies in this area
seem to correspond to the previously described observations.
Mahoney (1973), for example, found that teaching self-control
of eating habits in weight reduction diet, rather than just
controlling the quantity of intake, provided a more effective
way of controlling weight. He also noted that this self-
reward program increased the motivation for weight control
over a longer period of time than the more traditional weight
control programs which emphasize limited intake.

In another comparative study, Mahoney, Maura, and Wade
(1973) found that there was a significant difference in
weight loss between groups using self-reward, self—punishment,
or a combination of the two to control eating. They found
that the self-reward group lost the most weight over a period
of time. The self reward - self-punishment group was less

effective in weight loss than the first group but more effective

34

than the self-punishment only group. This would seem to
indicate that the utilization of self-reinforcement has more
applicability than self-punishment, however, there may be
some consideration given to applying both principles in a
self-control study.

Another study which combined the use of principles of
stimulus control and self-directed reinforcement was reported
by Penick, Filion, Fox, and Stunkard (1971). Through the use
of an elaborate program of stimulus control and prompt rein-
forcement, the researchers sought to increase those behaviors
that would promote weight loss. As hypothesized, the group
using the self-reinforcement principles lost more weight than
the control group which was participating in a traditional
group therapy and information exchange format. There was a
wide variation in the weight loss of the self-controlled
group, however, which negated the statistical significance
necessary for proving the hypothesis. Despite the lack of
significance, the authors reported that the results were con-
sidered superior in the self-controlled group.

Based on the data presented in the above studies, there
are some general conclusions which can be drawn. Without any
doubt, there is reason to believe that the use of reinforce-
ment, whether externally controlled or self-directed, enhances
the likelihood of a target behavior change. Although the
literature is not conclusive on the differences between the
externally controlled and self-directed reinforcement programs,
there are some subtle points to be made. It seems apparent

that the use of self-directed reinforcement causes individuals

35

to set higher goals for themselves in terms of an acceptable
standard of behavior. Once established, this behavior pattern
seems to exist for a longer period of time than does the be-
havior pattern of an externally reinforced group. These
considerations are of utmost importance when considering the
behaviors of the patients in a medical rehabilitation setting.
If the patients can be helped to produce a selected behavior
more often and over a longer period of time, a substantial
gain might be noted in their rehabilitation program. Since

a major portion of the patients'time is spent in situations
that are not immediately reinforcing, the teaching of the
principles of self-reinforcement in those situations would
perhaps help increase the likelihood of those behaviors
necessary for a successful and efficient rehabilitation.

The possibility of strengthening rehabilitation behavior pat-
terns in usually non-rewarding settings is a major reason for
completing a study of this nature.

Self-Monitoring

 

Self-controlled behavior requires the self-management of
reinforcers and it also requires self-monitoring. This concept
of self-recording and its overall effect on behavior change
has been addressed by a few authors.

Walls (1969), for example, stated in his discussion of
the application of behavior modification to rehabilitation
that the most expeditious plan in observing behaviors is
"to have the client count and record his own behavior". He

went on to note that "in many cases no reinforcement other

36
than auto-recording may be necessary to accelerate desired
behavior" (p. 174). Mahoney and Thoreson (1974) supported
this same contention when they indicated that self-monitoring
may be more than an assessment tool, it could also be a treat—
ment strategy. They called this possibility the reactive com-
ponent of self—monitoring and suggested that a baseline of self-
monitoring is essential to understanding other specific treatment
effects. The self-monitoring becomes a potential confounding
effect for the experimental treatment. It must, therefore,
be dealt with in this study as a secondary hypothesis.

Jeffrey (1974), in discussing the concept of self-mon-
itoring, observed that the effects of self-monitoring must
be ascertained in any research study. He recommended a
procedure whereby a multiple time series or reversal de-
sign with self-monitoring as part of the treatment strategy
should be considered.

Kazdin (1974), in an extensive review of the literature
wherein self-monitoring was part of an experimental approach,
found studies where the self-monitoring had an effect on
the behavior and studies where it apparently had no effect.

It was his conclusion that self-monitoring has not been
consistently influential in behavior change. He also addres-
sed the issue of the reactivity of self~observation. It

was his belief that whether or not the reactivity issue

was or was not a problem depended on how the self-gained
information was to be used. He noted that in many cases,

the effects of self-monitoring seem to lose their impact

on behavior change over time anyway and, therefore,

need not be addressed in a study on self-control.

37

In addition to the importance of self-reinforcement and
self—monitoring, it was noted in the previous chapter that a
program of self-reward necessitates the self-establishment
of a particular standard of behavior. This issue of personal
involvement seems to relate closely to the concept of patients'
rights as it is applied in a medical setting (Quinn and Somers,
1974). Among the many patients' rights listed in their article,
these authors included the following: the right to parti-
cipate in decisions about treatment, the right to discuss
treatment program alternatives, and the right to have staff
hear and understand their complaints and ideas about program
changes. These principles seem to be intimately related to
the entire process of self-standard setting for selected
behaviors.

The self-establishment mechanism and result of allowing
patient input into the system is described by several authors.
Saper (1974) described a group therapy program in a psychi—
atric setting. In this descriptive study, he told how the
patient's long- and short-term goals were developed with the
patient. A major component of this program was the regular
contact the patient had with all members of the treatment
staff. Of particular note in the program was the inclusion
of the patient's immediate family in both structured
and informal social situations with patients and staffs.
Although no conclusions were reached, the idea of patient-

staff communication was advised.

38

Skipper, Tagiacozzo, and Mauksch (1964), reporting on
observations made of patient and staff communication processes,
noted an interesting potential "anti" argument on the issue
of patients'rights. In the era of rising medical malpractice
suits, they found that the more that the hospital staff
wanted to protect themselves from errors and mistakes, the
less oriented they became to communicating with patients.

At the same time, they noted the "pro" argument which supports
the issue of patient involvement: the amount of communication
that existed between patient and staff was directly propor-
tional to the level of patient cooperation and to the clear
perception of patient needs by the staff. In summary, Skipper
et a1. maintain that the interpersonal communication process

is essential for effective patient care and treatment planning.

In a somewhat similar manner, Armacost, Turner, Martin,
and Holt (1974), in another descriptive study, described a
technique used with so-called "problem patients" in a chronic
disease section of a California V.A. hospital. When frustrated
by a number of patients who refused to follow treatment pro-
grams, hospital regulations, and staff orders, the nursing
staff received consultation from a psychiatric nurse. The
prominent recommendation was the apparent need to increase
the staff-patient interaction through regularly scheduled
meetings. This resulted in decreased hostility, less resis-
tance, and fewer antisocial behaviors on the part of patients
and in an overall "improvement in patient behaviors and nurses'

attitudes" (p. 292)-

39

In an attempt to encourage patient involvement in goal
setting, Becker, Abrams, and Onder (1974), at the University
of Michigan, applied the principle of patient and family par-
ticipation in treatment goal setting in a rehabilitation
center. She found, again in a descriptive study, that when
the patient and family were included in the admission conference,
there seemed to be an enhancement of patient-family communica-
tion, better patient-staff understanding of treatment goals,
and a reduction in the amount of sabotage of treatment plans
by the patient.

From these reports, it seems clear that including patients
in goal setting and treatment planning produces some positive
benefits. There appear to be greater amounts of patient
cooperation and reduced patient-staff conflict. In addition,
if the patient is included as a primary participant in goal
setting, there is a greater likelihood of the patient's cooper-
ation in reaching the goals. Furthermore, the more the patients
are involved in setting the standards for their behaviors, the
less likely they will be to complain about the care, and the
more motivation they will have to reach the objectives.

It has been noted so far that the principle of reinforce-
ment of appropriate behaviors does influence the probability
of the recurrance of the behavior. It has also been seen that
the application of self-reinforcement is at least as effective,
if not more so, than externally applied reinforcement.

Evidence has been cited demonstrating that including patients

in goal setting and treatment planning seems to promote a

40

better patient attitude and behavior patterns and increased
patient-staff interaction. Let us now extend the review

of the research to determine whether behavior modification
techniques when applied to medically disabled patients has
any effect on their behavior patterns.

Behavior Modification and Rehabilitation

 

It has been mentioned earlier that the field of medical
rehabilitation is closely allied to the area of behavioral
science. Couch and Allen (1973) indicated support for the
growth of the use of behavior modification techniques in re-
habilitation facilities. They indicated the "apparent
simplicity and built-in accountability" of behavior modi-
fication provides a sound rationale for the use of the tech-
nique. Staats (1964) maintained that the application of
behavior modification principles is badly needed in the field
of rehabilitation, especially since new behaviors are being
learned in those situations where reinforcement is generally
weak. Let us consider then, the variety of behavioral
studies employed in the area of medical rehabilitation. There
are countless studies of behavior modification with the re-
tarded and emotionally disturbed. However, since this study
is geared to the applicability of behavior modification in
medical rehabilitation settings, the review will concentrate
only on that portion of the disabled population.

Reinforcement programs have been applied to a variety of
behaviors in the medical rehabilitation setting. In the area
of improving the physical performance of the patient, several

reports are worth noting. Hollis (1974) reported on a series

41

of studies employing the operant conditioning approach in
training patients in the use of artificially powered pros-
thetic devices. He described particularly a variety of posi-
tive reinforcement techniques applied in the retraining of
selected hand muscles. These reinforcement techniques
included the observation of colored liquid movement in plastic
tubes and electronic signal feedback for the use of appropriate
muscle movement in arms and hands. As opposed to teaching a
patient to "move a finger or muscle", the therapist instead
taught the patient to control the movement of the colored
liquid and the feedback of the electronic impulse signals.
With the immediate observable reinforcement obtained through
external sources, the patient almost unknowingly strengthened
hand muscles more easily and with considerable less frustration.
In attempting to decrease the frequency of skin breakdown
in the spinal cord injured,wheelchair-bound patient, a major
problem facing such individuals, Malament, Dunn, and Davis
(1975) reported an effective behavioral method. Using a time—
buzzer-pressure switch combination, the patients were taught
through negative reinforcement to raise themselves periodi-
cally in their wheelchairs. By repositioning themselves
within a selected time span, the pressure sensitive switch
was automatically reset and a buzzer system deactivated.
In the three-phase experiment, which used a small number of
subjects, the authors found that the patients became effective
in timing their repositioning so as not to overact in a given

period, but to prevent the 15 second buzzer from sounding.

42
Through the pictorial representation of the data of the five
patients, this scheme was seen as effective in promoting body
repositioning. No statistical analysis was computed, however,
to verify the apparent success of the system.

Fordyce, Fowler, and DeLateur (1968) attempted to alter
the reinforcement received for low back pain patients. They
found that demanding more activity of the patient, encouraging
the patient to make daily graphs of activity levels, and self-
monitoring caused the patient chronically disabled by low back
pain to realize a significant improvement in overall activity
levels. They also noted a decrease in the subjective evalua-
tion of pain.

Friedlander (1974) described in some detail the various
technological materials produced for the benefit of patient
rehabilitation. His technological system utilizes the scien-
tific process of "specifying tasks, providing reinforcement,
and keeping detailed accounts" (p. 144). Through the use of
separately mounted and experimentally controlled T.V. switches
on opposite sides of his bed, a severely immobilized and
retarded young patient learned to control to a certain extent
his small environment and to "avoid a characteristic re-
gression . . . as (had) happened before" (p. 145) when the
patient had similar surgery. In another experiment, designed
to motivate a severely physically disabled child to grasp
objects, the author was able to train a relatively absent
grasping function to produce 600 responses in 15 minutes.

The self-obtained reward earned by the patient for the

grasping reflex was the playing of the Happy Birthday song.

43
Another activity Friedlander was able to promote included
the movement of the heel and toe of a young adolescent who
was wearing a full body cast for a broken leg. By the use
of a timer switch activated by his heel and toe, the patient
could listen to a favorite radio station. This activity was
not only reinforcing to the patient from the standpoint of
the music, but was also physically beneficial to the patient
in terms of continued movement of the affected leg muscles.
Another study by Friedlander reported on assisting severely
involved patients in the relearning of activities of daily
living such as pulling drawers, opening doors, etc., all of
which were rewarded by the lighting of electric lights when
done well.

Along similar lines in the treatment phase for rehabili-
tation patients, others have also succeeded in increasing
appr0priate behaviors when applying behavioral principles.
Goodkin (1966) used the behavioral analysis idea to define
specific rehabilitation related behaviors. The application
of rewarding appropriate behavioral management programs,
including self-evaluation of speech patterns in two separate
aphasic patients, seemed to expedite the total rehabilitation
program. In another case with a positive reinforcement of
approach behaviors, a cerebral palsied child was helped to
overcome the fear of falling; this case is described by Meyerson,
Kerr, and Michael (1967). Booraem and Seacat (1972), in a
study of three patients, found that the use of a financial

incentive for a selected physical therapy activity resulted

44

in an improvement of more than one standard deviation in the
behavior over a baseline period. Unfortunately this study
did not appear to control for several possible confounding
variables.

Along with the apparent success of the application of
reinforcement for patients in treatment, other work has been
done to promote patient attendance in therapy through the use
of behavior modification techniques, also with some success.
Ince (1969) reported on the application of the reinforcement
principle to stimulate patients to attend therapy. By encour-
aging patients to make their attendance in the apparently
enjoyable speech therapy activities contingent or dependent
upon their participation in other important therapeutic
activities which they often missed, the staff of a rehabili-
tation center was able to increase patients' attendance in
the less frequently attended programs. To increase the de-
sired behavior in the less desired therapy, the staff was
instructed to call the speech therapist when the patient had
attended the required physical or occupational therapy hours.
Without this verbal report the patient was not admitted to
the speech therapy. Along the line of therapy attendance,
Zschokke, Freeberg, and Errickson (1975) found that by posting
a chart and subtly recognizing patient attendance in occupa-
tional therapy they increased the patient attendance in this
therapy setting. They found further that by requiring a
patient to attend a certain amount of time in order to attend
subsequently a special social activity held each week, the

patient attendance increased even more.

45

All of these studies seem to support the recommendations
of Sieg (1974) and Wanderer (1974) that occupational thera-
pists should adopt the behavioral model in their treatment
programs. They felt that by recording rates, keeping time-
motion studies, and establishing a measurable standard of
behavior along with defining specific behaviors which meet
the clients' needs, therapists fit precisely into the be—
havioral model. Wanderer adds, further, that patients can
be taught to bring their responses under control "by training
them to control the functional antecedents of those responses"
(p. 207). This quotatflnicogently reflects the philosophy of
self—directed behavior and is the view taken in this study.

Finally, in an extensive review of the literature of the
application of behavior modification principles in rehabili-
tation settings, Walls (1969) provided considerable support
for the application of behavioral principles to rehabilitation.
In his all-encompasing survey, Walls found that application
to individuals, application to groups, and applications in
institutions had positive results. The behaviors which he
found could be changed included speech disorders, prevocational
behavior, disruptive classroom behaviors, verbal and social
skills, and self-destructive behaviors.

It should be pointed out that nearly all the studies
described fall within the framework of an externally operated
and manipulated behavior management style. In most cases,
the behaviors were defined by others although the reward was
on occassion controlled by the patient. In few cases is

there mention made of the patient's involvement in the

46

standard setting or in the determination or administration of
the rewards, Meyerson, Michael, Mowrer, Osgood, and Staats
(1960) allude to this as a typical problem in rehabilitation.
It was their feeling that the intrinsically motivated will show
a decided behavior change over the extrinsically reinforced.
They stated that "the problem of rehabilitation often consists
of a disabled person who . . . should be doing something other
or something more than he is doing" and they go on to ask the
inevitable question, "How can a person be stimulated and paced
so that he does what he 'should' and 'wants' to do it?" (p. 73).
This solution of allowing the patient the opportunity to get
involved in establishing standards of behavior, establishing
rewards for that behavior, and then initiating a program to
change the behavior may provide the answer. It, therefore,
forms the basis of the hypothesis of this study.
Design

It has been shown in the last several sections that the
theory of self-directed behavior seems to be supported. The
theory has been applied in a wide variety of locations with
apparent success. It has also been shown that the applica-
tion of behavior modification principles has been success-
fully employed in rehabilitation settings to promote desired
behavior change. One author, Goldiamond (1973) has subjec-
tively described his personal attempt to apply self-control
behavior principles within a medical rehabilitation setting
with some apparent success. There has been little scientific

evidence however, to validate his claim or to push the

47

frontier of self-control into the medical rehabilitation
facility. Therefore, in an attempt to validate Goldiamond's
observation and to also attempt to understand the dynamic
effects of self-monitoring and self-reinforcement on behavior
change in a medical rehabilitation setting, the intensive case
study or an N of 1 research design has been chosen.

Case Study Approach

 

The supporting rationale for the case study approach to
research is provided by several authors (Chassen, 1967;
Dinsmoor, 1973; Gottshalk, 1968; Holzman, 1963; Kiesler,

1971; Lazarus and Davison, 1971; Leitenberg, 1974; May, 1971;
Shapiro, 1966; Thoreson, 1972). Each of these authors noted
among many other reasons that research of this type emphasizes
the careful monitoring of each individual with respect to the
target behaviors. Since this is a necessary element in
behavioral area research, the case study approach seemed

very reasonable.

Another rationale for choosing the case study approach
is the diversity of the population in a medical rehabilitation
center. Because one patient's medical condition is dif-
ferent from another's, since each treatment program is varied
with the severity of the disability, it is practically im-
possible to establish a true comparative group study.
Establishing comparative groups on some selected demographic
variable would necessitate the use of several medical centers
or time lapse study, both of which promote confounding possi-
bilities. The use of a single subject study permits the

subject to be his/her own control and the various hypotheses

48
can be tested in a within-subject manner (Chassen and Bellack,
1966). If more than one research subject is used, a comparison
across the subjects is also a potential evaluation consideration.
A final consideration given to the choice of the inten-
sive case study approach is based upon its effectiveness in
defining treatment effects on the individual. As Chassen,
Thoreson, Lazarus and Davison, and Shapiro indicated, the
problem with the comparative group design is that a statis-
tically significant effect may, in fact, reflect a true effect
in very few individuals but the influence in those is strong
enough to elevate the entire group norm. These authors noted,
further, that the effect of treatment on the individual per-
sons involved is 1ost to the researcher.
Davison summarized all of the above considerations,
giving four additional supporting reasons for such a design:
1. It (Single Case Study Design) reduces . . . the
'error variance' by eliminating the usual con-
founding between variations in behavior associated
with different values of the independent varia-
ble and the variations between individuals.
2. This design may be used with considerable
effectiveness . . . in clinical practice . . .
in which each individual represents a unique
case.
3. The within-subject design makes it possible to
study differences between individuals in the
characteristic way.
4. The functions which are apparent when the
individual design is employed may be lost or
distorted when average values are substituted
as required by the group design. (p. 508)
In assessing the variety of research designs to use for
this experience one must consider the hypotheses to be tested.
Since the credibility of the research reviewed with respect to

self-controlled behavior seems to be influenced somewhat by

the research on self-monitoring there seems to be a need first

49

of all to distinguish between self-monitored behavior patterns
and behaviors being self-rewarded. Since the intensive case
study will be used which negates the potential to place persons
into self-monitoring only and self-reinforcement only groups

in true experimental fashion, the most logical and most
defensible research design to use is the Multiple Baseline

Time Series Design as recommended for intensive case studies

by Thoreson (1972).

Multiple Baseline Time Series Design

 

The benefits of the multiple baseline time series design
must now be considered. The typical single baseline time
series design employs a periodic measuring process of a behavior
with the introduction of an experimental change into the series
of measurements at a preselected point. This quasi-experimental
approach, however, provides no control over the potentially
confounding effect of an unrelated event, which occurred at
the same time as the experimental treatment, causing the ob-
served behavior change. Alternative actions to control for
this possible confounding effect would be the establishment
of a certain amount of isolation of the experimental subjects
or the use of a reversal design. The reversal design allows
the subject to return to a previous type of behavior after a
treatment. It is difficult to manage and justify, especially
when behavior change is the goal of the treatment. Reversal
in this case is highly illogical and anti-human.

The best alternative to control for the potential effects
of internal confounding factors is the use of a multiple base—

line time series design. Thoreson describes the use of such a

50

design as most applicable when an experimenter is "concerned
with (l) the effects of a treatment on several behaviors of

the person, (2) the effects of multiple treatments administered
by different persons simultaneously or (3) the effects of a
treatment on the same behavior in different settings" (p. 28).
Wolf and Risley (1971) added the observation that this design
can also be useful when carried out (1) across two or more
different responses under the same environmental condition(s)
and on the same subject(s), or (2) across two or more environ-
mental conditions with the same response(s) and on the same
subject(s), or (3) across two or more subjects with same
response(s) and under the same environmental condition(s).
Hence, there are a variety of application possibilities for a
design of this nature. The value of the multiple baseline

is that it also controls for the potential confounding effect
of history by introducing the experimental treatment at several
selected points in time. If the experimental treatment pro-
motes the desired change at each interval, the treatment will
be viewed as effective.

Gottman, McFall, and Barnett (1972) advocated the utiliza-
tion of a multiple baseline study, observing that such a design
is most beneficial in those situations where selected variables
cannot be controlled and/or where a control group concept is
impossible. They indicated the multiple baseline design pro-
vides the analytical advantages of a single group pre-post
type of design where the researcher can observe the overall
treatment effects and permits a post-hoc analysis of results

over a time period. Finally, it provides for a control of

51
the possible confounding effects by removing the effects of
history with multiple starting points.

Finally, Jeffrey (1974) described the essentials of im—
plementing the multiple baseline research design. He indicated
that to successfully implement a multiple baseline design,
three independent behaviors should be observed. Treat~
ments are then applied to each behavior until a change is
observed. If the target behaviors change when the treatment
is introduced, a cause-effect relationship can be inferred.

The design of this experiment, then, is geared to observing
the effects of a treatment on specific individuals and specific
behaviors. By initiating the experiment with different indi-
viduals and at different times while maintaining a concise
data base over time, the mandate of Thoreson (1972) can be met.
He postulated that research in counseling must get back to
"the basics" meaning there is a need for "direct observation,
careful description, and systematic planned interventions with
individual subjects" (p. 4). The intensive case study applying
the multiple baseline research design provides the structure
for fulfilling such a statement.

Analysis

As was previously noted, one of the benefits of conducting
an intensive case study is to assess the specific effects of a
treatment program on the individual subjects. This analysis can
be both statistical and nonstatistical in nature. One needs
simply to observe the graphs of the data obtained and draw

some general conclusions about the treatment effects. This

52

approach generally coincides with the detailed post-hoc
analysis of the data to further understand the treatment
effect, however. In a multiple baseline design involving
three independent behaviors and repeated over a few subjects,
all time-lagged with respect to their initiation into treat-
ment, one can analyze the effects of treatment within each
subject and comparisons can also be made across subjects.

The analysis of the intensive case study has been per-
ceived differently by several authors (Chassen, 1967; Holtzman,
1963; Namboodiri, 1972; Shine and Bower, 1971). These
authors prefer to treat the data gathered in a static manner
using the t or F statistical tests. The difficulty imposed
by such an analysis is the potential violation of the assump-
tions underlying the statistical tests. Most prominent among
these assumptions is the question of whether the daily obser-
vations are statistically independent. Varying techniques
have been devised to circumvent the problem however, but
with questionable validity.

Another proposed way of assessing the effects of treat-
ment on behavior is a dynamic analysis. Instead of concen-
trating on the analysis of the data as it is grouped through
summations, and statistically comparing the values of the
grouped data, the dynamic analysis of data keeps each of the
data points separate. The analysis is done based on the
general distribution of the data points. This method, described
by White (1971, 1972) is built from a relatively simple com-
putation of the median $10pe of the distribution of points
for any period of the research with a comparison of the slopes

for each phase.

53

This computation of trend lines improves greatly over
the least squares regression line in its predictability.
White (1971, 1972), in a study of 166 previously completed
research studies of classroom behaviors, found that the
median slope method proved to be the most effective predictor
of future performance over either the more typical regression
model, or a "Quickie Methodfl a. shorter method of calculating
the median slope or a corrected median slope method.

The median slope of the data is that trend line which
divides the data points in half. This method is not then
greatly influenced by the extreme deviation of one or two
grossly deviant data points. What the median 510pe line
becomes then,is»that line above or below which 50% of any
given individual's data points can be expected to fall. By
projecting this slope into the future, the researcher can
test whether the number of data points actually falling above
or below the projected trend line is significantly different
than expected. The regression line, on the other hand, tends
to be more affected by major deviations of scores. Because
of this influence, the slope of the line may be significantly
changed and may not provide accurate prediction for future data.

With the application of a dynamic analysis of an N of 1
study the advantages seem important. Although a static analysis
of some data may show no significant differences between two
or more sets of data, the dynamic analysis may show that the
data, in fact, was proceeding in dramatically different

directions. It might also show, for example, that the observed

54

differences between two sets of data was predicted, in fact,
based on the trend analysis of the data. Hence, for the pur-
pose of using all the data collected in this study, the median
slope technique will be employed.

Instrumentation

 

In an intensive case study on self-control, considerable
observational data will naturally be collected. Rice and
Glenn (1973) found in assessing a large number of patient
personalities in a rehabilitation center that the per-
sonalities generally fell into three categories on the 16
Personal Factors Test. Some they considered "Normal Adjusted",
who simply needed to develop interpersonal skills. A second
group they found to be "Assertive Aggressive" with the recom-
mendation that this group needed to control appropriate and
inappropriate behaviors. The third group were considered
"Passive Aggressive", with a tendency toward higher anxiety,
apprehension, and tenseness. This group needed to learn to
express themselves more Openly and thereby control undue anxiety.

The Edwards Personal Preference Schedule (1953) is a
225-item forced choice questionnaire. It was designed for
research in counseling purposes to provide a quick and con-
venient measure of 15 personality variables. One population
on which this test was standardized was a college sample
composed of 749 college women and 760 college males with
an age range from 15 to 59. A second norming sample was
comprised of male and female adults (8,963 in total) selected
from a nationwide consumer purchasing panel. Means and stan-

dard deviations were computed for each of the 15 subscales.

55

The internal consistency scores derived by a split-half calcu-
tion ranged from .60 (Deference) to .87 (Heterosexuality).

The stability scores range from .74 (Achievement and Exhibi-
tion) to .87 (Order). Finally, an intercorrelation of the 15
subscales was conducted with the highest correlation at .46
and the second highest at .36 thereby showing that the sub-
scales are seemingly quite independent. Validity studies

have been conducted showing a relationship between EPPS scales
and other personality measures. Self-ratings on the 15
subscales have compared highly with actual EPPS scores. It
thus appears that the test itself has sufficient reliability
and validity to be useful in understanding personality
characteristics in general.

For this study, selected subscales were picked which
seemed to have the closest relationship to the concepts of
rehabilitation. For this reason the subscales of Achievement,
Deference, Autonomy, Succorance, Endurance and Aggression, a
total of 130 questions will be used. In this study, the indi-
vidual scores obtained have little meaning when compared to
national norms, but have considerable meaning in terms of
internal comparisons and the information they supply with re-
spect to the individual patient personality and behavior
patterns.

The Self Evaluation Questionnaire, a state-trait anxiety
inventory (STAI, Spelberger, 1970) is a self-report measure
of two separate anxiety constructs: state anxiety (A-State)
and trait anxiety (A-Trait). This inventory of 40 brief

statements asks the reader to rate on a 4 point scale how they

56

feel "at this moment" (A-State) and on a 4 point scale how
"they generally feel" (A-Trait). The value of administering
this test will be to assess the personality of the patients
involved, not in terms of a national norm but in order to
provide data on which speculation can be made relative to
the patients behavior patterns in the study.

The STAI has been normed on 484 college undergraduates,
982 college freshmen, and 377 high school students. In
addition, normative data has been calculated for male neuro-
psychiatric patients, general medical and surgical male
patients, and young male prispners. The stability of the
A-Trait subtest was shown to range from .84 to .73 over 104
days for the college undergraduate males and from .76 to .77
for the corresponding female group. The A-State subscale are
substantially lower, as expected, ranging from .33 to .54 and
.16 to .31 respectively. Internal consistency reliability
measures show a range from .83 to .92 for both subscales
thereby showing a good overall internally reliable test.

The concurrent validity of the STAI was done by cor-
relating the obtained scores with three other personality
tests. It showed a range of correlation between .41 and .85
over the three tests and separate comparison groups (college
females, college males, and neurOpsychiatric patients).
Construct validity was addressed in separate experiments in
which the A—State was expected to change, which it did with
an alpha reliability coefficient ranging from .83 to .93.
From this data, it would appear that the STAI will be an

accurate and sensitive instrument to test the anxiety level

S7

of the involved patients throughout the study. Once again,
the results will be meaningful when compared within the study
and will not be meaningful when compared to a larger population.
Another personality theory which on the surface seems to
bear some relationship to the study derives from Rotter's
Social Learning Theory (1954). In this theory, Rotter
described the occurance of the behavior as dependent upon the
expectancy that the behavior will lead to a particular rein-
forcement in that situation and the value of that reinforcement
to the person. He arrived at the concepts of internal and
external locus of control. These concepts he defined as
follows:

When a reinforcement is perceived by the
subject as following some action of his own, but
not being entirely contingent upon his action, then
in our culture, it is typically perceived as the
result of luck, chance, fate, as under the control
of powerful others or as unpredictable because of
the great complexity of the forces surrounding him.
When the event is interpreted in this way by an
individual we have labelled this a belief in
external control. If the person perceives that
the event is contingent upon his own behavior or
his own relatively permanent characteristics, we
have termed this a belief in internal control.
(Rotter, 1966, p. l)

 

 

Some authors have attempted to apply this concept of locus
of control to the disabled population. McDonald and Hall (1971)
tried to correlate the effects a variety of hypothetical disa-
bilities would have on those persons previously categorized

on a locus of control scale. They asked 479 non disabled

 

(emphasis mine) college students to complete an Attitude Toward
Disability survey. They also asked the students to rate their
perception of the debilitating effects of the various disa-

bilities on a hypothesized male head of family, as well as

cul
int

beh

58

on his surrounding society. The outcomes showed that ex-
ternally classified students rated the disabilities as more
personally debilitating than did their internally classified
peers. The results showed that the externals also rated the
effects of the disability on others as greater than did the
internals. It must be emphasized that this is a hypothetical
situation and that the students with no identifiable limi-
tations took this test and projected themselves into the
situation. It is uncertain whether disabled students would
perceive the effects of their disability in a similar manner
because such a study has not been found. Nevertheless, one
might wonder whether the locus of control of the disabled
does influence their behavior.

In a study of behavior patterns of hospitalized tuber-
culosis patients, Seeman and Evans (1962) found some additional
interesting information regarding the difference in hospital
behavior patterns between the internal and external control
groups. The internal control group tended to ask more ques-
tions and showed an overall better knowledge of their condition
than did the externally controlled group of patients. They also
were noted to progress faster in their treatment. This result
seems to correspond with that found by Ireland (1973) in a
doctoral dissertation. He found that 25 male subjects who
were given three separate tests of the I-E variety showed a
significant correlation between their involvement in treatment
and their locus of control scores once again with the internally
controlled showing a greater awareness and knowledge about

the situation.

S9

Wendland (1972) attempted to investigate the correlations
between institutionalization and the chronicity of disability
with locus of control scores. In a study of 80 white males,
18 to 35 years of age with an I.Q. of more than 90 and all
of whom had muscular and/or skeletal impairments, it was
hypothesized that those individuals who had spent less than
1/3 of the days since they were disabled in a medical insti-
tution would have a higher external control score. The second
hypothesis studied was that those individuals who were disabled
for less than l-l/Z years would have higher external control
scores than those disabled longer than 1-1/2 years. The
results of the study show that there was no correlation
between the amount of time spent in the hospital and locus
of control scores. However, a significant result at the .07
level occured when relating the onset of disability with the
locus of control. The overall results from this study would
seem to indicate that immediately post-disabled peOple tend
to rely on the external means of reinforcement, but that over
time the individual tends to become more internally controlled.
One of the other observations that was noted in this study
was that those individuals who were disabled by injury showed
a higher external score than those who were disabled from
birth. Results also showed that external locus of control
persons tended to be younger, have more schooling, were
instittutionalized less, and rated the disability more severe

and the future less severe than did the internally controlled.

60

In a survey on the literature of locus of control and
reaction to illness, Ripstra (unpublished manuscript, 1974)
summarized the observations of several authors. She noted
that internal locus of control patients seem to cope better
with their illness than the external control group. It was
her observation that in instances of long term illness or
disability the locus of control model could be used as a
rehabilitation variable.

Relation of Self-Control and Locus of Control

 

At this time it is important that the differences and
relationship between the concepts of self-controlled behavior
and locus of control be explained. It has been noted that
self-controlled behavior in this study demands a self-awareness
of the need for behavior change, a self-monitoring of the
behavior, and a self-controlled reinforcement system. It has
been noted that the locus of control concept is related to the
issue of reinforcement as well. Locus of control refers to
the person's perception as to whether they actually can control
their own reinforcers. The subsequent life style bears out
this perception.

Hence, in a study on self-control, persons may be likely
to claim they are capable of controlling their behavior, such
as controlling angry outbursts, overeating, or exercising, but,
in fact, may live a life style which solicits reinforcement
from others for the opposite behavior. On the other hand,
persons may indicate they are unable to control their behavior
while at the same time giving themselves suitable reinforcements

for the behavior. Finally, the self-control and locus of control

61
may be in total agreement when the individual admits to not
having control of his behavior or of the reinforcers. The
theoretical link, then, between self-control and locus of
control is an intriguing one. To further assess the recent
work in this field, few studies are available. The two most
related studies are presented here.

Jeffrey (1974) addressed the issue of self-control and
locus of control. He noted that the process of self-control
demands a change in the individual's perspective with re-
gards to the responsibility for behavior. It was his ob-
servation, based on the survey work of Lefcourt (1966) and
Rotter (1966), that the internally controlled individual
will be more responsive to environmental cues for behavior,
will be active in improving his own situation, will be more
achievement oriented, and will be resistant to external
interfering forces.

Bellack (1975), in a study of self-evaluation, self-
reinforcement, and locus of control found some interesting
relationships. He found that the internally controlled indi-
viduals as a group had higher self-evaluations and utilized
more positive self—reinforcement and less negative reinforce-
ment than did the externally controlled individuals. He
wondered whether the external control individuals might have
a personality characteristic related to self-regulation which
the internal group does not have.

Since the locus of control concept seemed to have a
definite relationship to the concepts of this study, a locus

of control assessment of the patients in the study seemed

62

important. The major question was whether the patient's locus
of control affects his use of the self-control concept.

To assess the patient's locus of control, 3 Rehabilitation
Attitude Survey (Appendix C-l) was previously developed for use
in this study. This questionnaire was rationally developed
using items similar to that which appeared on Rotter's original
I-E scales, but modified to reflect a person's attitude in a
medical rehabilitation center. In addition, new items were
developed which were also directly related to the patient's
perspective of their treatment responsibilities. The scale
was developed to measure both the trait and state locus of
control scores. Several months prior to the onset of this
study, the questionnaire was given to 22 adult patients. At
the same time they were given the 29-item of the Opinion Survey
developed by Rotter (1966). A correlation of the results of
the instruments was completed showing an overall correlation
of .53 (p< .02). It is felt that the Rehabilitation Attitude
Survey reflects somewhat accurately the internal-external
locus of control score of the individual particularly as it
pertains to the medical rehabilitation center and in that regard
provides additional data upon which to analyze the study outcome.

Another instrument used in the study was a Behavioral
Rating Scale (Appendix C-2) of patient activity. This 35-item
instrument was modified from a Job Behavior Scale developed by
Fairweather (1964). The wording was changed to reflect the
kinds of patient behaviors commonly found in a medical reha-

bilitation center. The instrument is a forced choice checklist

63

of typical patient activity levels and offers an "always" or
"never" option for the staff members to describe patient
activity. The scored responses were coded in the positive
direction. One staff member most knowledgeable about the
patient from each of the groups, Occupational Therapy, Physical
Therapy, Nursing, and Social Service-Psychology, were asked

to complete the Behavior Rating for the three participants

in the study. To provide a comparative score, sixteen other
inpatients at the time of the study were also rated by the
staff. The results were then averaged for each patient and a

rank order was established for the patients.

Chapter III

Methods and Procedures

 

The earlier chapters have noted the need for further
research in the area of medical rehabilitation. It has also
been suggested that the link between the behavioral science
field and rehabilitation should be carefully addressed. The
theory and practice of self-controlled behavior modification
have been reviewed and the overall positive effect on selected
behaviors has been noted. It then seems reasonable to study
whether the introduction of a self-controlled behavior modi-
fication program into a medical rehabilitation setting has
a positive effect on selected patient behaviors.

In this chapter the design and implementation procedures
for such a self-directed reinforcement program in a medical
rehabilitation center will be considered. The hypotheses of
the study will be considered first. In subsequent sections
the sample, the experimental procedures and, finally, the
method of analysis used in assessing the effects of treatment

will be discussed.

64

65

Hypotheses

 

The purpose of this study was to test whether the estab-
lishment of a self-directed reinforcement program had any
effect on selected medical rehabilitation patient behaviors.
As noted earlier, a self-reinforcement program necessitates
the use of some self-monitoring technique, but self-monitoring
itself may have a reactive effect on the behavior being observed.
Hence, it was essential to separate out of this study the
potential confounding effects of self-monitoring from self-
reinforcement effects. For this reason, the design of the
experiment was such that the following directional hypotheses
could be tested:

Hypothesis 1:

 

The implementation of a self-monitoring (SM)
technique for selected patient behaviors will
significantly change the occurrence pattern of
the behavior in the desired direction over a
pre-treatment baseline period.

Hypothesis 2:

 

The implementation of a self-reinforcement (SR)
program (Which includes self-monitoring (SM))
will significantly change the occurrence pattern
of behaviors in the desired direction over a pre-
treatment baseline (B) period.

Hypothesis 3:

 

The implementation of a SR program will signi-
ficantly change the occurrence pattern of
selected behaviors in the desired direction over
a SM only period.

Hypothesis 4:

 

As a result of the SM and SR intervention, the
occurrence pattern of selected behaviors during
the post—treatment extinction period (B) will

be significantly different in the desired direc-
tion over the pre-treatment baseline period.

66

Design

The design chosen for this study was a multiple baseline
time-series design as applied to a single subject. The reader
is referred to Chapter 2 for the rationale for this choice.
To review, however, the N=1 approach was chosen in order to
more carefully assess the specific effects of the treatment
on the individual behaviors. The multiple baseline time
series was chosen in that it adequately controls for potential
confounding variables. Figure 3-1 shows the format of the
experimental study as it was applied with each subject. In
this figure, B refers to a no-treatment baseline, SM refers

to Self-Monitoring, SR--Self-Reinforcement, and E refers to

a post treatment extinction phase.

Figure 3-1

Multiple baseline design applied to 3 behaviors
for each patient

 

Calendar Days 9 18 27 36 45 54
Behavior 1 SM SR E E E
Behavior 2 B SM SR E E
Behavior 3 B B SM SR E

 

 

 

 

 

 

Figure 3-2 shows the actual research time line as it
occurred over the three patients. Patient B is shown to
begin the study on the 17th calendar day while Patient C
began the study on day 25 of the study. The total time
used for the study was 79 calendar days. One should readily
see from Figure 3-2 that there is a multiple baseline effect

both within one patient's experiment study as well as across

 

67

Figure 3-2

Multiple Baseline Design as applied to the
selected behaviors of 3 patients

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Behaviors
Calendar Days 18 27, 36 45 54
1518 B SM SR E E E
Sue
2 B B SM SR E E
3 B B B SM SR E
Calendar Days 17 26 35 44 53 62 71
1 ~) B SM SR E E E
Bob 2 e B B SM SR E E
3 e B B B SM SR E
Calendar Days 25 34 431 52 61 7o 79
1 ) SM SR E E
Doug 262a ; B SM SR E
3 ) B B SM SR

 

 

 

 

 

 

 

 

 

 

68

the three patients, adequately controlling for any potential
confounding due to external factors.
Sample

Since this study intended to test the effect of a self-
controlled reinforcement program on medical rehabilitation
inpatients, the population from which the sample was taken
was in a medical rehabilitation center. Further, because the
study concentrated on the individual effects of an experimental
treatment on selected behaviors of an N of 1 design, only a
small segment of the medical rehabilitation inpatient pepula-
tion was used.

The population from which three persons were selected
for this study was the adult and young adult inpatient pepula-
tion at Mary Free Bed Rehabilitation Center in Grand Rapids,
Michigan. The facility is a comprehensive medical rehabili-
tation center offering total rehabilitation services to the
entire Western Michigan area. The types of rehabilitation
services offered include medical and nursing care, occupational,
physical, and speech therapies, psychological and social services.
Mary Free Bed is a fully accredited 78-bed medical center open
to all ages and disability types. Children, which comprise
about 25-30 percent of the total population, are admitted
with developmental disabilities such as cerebral palsy or
brain damage, severe asthma, congenital and traumatic amputations.
The facility serves young adults with similar diagnoses or
other long-term medically complicated cases, and it admits

adults who have a variety of disabilities resulting from

69

closed head injuries, spinal cord injuries, strokes, arthritis,
amputations arising from injury or illness,among other
diagnoses. The overall length of stay in this center averages
about 43 days, with adults staying slightly longer than the
population in general.

For the purpose of this study, three patients were selected
from these two older groups. This number was chosen in order
to provide ample opportunity to test the effect of the princi-
ple of self-reinforcement on inpatient behavior and to
formulate the basis for future work in the area. Since this
study was designed to test the application of the theory in
a different setting than what had been previously used, the number
chosen was small. This intense study permitted a greater
in-depth analysis of what transpired rather than to prove
that self-control makes a significant change in all medical
rehabilitation patients.

The three persons selected for the study were chosen
because they met certain standards. These standards included
the need in the patient's treatment program for both occupa-
tional and physical therapy and a minimum anticipated stay
of 60 calender days. In addition, the selected patients
were required to have little or no mental impairment which
would affect their comprehension of the anticipated activities
in the study. The ultimate acceptance of the patient into
the study rested with the researcher and was based on the
medical reports, a subjective assessment of the patient's

mental status, as well as on the patient's overall physical

functioning level.

70

Hence, variables such as age, sex,

disability type, length of previous limitations, work status,

and educational levels were not considered specifically in

the selection of the patients.

The three patients selected for the study are described

as follows:
Patient A: Sue

Demographic:

Disability 8

Limitations:

Time Since
Onset of
Disability:
Nature of

Condition:

40-year-old female, married, mother of two
teenage sons, registered nurse, socially

active

Hemiplegia and Heminopsia due to Cardio-
vascular accident and/or right temporal

lobe hematoma; partial paralysis of left
side, vision loss on left side, weakness
of right hand, secondary to pre—existing

condition

Approximately 9 weeks

Confined to wheelchair with functional use
of right side only. Wore a short leg brace
on left leg and used a mobile arm support

on wheelchair for mobility of left arm and

shoulder and prevention of drooping shoulder.

71

Patient A: Sue (cont.)
Patient's
Goals for
Treatment: Learn to walk, or at least stand with support,
to cope with restricted visual field, to
strengthen dominant hand and use affected
arm for support activity, to function as

mother and wife under restricted limitations.

Patient B: Bob

Demographic: 27-year-old male, divorced, father of two
children, used car salesman, previously
physically strong and socially active
person living with mother.

Disability 6

Limitations: Spinal cord injury at CS-6 (Cervical ver-
tebrae #5, 6) causing partial paralysis of
hands, fingers, and total paralysis from

upper chest down, but with some sensory

retention.
Time Since
Onset of
Disability Approximately 7 weeks
Nature of
Condition: Confined to wheelchair, totally dependent

for transer, bowel, bladder, hygiene,

eating, and mobility at onset of study.

72

Patient B: Bob (cont.)

Patient's
Goals for

Treatment:

Patient C: Doug

Demographic:

Disability 8

Limitation

Time Since
Onset of
Disability:
Nature of

Condition:

Wore a neck movement restricting Halo
Brace until day 42 of the study to assist

in healing of spinal fusion.

To walk, and use of hands, to regain

independence.

ll-year-old male, foster child living with
grandparents in small rural community,
previously enjoyed scientific and athletic

activity.

Extreme total body muscle weakness due to
Guillam-Barre Syndrome, a deteriorating, but
reversible condition affecting all muscle

groups, following a severe appendicitis.

Approximately 11 weeks

Confined to wheelchair, nearly totally
dependent for assistance in feeding,
toileting, transfers. Doug was very weak

and frail looking, had supposedly lost

73

Patient C: Doug (cont.)

about 30-35 pounds since his illness and
moved about very slowly in wheelchair.
Began to stand in a tilt table 30 minutes/
day just as study was started.

Patient's

Goals for

Treatment: To walk, run, use arms and hands, and go
home.

Procedures

 

Pre-Study Sequence

 

Prior to the onset of the study, having obtained the con-
sent of the Executive Director of the Center, the physical
therapy (PT) and occupational therapy (OT) departments, nursing
units, psychology and social service departments were told of
the study in general terms. Their respective roles in the study
were described as they related to the planned patient selection
and patient conferences. Subsequently, a one-week pilot study
was introduced with one patient to refine specific systems,
procedures, and forms. In addition to staff training, paid
observers for the study were given an overview of the study
in terms of the research design and hypotheses being tested.
Specific considerations for observer behaviors were described
as outlined in Appendix B-l. Each of these observers parti-
cipated in at least one joint observation(with the researcher)
of the chosen behaviors of each patient prior to the beginning

of any data collection on the patient.

74

The typical admission procedure to the center remained
in effect throughout the study. This procedure included
admission office assignment to nursing unit and room. Within
one or two days, the patient's medical record was reviewed
by each department with assignment to appropriate therapists
determined either by who the physician was, the nursing unit
the patient was on, or the primary limitations of the patient.
Subsequent to this determination, the physical therapist and
occupational therapist scheduled the patient into a treatment
routine usually consisting of two 30-minute sessions per day,
or more, depending on the patient's physical tolerance. The
other staff members scheduled their less frequent appointments
as fit best with the patient's daily schedule.

Patient Selection

 

As new patients were admitted to the center, or as
existing inpatients made sufficient progress, the head of the
physical therapy department informed the researcher of prospec-
tive candidates for the study. The researcher then met with
the occupational therapist (OTR) and physical therapist (RPT)
assigned to the patient to obtain their subjective evaluations
of the patient's capacity to participate in the study. At this
point the researcher casually observed the patients in their
treatment programs and became briefly acquainted with them.

If, after this brief exposure to the patients, the researcher
considered the patients to be good candidates for the study,
the patients were informed of the study. Each was told they
were part of a research project but that it would not hamper

their treatment. They were told that there would be some

75

recordkeeping and paper work. The patients were also told

they would be included in a special team conference to discuss
their personal goals for their treatment and objectives for
their own discharge. Each was informed that "as a result of
that conference, three behaviors would be selected" which would
form the basis of the study. If the patient consented to be
part of the study, the patient's immediate family was contacted
and briefly advised of the study. If they concurred with the
patient's consent, a patient conference was arranged. Of the
first four patients selected for the study, three were interested
and became the participants for the study.

Patient Conference

 

Sue's initial conference was held in the patient lounge
on the nursing unit. It was attended by the entire team
(physical therapy, occupational therapy,social service,
psychology, nursing) and included the patient's husband as
well. Sue was informed that this was a research project.

The conference enabled Sue to verbalize her goals and
feelings about her treatment, allowed the staff to give their
perceptions of the goals, and concluded with a general dis-
cussion about the total program. The specific goals of the
patient, and the related behaviors and recommended time for
completing behaviors as determined by the researcher and staff
(without the patient's knowledge) are shown in Figure 3-3.
After one day of additional instruction for selected behaviors,
the baseline period was initiated.

The conference for Bob was held at his bedside with RPT,

CTR and nursing in attendance. Bob's goals and feelings about

6
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77

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79
his program were solicited. The attending staff were
encouraged to respond to the patient's concerns. Again,
specific important related behaviors were singled out by
the staff and the researcher for inclusion in the study.
These are shown in Figure 3-4. The subsequent day was used
by the staff to give instructions to the patient on the
routine therapeutic activities demanded "for his rehabili-
tation" and to write ward orders, a description for the
nursing units to follow in implementing therapy-related
behaviors during off-therapy hours.

The patient conference with Doug, because of scheduling
problems, was less efficient. It was anticipated that the
conference would take place during a routine medical conference
at which all involved staff and attending physician were in
attendence. Due to an unavoidable problem,the entire con-
ference (including RPT, OTR, social service, nursing, physician
and medical students) moved to Doug's bedside where his
condition was briefly checked by the physician. The group
then reconvened for a reporting session without Doug to dis-
cuss treatment plans, problems, and progress. The researcher
subsequently interviewed the patient alone to obtain his
goals for treatment. Once again, a one day lag time was
established to allow for appropriate therapy training and
encouragement to occur and to establish observer schedules.
Doug's specific goals and the behaviors selected for his

treatment are shown in Figure 3-5.

80

Once each of the behaviors had been identified and the
best time established for observing the behaviors had been
cleared with all team members, the baseline period for each
person was begun. In each case where observers were to be
trained, a one-day practice observation was completed with
an observer to make sure he/she understood the specific
behavior to be observed, the best way of monitoring the
behavior, and the proper method of recording the behavior.
Appendix B-2 shows the log sheets used for recording the daily
occurrence of the behavior by the observers. Appendix B-3
shows the research journal sheet that was kept on the logs
to use in recording unusual observations or comments which
were pertinent to the day's observations.

Elaboration of the Behaviors Chosen and MonitoringTechniques
Based on Sue's overall desire to regain lost skills
needed for homemaking and for her potential return to her job
as a nurse, several behaviors were noted for inclusion in the

study. Of particular importance to these goals was her
definite vision loss. Loss of the vision in one eye was
uncompensated for at the onset of the study. Typical of most
persons with this type of loss, Sue would forget she couldn't
see out of one eye and would frequently hit things with her
wheelchair such as doors, other persons, protruding objects,
or would not be able to locate things even though they were
in front of her but off-centered in her vision field. She
also missed turns in hallways and became quickly disoriented
in location. The first major behavior unit selected was the

process of going from her room to the OT area. This behavior

to re
was t

that

room
butt:
[1'68
whil
fina
hers

both

81

was broken into two separate functions-~physical strength

as measured by time, and visual accuracy as measured by lack
of accidents. Thus, behavior 1 and 1a were related to the
length of time it took Sue to get to therapy from her room
and the number of objects she hit which impeded her progress
to her destination. These skills were related to her desire
to regain homemaking skills. Another benefit of behavior 1
was that it put additional pressure on her right hand in

that she wheeled her wheelchair with this hand and was there-
fore a strengthening exercise. Since the therapy area is

on a different floor than the nursing units, Sue was timed
with a st0pwatch as she began her trip to therapy from her
room. The watch was stopped when Sue pressed the elevator
button and started again as she got off the elevator on the
treatment floor and proceeded to the OT area. It was stopped
while she waited in the OT room to get directions to her
final therapy station, and was reactivated until she got
herself to the area. All "accidents" were counted during
both timed or untimed periods.

Behavior 2 was also developed to assist Sue in her ob-
jective of homemaking. The OTR agreed to make a list of
recommended activities and place some materials in Sue's
room to help her to develop her eye-hand coordination.
These exercises were necessary both for strengthening the
weak but dominant hand and learning to c0pe with her restricted
visual field. The activities prescribed included any writing,

playing cards, games, doing leather work. Sue did not have

82

therapy between 2 and 3 p.m. so this was considered an ideal
time to engage in these activities. Initially,both the num-
ber of specific goal directed movements of the right hand

and the amount of actual time Sue spent in a continuous 30-
minute time period were monitored. Because of the variety

of activities and difficulty in assessing goal-directed
activity, as the study progressed, only the actual number of
minutes spent in an activity as measuraflby a stopwatch was
recorded. Once Sue began an activity, a 30-minute continuous
time period was observed. That is, if Sue began playing cards
at 2:10 the observation period would end at 2:40. Any major
interruption in Sue's activity where her attention was
diverted from working with her eyes and hands led to a termi-
nation of the timing. But as Sue resumed her activity, the
timing resumed until the end of the 30-minute observation
time or until Sue terminated the OT prescribed activity. None
of Sue's goal directed behavior beyond the 30-minute continuous
time period was recorded.

The third behavior observed included a series of exer-
cises Sue was trained to perform on her paralyzed fingers,
hand, arm, and shoulder. Called passive range of motion
exercises, these required taking the affected part of the
body with the functional hand and moving the affected part
through its total range of motion. The need for this activity
was to prevent tightening of the affected muscles with possible
pain and deformity the result. The activity was designed also
to help firm up the muscle groups and build whatever residual

strength might be left. Each complete passive flexion of the

83

muscle group was counted separately. The muscle groups
affected included the thumb, the fingers as a group, the
wrist, the elbow, the shoulder muscles up and down and
across the body and out to the side, a total of six
separate exercises.

Bob's three behaviors were derived primarily from his
goals of desiring to walk again and to be functionally inde-
pendent. Behavior 1, called resistance exercises, were
necessary for building strength in his upper extremities. In
this activity, Bob had weighted cuffs (beginning with 5 pounds,
slowly increasing) placed around the wrists. He was required
to flex the muscles of his arm in order to lift the weights
and to swing the arm inward and outward. The goal was to
develop gross muscle strength in the biceps and triceps. In
this behavior, Bob was given RPT instruction to use the cuff
weights daily between 4 and S p.m. when on the nursing unit.
Ward orders were sent to the nursing unit "encouraging Bob
to use the cuff weights and exercise both arms" between 4
and 5 p.m. For the study, the specific number of contraction
and relaxation cycles of his right arm were counted. This
arm was chosen since his right hand was his dominant hand and
this arm needed the most strengthening for subsequent inde-
pendent activity. The anticipated length of time for this
exercise was about 15 minutes before Bob would be expected
to tire. The cuff weights were left in Bob's room during the
study so that he could make a request of the orderly or other

nursing staff to put them on.

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84

Behavior 2, range of motion exercises of left upper
extremity, was related to Bob's overall goal of mobility
and strength. Through disuse and the presence of the large
head and neck controlling Halo Brace, his left arm was re-
stricted in its movement at the shoulder. It was increasingly
painful to him to have it moved beyond a certain point.
Because this restriction could easily lead to reduced func-
tional ability in terms of dressing or hygiene, he was en-
couraged to conscioqurmove his left arm as much as possible
between the hours of 4 and 5 p.m. Bob was given specific
instructions on how to do the ranging activities. Ward orders
were sent to the nursing unit to "encourage Bob to do his
range of motion" at the selected time. A simple count of the
number of complete upper left arm range exercises was the
observational requirement. Since this activity generally
takes no more than 5 minutes, it was felt that the performance
of this behavior would not interfere with the performance of
Behavior 1.

Behavior 3, OT attending behavior, was selected not so
much from Bob's goal statement as from the researcher's
observations of his activity level in both PT and OT. With
the OTR'S agreement, it was decided to attempt to influence
Bob's attending behavior in OT. To measure this behavior
once Bob reached his assigned station in the OT area, a stop-
watch was activated whenever he was not actively doing some
goal directed activity with his upper extremities. He was

not timed while the upper extremity muscles were actively

85'
exercised. When he stopped, the watch was activated after
a count of 5. When he began to work again, the watch was
deactivated after a count of 5. This count was necessary since
Bob made considerable random movements, and a count of 5
seemed to provide the necessary time to determine if the
behavior was to continue in goal directed action. In this
setting a 30-minute continuous observation time was maximal.
Since a number of observation periods fell short of this
maximum, the observed data were converted to percentages of
time not engaged in activity. For presentation in the graph
in the Appendix (A-8), the percentages were reversed to show
percentage of activity time.

Doug's behaviors were related to the very obvious need
of strengthening. Behavior 1, range of motion exercises, was
related to Doug's arm strength. He was advised by both his
RPT and OTR to continually and actively move his shoulder,
upper arm, and wrist muscles to strengthen them and to keep
them from becoming restricted in movement. A ward order was
sent to the nursing unit to "encourage Doug to do his upper
extremity range of motion exercises between 3fiflland 4:00 p.m.".
For observation, the number of complete cycles of exercises
were counted and recorded as described for both Sue and Bob.

Behavior 2 and 2a, travel time and number of pushes,
were also related to upper extremity strengthening. Since
Doug was very weak, wheeling himself around in a wheelchair
was difficult and tiring for him. In an attempt to get him
to become more vigorous in wheeling his own wheelchair, he

was timed in his trip from a specific area in OT to the elevator.

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86
At the same time the number of distinct and separate pushes
of the wheels of his wheelchair were counted. Any simultaneous
push with both arms was counted as a single push while any
single arm push also counted as one push. The timing was
done by a stopwatch while the number of pushes was simply
counted as Doug wheeled down the hall, an estimated 80 feet
to the elevator.

Behavior 3, amount of time spent in OT activity, was
related to Doug's overall desire to get out of the rehabili-
tation center. It was the observation of the researcher that
Doug seemed to spend a great deal of time in OT therapy
sessions observing others while accomplishing little himself.
Hence, as in Bob's situation, the OTR agreed to try to im-
prove Doug's OT activity time. Observation for a 30-minute
maximum time period in his afternoon OT session was initiated.
Because of the observer schedule, the start of the period was
somewhat contingent upon when Sue got to the OT area in the
afternoon. As soon as the observer and Sue arrived from her
“timed trip to OT, timing began on Doug's activity. Any time
Doug was active with his arms and/or hands in therapeutic
activities the stopwatch was activated. When Doug's attention
‘was diverted and he stopped working, the watch was stopped.
Self>Monitoring Technique

On the last day of the pre-treatment baseline period for
each behavior, each of the patients was informed of the
specifics of the behaviors being observed. They were told
that on the next day they were to begin keeping a record of
‘that behavior themselves. In some cases this recordkeeping

only'required counting. In some cases the patient was given

87

a stOpwatch with which to keep a record. In Doug's case

with behavior 2, travel time, since he lacked the strength

to quickly start and stop a stopwatch, a wooden holder was
made into which the stopwatch fit snugly. He could then
start and stop the watch by hitting the control button rather
than squeezing it since the watch was firmly placed in his
lap or on his wheelchair seat. He could carry the watch with
him relatively simply as he "ran his race". In the behaviors
where self-monitoring of OT activity levels was required

(Bob and Doug), an electric alarm clock was wired to a very
wide, easily engaged electrical switch. Since both Doug and
Bob lacked the finger strength to manipulate even an ordinary
toggle light switch, the larger switch, which was controlled
by the entire hand, allowed easy self-timing of their activity
in the therapy hours. Throughout the entire study, the
external observers kept a record of observations with the

use of a stopwatch and hand-operated digital counters like
those used to keep track of expenditures in grocery shopping.
The researcher was present at the beginning of each self-
monitoring phase to assist in counting and recording of the
target behaviors.

In all behaviors, Sue used the same type of log used by
the external observers to daily record her observations. She
generally kept the log book at her bedside throughout the SM
and SR periods of her study. Similarly, Doug was given the
same type of log which was placed in a folder by his bedside.

He did not wish to keep the records on the wall near his bed

88
or in any other visible place. Because Doug was unable to do
anything requiring fine hand coordination, the researcher
wrote Doug's verbal report into the chart for him. The OTR
kept a daily log with him for behavior 3, OT activity time.
Bob, being nearly completely paralyzed, could not use his
hands for any recording. In his case, a log sheet was posted
at his bedside and the orderly was taught to fill in the chart
when Bob reported on his target behavior performance. Once
again, the OTR filled in the daily performance log for Bob on
his activity time in OT. She would verbally check the
accumulated clock time with Bob prior to recording the accumulated
time on her sheet. These sheets were kept in the OTR'S file.

Self-Reinforcement Period

 

At the conclusion of each SM period, the researcher had
a conference with Sue about her perception of the activity
level of the period. The concept of reinforcement for per-
forming the target behaviors was discussed. Sue readily
grasped the concepts of reinforcement planning. A discussion
was held about what kind of things would be rewarding for
her when she successfully completed the target behavior. In
addition, a standard of behavior was established by Sue based
on her performance level during the SM period. Once this
standard was set, the reward was related to it in a contract
which was written onto her recording log. Since Sue was
attempting to gain weight, eating snacks was a high frequency
and pleasant activity for her. It should be noted in
Figure 3-3 that for behaviors 1, la, and 3 the reinforcer

Sue chose to use was related to eating. The mind games and

89

puzzles which Sue chose to reinforce behavior 2 were acti-
vities which she indicated she always had enjoyed, but which
the researcher noted were not common occurrences. In lieu
of a better alternative at the time, however, her choice
remained. Per the theory of self-controlled reinforcement,
the reinforcers were all under Sue's direct control pending
the accomplishment of what Sue felt was acceptable minimal
performance. She continued to monitor the daily results

of her behavior in her bedside log book.

Bob's self-reward contract was developed in the same way
as Sue's for behavior 1 (resistance exercises of left arm).
The researcher attempted to explain the concept of reinforce-
ment to Bob. He realized the basic values of the concept and
suggested some potential reinforcers which evidenced his
knowledge of reinforcement. The researcher helped Bob chOOSe
a high probability and pleasant activity which was under his
direct control. Based on his SM performance levels, a standard
of behavior was established by Bob as noted in Figure 3-4,
and for meeting this standard for behavior 1, Bob chose to
allow himself cigarettes after his supper. A slightly modi—
fied approach was attempted for behavior 2 in light of the
poor results during the SR period of behavior 1. Since Bob
did not really wish to give up a reward for lack of performance,
for behavior 2, Bob agreed that during the 3-4 minutes he was
smoking a cigarette (a high frequency behavior after his
afternoon therapy) he would do the range of motion exercises
of his left arm. In this case no specified standard was set,

simply that he would perform a less pleasant activity while

90

simultaneously performing a pleasant activity, a direct
application of the concept called contingency management.
Since Bob's 3rd behavior was occuring in the OT area, the
researcher was interested in whether the self-control system
could be taught to and implemented through a staff person.
In this case the therapist was given instruction in the process
of allowing the patient to dictate a standard of behavior, a
suitable high probability reinforcement and also a method of
recordkeeping. The therapist was encouraged to help the
patient select a reasonable standard based on the SM period
level of activity and assist in selecting a meaningful
reinforcer. Figure 3-4 summarizes Bob's Self-Reward Contract
as it was developed for this behavior.

Doug's SR phase was handled very similarly to the others.
For behaviors l, 2, and 2a, at the end of the SM periods, a
conference was held with Doug to talk about the concept of
giving rewards to himself as a way of increasing or maintaining
appropriate behaviors. Doug also readily grasped the basic
idea of the meaning of rewarding behavior with nice things or
pleasant activities. At the appropriate times, his SM period
jperformances were reviewed with the researcher for behavior 1
and 2 and he was asked to pick something enjoyable which he
often did at about the same time of the day as the target
behavior which could be related to the research behavior. He
was then encouraged to choose a goal for his behavior which

would be acceptable to him and for which he could have his

self-controlled reward. Since Doug wanted to gain weight, and

 

91

since his friends often had a snack, he often had p0p and
candy from the cafeteria after his afternoon therapy. He
also thoroughly enjoyed associating with his peers in recrea-
tional and social activities late in the day. These were
logical choices totally under his control and were very rein-
forcing to him, and as shown in Figure 3-5, became the basis
for his self-reward contracts for behavior 1 and 2. As with
Bob, Doug's third behavior was monitored in the OT area.
Once again, the OTR was encouraged to help Doug establish a
reasonable standard of behavior based on his SM period per-
formance level and to choose a suitable reward for accomplishing
his behavior. In this situation, Doug chose to work on a model,
or other activities he preferred to do over some OTR prescribed
activities. The chance to work on an activity he particularly
enjoyed became the reinforcer for appropriate activity levels
for Doug in OT.
Additional Data ColleCted

In addition to the daily behavior data of the individuals,
the test data previously described were also collected. At
the onset of the study, each participant was given the pre-
viously described Rehabilitation Attitude Survey, the locus
of control instrument. Throughout the study, the state trait
anxiety inventory was repeatedly given to assess potential
change in the A-State. These were administered as often as
conveniently possible, given the patients' cooperation and
schedule. In addition, the STAI was administered to a variety

of other patients in the center to establish a generalized

92

norm against which to compare the results of the research
patients. At the conclusion of each patient's study sequence,
he or she was given the selected subscales of the EPPS as pre-
viously outlined, an Incomplete Sentences Test (Appendix C-3)
designed to assess the general attitude to the study itself,
and a Research Questionnaire (Appendix C-4), a study related
true falsetest designed to test the level of knowledge and
interest the patient had in the study.
Analysis

The analysis of this study was done with the application
of median slope analysis described by White (1971 and 197bgb).
This technique utilizes data collected over time for the pur-
pose of predicting future behavior patterns. Although origi-
nally intended for use in assessing the effectiveness of edu—
cational programs in a child's learning, the technique is
useful as a post hoc test for the effects of an experimental
procedure on any single subject study. The accuracy of this
predictive technique depends on the number of original data
points from which the original trend line is derived. More
data points improve the accuracy and increase the length of
time into the future which the slope can predict. If a
slightly greater deviation about the projected slope is
allowed, a still higher chance of accuracy of prediction is
possible. White notes that a 25 percent increase in allowable
deviation increases the accuracy noticeably. White described
four types of significance testing which can be done through

the process of median slope calculation. The first includes

93

the test of whether the trend of the data is different than

a flat or no trend distribution. A second test is whether

the lepe for a particular phase of the study is signifi-

cantly different than for a slope in the subsequent phases.

This latter test is a test of treatment effects. If the

slopes vary significantly between phases, the differences

in a single subject study must imply some treatment effect.

This test of trend line differences can be further broken

down into two more analyses. The third analysis, then, is a

test of the immediate effect of the treatment by testing the

step changes between two phases of a study. The fourth test

is of the longer range effect of the intervention which is

again done by testing the differences of slopes between

phases but in a slightly different manner than the second test.
The step change is noted by simply comparing the behavior

level at the completion of one phase and the level of the

same behavior immediately after the initiation of a different

treatment. In this study, if behaviors show a large difference

from one phase to the next phase immediately after the change

in process, the deduction would be that the treatment itself

caused an immediate change in motivation or facility to perform.

If, on the other hand, we notice that the immediate" change

in levels of performance takes place over the entire period

and the distribution of data points shows a different slope

than previously, then we can describe the longer term effect

of the treatment itself by noting the direction of the SIOpe.
In this study, the analysis of the overall significant

differences between phases utilizing the binomial distribution as

94

described by Siegel (1956). In this analysis the significance
test derives from whether the actual number of data points
falling above and below the projected trend line could be
due to chance occurrence and the comparison of phases was done
in terms of significant step and significant trends. The re-
sults of this analysis are described in the following chapter.
As was mentioned previously, the value of the intensive
case study is that it permits both a statistical and non-
statistical analytical approach. The analysis of this study is
carried out at both levels. The statistical approach has been
described. The non-statistical approach includes considera-
tion of the subjective climate during the study, the individual
influences affecting patient behaviors, and the changes in
daily procedures which might explain the variety of behavioral

observations. Chapter 5 addresses this analytical process.

Chapter IV

Statistical Analysis of the Data

 

The N of 1 Intensive Case Study Approach to research
produces a considerable amount of useful data. The statis-
tical analysis technique recommended by White (1971, 1972 a,b)
provides a statistical assessment of the immediate and longer
term effects of an experimental intervention. However, a
statistical analysis of this type does not utilize the nominal
data and subjective observations gained over the period of
observation. Since the researcher was interested in the
effects of SM and SR on patient behaviors, a statistical
analysis is important. At the same time, a considerable amount
of other observational data were collected which cannot be
statistically analyzed but which may have meaning for the prac-
titioner interested in the problem. For this type of data a
separate analysis is very important. Hence, the analysis of
this research will be two-fold-—statistical and descriptive.
This chapter will deal with the question of what were the
effects of SM and SR treatment on the behaviors statistically.
The subsequent chapter, which could be considered an assessment
of the meaningfulness of the study, will attempt to isolate
factors which might be of benefit to the rehabilitation or
medical profession.

To assist in the statistical analysis of the data, the
reader is referred to Figures 1-11 in Appendix A. These figures
show the data point distributions for each of the 11 specific

behaviors. The figures also Show the median SIOpe trend line

95

96

for each phase of each behavior. Each of the stated hypotheses
will be reviewed and summarized in terms of the overall outcomes.
Once again, the point is to be made that in White's median
slope analysis there is the possibility of four separate
analyses: (1) The testing of difference from a no-trend dis-
tribution, which will not be addressed; (2) the testing of
differences in slopes between phases, which will be tested;
(3) the testing of differences due to step changes or the
immediate effect of the treatment,which will be addressed;

(4) the differences in trends between phases or the longer
range effect of the treatment, which will be assessed. In

the following description, the test of overall statistical
differences is the test of overall differences between phases.
The Step Differences addressed immediate change effects and
Slope Differences addressed the longer range effects.

In each of the tables a range of accurate prediction is
also presented. The figures in this range show the highest
possible accurate prediction from one phase to another and
from one end of the projected phase to the other. The more
data points which originally exist upon which to plot a trend
line, the higher the predictability. On the other hand,
the farther ahead into the future one wishes to predict a
trend, the less accurate is the probable prediction. The
figures were computed by White from the actual data analysis
Of 166 analyzed studies and reflects a deviation error of

.25 in.the data distribution.

97

 

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98

General Findings

 

Hypothesis 1:

 

The implementation of a self-monitoring (SM)

technique for selected patient behaviors will

significantly change the occurrence pattern of

the behavior in the desired direction over a

pre-treatment baseline period.

This hypothesis was rejected.

In this analysis, the trend line obtained in the total
baseline period was extended into the SM period. The binomial
test was used to calculate the probability of the differences
between the projected trend and the actual trend of the SM data.
The same procedure was used to calculate the significant
findings of the step and slope changes.

It is noted initially that for Sue (Behavior 1) and Doug
(Behavior 2), although the actual travel time was not signifi-
cantly altered, the corresponding behaviors (accidents and pushes)
were both significantly different because of self-monitoring.

Both showed that the statistical difference was due mostly to

a change across phases of the slape of the data and not a large
step difference. This result might be expected in behaviors of
this nature where practice is essential for improvement. A slow
improvement would undoubtedly occur rather than an immediate
change simply because of the learning required to become more
effective. We further note that Sue's ROM exercises show a signif-
icant change this time due primarily to a step change. One might
speculate that self-recording of her behavior in this case changed
the fact that the behavior occured at all. However, upon further

analysis, we note that Sue's ROM trend line is steeply declining

during the SM period but the scatter of data in that period

99

was enough to make the overall decision regarding significance.
We also note that the mean of the SM phase is progressively in
line with the changes in the period means from B to SR. Further
analysis shows that neither Bob's nor Doug's ROM exercises were
significantly altered when they were asked to self-monitor their
behavior, however. Finally we note that Bob's percentage of OT
activity significantly improved as a result of the self-monitoring.
In this case, step and slope differences apparently combined to
cause the change although neither the step nor slope differences
were significant in themselves.

One must conclude from the data that although SM seems to
have some effect on some behaviors, it does not routinely effect
all behaviors. We can further speculate that the effects, if
any, of self-monitoring vary from an immediate effect to a longer
term effect depending on the type of behavior being measured
where practice or motivation is the basis for activity.

Hypothesis 2:

 

The implementation of a self-reinforcement (SR)

program (Which includes self-monitoring (SM))

will significantly change the occurrence pattern

of behaviors in the deSired direction over a pre-

treatment baseline (B) period.

This hypothesis was rejected.

For this analysis, the total number of B data points were
used to develop the trend line. This line was projected across
the SM period and into the SR period. Of particular note, 4-2
shows that in Sue's case the probability ranges for successful
prediction are very low and little reliability can be placed on
the statistical outcome for behavior 1 and la. This is due to the

fact that very few baseline data points were available upon

which to base a prediction from 9 to 18 days into the future.

100

 

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101

Figure 4-2 shows that statistical significance again
occurred not in actual travel time for Sue and Doug but in
the related activity associated with accidents and pushing
behavior. It would appear from this data that recording and
reinforcing appropriate behavior levels does little to affect
the speed of an activity but it does help to influence the
energy exerted (pushes) and awareness of body position
(accidents). The other significant results were found in Sue's
and Doug's range of motion exercise behavior. In this case
considerable significance can be attributed to the immediate
effect of the SR program as indicated by the fact that signifi-
cant differences were due to step changes which implies that
this activity may be motivated rather than learned. Bob had
no behaviors affected by the SR program, which detracts from
the value of the other findings. Based on these outcomes,
it would appear that SR has a limited effect on behaviors.
There seems to be a tendency to produce changes in those be-
haviors which ordinarily do not occur in daily behaviors and
for which additional awareness and motivation is required.

Hypothesis 3:

The implementation of a SR program will signi-

ficantly change the occurrence pattern of

selected behaviors in the desired direction over

a SM only period.

This hypothesis was rejected.

To study the effects of a SR program wherein the indi-
vidual not only kept records but also reinforced the behavior,

the SM median slope was extended into the SR period data.

102

 

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'103
With the application of the binomial test, tests of signifi-
cance were calculated for total difference between phases,
differences between steps only and differences of slopes.
Table 4-3 provides a summary of the statistically significant
differences due to the effect of SR.

Only one type of behavior was shown to be significantly
different because of the administration of a self-controlled
reward. That behavior in Sue and Doug was range of motion
exercise. In looking further at Bob's behavior 2 (also ROM),
the only change from a 0 level occured during the SR phase;
however, the change was not great enough to create statis-
tical significance. Hence, it appears that the introduction
of a SR program may have some benefit for encouraging patients
to exercise outside of the therapy hour, but the introduction
of a self-reward system seems to do little to influence the
other behaviors over and above whatever reactive effects self-
monitoring may produce in itself.

Hypothesis 4:

As a result of the SM and SR intervention, the

occurrence pattern of selected behaviors during

the post-treatment extinction period (B) will

be significantly different in the desired direc-

tion over the pretreatment baseline period.

This hypothesis was rejected.

The question of concern here is whether there is any bene-
fit to the patient because of the combined treatments over a
period of time. To assess this statistical question, the
median slope of the total B period was projected into the E

period. Once again, with the application of the binomial test,

levels of significance for the probability of the E period were

.104

computed and are shown in Table 4-4. A careful evaluation
of the table shows that two behaviors showed a significant
difference in the E period over the B period. Sue's post-
treatment accident-avoidance behavior and Bob's OT activity
levels were both significantly different from their pre-
treatment baseline levels. One must wonder naturally why
these particular behaviors reflect the improvement. Is it
a function of the treatment, the behavior, of some other
factor? Itmight reflect a simple adjustment factor of the

individual.

Table 4-4

Statistical probability of E)B for each behavior
using all the data points for E and B periods

PREDICTION STAT.

 

PATI BE ' I
ENT HAVIOR AggURACY {2253
Sue 1 Travel Time .69—.60 N.S.
1a Accidents .69-.60 .002
Eye-Hand OT .96-.94 N.S.
Range of Motion .96-.94 N.S.
Bob 1 Resistance
Exercises .97—.98
Range of Motion .96- N.S.
OT Activity .96-.94 .016
Doug 1 Range of Motion .97 N.S.
Travel Time .96-.94 N.S.
2a Pushes .96-.94 N.S.

3 OT Activity .96-.94 N.S.

105

Care must be exercised, however, not to be overly criti-
cal of the treatment because of the statistical results. It
is true for all patients, range of motion activities dropped
to zero or near-zero levels during the E phase. However,
looking at Sue's Behavior 1 and Doug's Behaviors 2, 23, and 3,
it is clear that the general E levels are not much different
from either the SM or SR phases. In each of these cases,
however, the initial baseline slope had such a dramatic de-
cent level that it would be nearly impossible for the patients
to perform at the predicted level in the E phase. In other
words, a "leveling off" process in "travel times" and "pushes"
seemed to occur beyond which the patient was unable to
improve. Also, in some cases prediction from baseline into
the E phase was at a level impossible to attain physically
and hence impossible to assess statistically. Nevertheless,
it must be stated that, with the exception of two behaviors
mentioned, there was a general slippage in almost all other
behavior categories once the treatment had ended, in con-
traindication to previous research which indicated a con-
tinuing level of performance.

Consideration of the Summary of Mean Values (Table 4-5)
provides information about the number of behaviors in which
the E period levels are better than the B periods. In Sue's
case, Behavior 1 and la both show a substantial improvement
over B while Behaviors 2 and 3 show a performance at or below
the B period. In Bob's case, Behavior 3 has already been noted.

In Doug's case, the OT activity level shows a higher mean

Table 4-5

Summary of Mean Values Obtained Across Phases

 

SUE

Behavior 1
(Travel)
Behavior la
(Accidents)
Behavior 2

(0T)
Behavior 3
(ROM)

 

PHASES

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BOB

Behavior 1

(Resistance '

Behavior 2

(ROM)
Behavior 3
(OT % Act.h

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOUG

Behavior 1
(ROM)
Behavior 2
(Travel)
Behavior 2a
(Push)
Behavior 3
(OT % Act.)

 

   

74

.49

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

o” Ifil“

 

:44

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self-Monitoring

- Self— Reinforcement

:58

29

.74

 

107

performance than the baseline and a lower travel time and push
average than during the B period, while the ROM was only
slightly better than the B.
Comparison of Self-Monitoringand External Monitoring

One of the elements of self-control theory which has been
noted to need further explanation is the process and accuracy
of self-monitoring techniques (Mahoney and Thoreson, 1974;
Kazdin, 1974). Of concern is whether the individual will
manipulate the self-observation to "prove" a change in behavior.
A comparison of the obtained results for each subject for both
SM and SR periods are presented in Table 4-6. A range from
no correlation (Bob, 2 SR) to perfect correlation (Sue, la SM:
Bob 2, SR; Doug 1, SM and SR) was obtained. The method used
to obtain these results was to compare the recorded self-
observations and external observations for each of the data
points. Those days on which the patient did not record any

data were eliminated from the comparisons.

Table 4-6

Correlation of Self-Observation and External Observation

 

PATIENT BEHAVIOR SM PERIOD SR PERIOD
Sue 1 Travel Time .93 .91
la Accidents 1.00 .46
2 Eye-Hand OT .70 .92
3 Range of Motion .91 .93
Bob 1 Resistance Exer. N.A. 0
2 Range of Motion N.A. 1.00
3 OT Activity .72 .90
Doug 1 Range of Motion 1.00 1.00
2 Travel Time .97 .99
2a Pushes .80 .76
3 OT Activity .91 .26

f108

Of greatest concern are those correlations which fell
below .90. Sue's accident report shows a dramatic change
from a perfect (1.00) correlation in SM to a .46 in the SR
period. This was due to a difference between SM and SR self-
and external observation for two days. In these days a dif-
ference in interpretation of one accident-~a 100% difference--
occured. It should be noted that out of 18 days there was a
total difference of only two accidents, a reasonably accurate
evaluation. In the evaluation of Sue's self-report of her
OT in-room activity (Behavior 2) the difference was caused
by one observation day where Sue recorded a 20 minute per-
formance while the observer noted no such time. It is felt
that Sue probably recorded her activity for a period outside
of the 2:00p.m.-3:00p.m. time period.

Since Bob recorded no performances during the SM period
of either Behavior 1 or 2, no correlations were possible. As
for the low correlations for the SM period of Behavior 3,
most of the difference is due to the inaccurate timing process
Bob used. Bob often allowed the clock to run while he was

to have turned if off and vice versa. As for the SR phase,

 

Bob reported his performance in general terms. On one occa-
sion, for example, Bob was observed to have completed 82
resistance exercises. Subsequently he was asked how many he
did, his response was "at least 50", indicating that Bob
apparently did not keep an accurate record. The perfect
correlation (1.00) obtained for Behavior 2 was based only on
one reported response which agreed with the external observa-

tion of 10 range of motion exercises.

109

Evaluation of Doug's self-monitoring process shows a
relatively high correlation overall. Behavior 2 (SM and SR)
both show a difference. This was undoubtedly due to the
fact that there was a different interpretation of the defi-
nition "pushes". Doug would often count a simultaneous push
of both arms as "2" while the explanation given to him was
to count it as "1". Another potentially confounding activity
occurred when Doug's wheelchair on a few occasions rolled on
a depressed area of the floor and the wheel would spin freely.
On a few occasions it took several pushes of the wheel to
get over the floor depression. On these occasions, differences
in interpretation of whether the pushes were counted was a
possibility. Since the actual number of pushes counted for
this nonproductive activity could not be isolated after the
experience, no change in counted pushes was possible. The
final major discrepency occurred in the OT SR period. In
this case the noted differences probably occurred due to the
self-reward contract Doug established. The external observer
was asked to observe for a 30-minute continuous period once
the timing began while Doug continued to time his activity
in the anticipation of completing the 35 minutes. Doug often
stayed longer in OT during this period in order to achieve
his goal than during the SM period. A modification in the
process should have been to subtly note Doug's accumulated
time at the end of the 30 minute external observation period.

Undoubtedly this would have led to a much higher correlation.

110

Overall, this would seem to indicate that, in most cases,
the patient's self-reports were not distorted in order to
obtain any self-controlled reinforcement. Furthermore, it
should be noted that the self-reinforcement contracts were
formulated on the basis of the patient's obtained behavior
pattern in the SM period. Any changes in behavior pattern,
then,can be related to the introduction of self-controlled
reinforcement and not to a change in monitoring process.

One final observation should be made, however. Mahoney
and Thoreson (1974) advocated training people to monitor
their own behaviors over a series of observations. Such
training would seem to be a reasonable suggestion. Further
training time for each of these patients would undoubtedly
have improved the overall reliability and validity of the
patient's observations.

Summary of Statistical Findingg

 

In general we can say that none of the hypotheses were
totally supported statistically. There is reason to believe
that the application of self-monitoring has a positive
benefit when applied to those behaviors which the patient
engages in out of necessity rather than as a result of some
special training. Therefore, activities like eating and
walking, behaviors which are repetitive and produce an im-
mediate reward, may be representative of the kind of behavior
which one might consider for the implementation of a self-

monitoring approach in the production of change.

111

Self-reinforcement, on the other hand, seemed to be more
effective, at least for two of the three patients, for accom-
plishing unusual behaviors not within the current repertoire
of behaviors. For example, active and passive range of motion
activities are not typical behaviors of most healthy adults or
adolescents. All normally functioning adults daily engage
in range of motion because of the constant movement of arms,
wrists, hands, and legs, but, when one becomes disabled and the
limbs are suddenly paralyzed or weakened, the movement is
grossly reduced. Hence, in healthy individuals the ranging
activities are usually related to a function such as writing,
climbing, bending, or reaching, for which there is an
observable and definable outcome. On the other hand, range
of motion when practiced in rehabilitation therapy is often
used only as an activity for the movement of the affected
body part with no other personally beneficial goal. In
this case, some meaningful external reinforcement may be
necessary to create a desire to perform the behavior.

Further analysis reveals that, although the effect of
the treatments found by comparing the pre-treatment and post
treatment trends of behavior seems non-significant, compari-
son of the pre- post treatment means of behavior gives a
slightly different picture. It must be emphasized that having
dramatically increasing or decreasing slopes produces consider-
able difficulty in establishing statistical significance. At

the same time comparison of the grouped data provides a much

112

different perspective on occasion than the trend of the data.
Hence, the argument regarding static versus dynamic analysis
of N=l data seems to be legitimate. The question ultimately

is which type of analysis is the most meaningful for the

research hypotheses.

Chapter V

Descriptive Analysis of the Study

 

The statistical testing of the Intensive Case Study has
been discussed earlier. At that time, it was noted that the
N=l design gives the interested observer the opportunity for
a descriptive assessment of the day-by-day events which may
add insight to the statistical analysis. This type of infor-
mation is often more meaningful to those who are directly
involved in the area with which the study is concerned. To
assist the practitioner in the analysis of this study, three
additional components are addressed. The first analysis for
each participant is a within-behavior analysis; the second
is an across-behavior data analysis; the final section of this
chapter deals with the personality-related components of
the study.

Within-Behavior Analysis

 

Sue: Behavior 1 (Travel time and Accident)

 

It was noted in the statistical analysis of this behavior
that there was no significant effect due to treatment in Sue's
travel time to OT, but there was a significant effect in the
accident prevention in both the SM and SR phase. An analysis
of the successive trend lines shows a period-by-period leveling
off of the slopes to approximately a no-lepe trend. It is
interesting to note, however, as Sue began to monitor Behavior 1
for the first time, the slopes of both the time and accidents
behaviors proceeded in the expected direction implying an in-

creased awareness of the behavior unit. It is also interesting

113

114

to note that the travel time in B and SM periods represent
nearly identical shapes. This phoenomenon is difficult to
explain, especially in light of the unobtrusive B observation.
It was noticed at the onset of the SM period that Sue had

some difficulty coordinating the stOpwatch and the counter

and manipulating her wheelchair at the same time. However,

by the third day she was doing well. It should be noted further
that during the early phase of the research, Sue did not have
therapy on Saturday or Sunday, thereby leaving a number of

days uncounted. This situation changed when the Rehabilitation
Center began Saturday a.m. therapy after the study began. Sue's
husband did attempt to report the number of accidents Sue had

at home on one trip from living room to kitchen, although this
reporting did not occur with any regularity over the duration
of the study. Furthermore, considering the total change in

the environment, one might wonder about the value of these

data points to the overall study.

As for Sue's self-monitoring period,behavior lwas the most
closely and accurately monitored of all behaviors. At the
completion of her "run" to OT, Sue's first activity was to
fill out her own behavioral log kept in the OT area during
this period only. It was surmised that the physical presence
of a stopwatch and counter and the concurrent presence of the
observer provided an observable reminder of the need to record
the results of her trip. A record was kept for each of the

possible days in the study.

115

Sue's self-reward contract, eating some fruit or snack
she was keeping on the unit, seemed to provide a suitable reward
for this behavior. She was unable to have the reinforcement
immediately after the behavior since she was in OT, however
observation validated that she claimed the reward later in
the afternoon when she returned to her room. Sue met her pre-
established objective each day of the SR period, thereby
seemingly confirming the value of goal setting, monitoring
and reinforcement system.

Sue: Behavior 2 (OT Activity)

 

This behavior was the most difficult to monitor and one
of the least effective behaviors included in the entire study.
For one thing, only five of the first six days in which there
was any noticeable time spent in OT activity on the ward, Sue
spent that time on written work directly associated with the
study. Sue had been asked by the researcher to keep a daily
log of her activity for the hypothetical purpose of obtaining
data for establishing the later reinforcement program. She
usually chose to fill in this log during the prescribed time
period for OT activity. This recording continued for 10 days,
so much of the early data are biased by this activity. In
addition, Sue used this time to fill in the STAI instrument
and other test-like materials, all worthwhile activities but
completely externally imposed. The greater part of the other
days in which Sue was noted to be engaged in OT activity, she
mostly spent her time playing solitaire, an activity she seemed

to enjoy on occasion but not very reinforcing for a person who

116

enjoyed socializing as much as Sue did. During the later
phases (SR and E), Sue was making considerable physical
progress and was spending a longer time in her afternoon
appointment. In addition, she became responsible for more
independent activity including washing some of her own clothes
and making her bed, both of which were important, of course,
for her goal of returning to housekeeping activities. These
two activities however, took up much of the observation time
between 2 and 3 p.m. and her small eye-hand activity became
secondary for her. Furthermore, the OTR prescribed activity
seemed to provide little intrinsic reward and seemed to lose
its effectiveness over time. Sue's self-monitoring and self-
reinforcement did not seem as effective during this period
either. Sue made no record in her log for 12 of the 18 days.
The researcher, with little success, attempted to change this
pattern by periodically inquiring whether she had recorded
her OT time. It was felt that the lack of a specific moni-
toring technique, other than "keep track of the time you
Spend", the relative value of her OT-prescribed activity when
compared to the other physical progress being made, the lack
of intrinsic reinforcment for the activity, and the weakness
of the self-reward contract all contributed to the apparent
lack of motivation Sue had for this activity. It seems obvious
by looking at Table 4-5 that Sue reached her performance peak
during the B period and simply lost interest in that activity

as the study progressed.

117

Sue: Behavior 3 (Range of Motion)

This behavior represents what seems to be exemplary of
the kinds of behaviors to include in a study of this nature.
Consideration of the slopes across all periods show an inter-
esting pattern. It is to be noted at the outset a strong deter-
mination to exercise probably more out of duty than anything
else. It is surmised that after this initial rush of activity
there was a lack of reinforcement and hence a drastic drop to a
flat trend at the 0 level with only occasional spurts of activity
during the final B days. At the outset of the SM phase it
appeared that the instructions about self-monitoring again
reminded Sue of the potential value of the activity; however,
by the last day of the SM.period she had reverted to an off-
again, on-again behavior. The SR period shows a substantial
increase in performance although the trend is relatively flat.
This would confirm the value of reinforcement in this behavior.
During the SM and SR periods, Sue recorded her range of motion
16 out of a maximum of 18 possible times with the researcher
recording the first day amount with Sue. The accuracy of her
recording is somewhat in question; the external observers
reported that their location, the position of the patient at
times, and the nature of the exercises (ranging of the fingers
can be done relatively subtly and is hard to discern if the
patient is not facing the observer directly) may have made
this reporting inaccurate. In addition, it is possible that
the patient on some occasions included ranges completed prior

to or after the actual observation period. This discrepancy

118

was particularly noticeable during the SM period when the
external observers consistently rated Sue's performance lower
than she rated herself. During the SR period however, probably
because of the slight change in observer pattern to accommodate
Sue's reward selection (do 50 ROM to earn luncheon dessert),
the observers began to watch Sue a little earlier with a higher
correlation noticeable. Sue rewarded herself each day, since
according to her records she maintained an acceptable level

of behavior. It is finally to be noted that the only sub-
stantial activity occurring in the E period was done at home
and reported by Sue's husband.

Sue: Across-Behavior Assessment

 

In looking at all three of Sue's behaviors, the following
things are of interest. It seems apparent that meaningful
behaviors were the most motivating in Sue's case. That is,
it was meaningful that she learned to avoid hitting things
despite her restricted vision because in the role of house-
keeping inefficiency would be harmful or dangerous. It is
also noteworthy that housekeeping related activities soon re-
placed the small motor coordination activity. It was also most
important to note that reinforcement with food was successful
in that it generally promoted a more stable and acceptable
standard of behavior than either in the B or SM period. Through-
out the study, visits home were important for Sue. These visits
meant many missing data points and an unfortunate variability
within the "own control" aspect of the N of 1 design, since the

environment changed for Sue 2 days out of every 14 or less.

119

Overall it seems, that with the exception of the apparent
non-rewarding OT activity, the technique of SM and SR seemed
to promote behavior change in the desired direction for Sue.
Due to the unstable baseline periods the statistical signifi-
cance issue was clouded and the overall results do not seem
as positive as the total data might suggest. Nevertheless,
there seems to be sufficient data in Sue's case to support
the application of SM and SR in a medical rehabilitation center
if meaningful tasks are developed and suitable rewards chosen.

Bob: Behavior 1 (Resistance Exercise)

 

There is relatively little that need be said with respect
to this behavior pattern. It seems probable, as it was in
some of Sue's behaviors, that the duty and the knowledge that
exercising outside of scheduled therapy was important and
therefore done. At the outset it is noted that Bob used the cuff
weights to perform his resistance exercises. It is highly
possible, since Bob needed assistance to put cuff weights on
and since the ward order was new, that the staff influenced
Bob's decision to exercise by encouraging him to wear the
weights on the first few days. However, as time progressed,
the ward order was forgotten (not an unusual occurrence), the
reinforcement obtained did not stimulate the continuation of
activity, and Bob did not pursue the issue. The SM period was
met with little enthusiasm by Bob. Although he agreed to have
the orderly record his exercise rate, he never had any data
recorded, obviously because he didn't do any. The SR period
continued to show Bob's less than whole hearted support of the

research idea. Although he made some attempt to exercise, it

120

was only when this researcher was in his room that Bob
attempted his exercises. On the first day of the SR period,
Bob manipulated the staff somewhat to make them think he had
done his required activity. He kept the weights on his wrists
purportedly to do his exercises while visiting in the cafeteria.
Upon arrival there, however, he was soon able to shrug the
weights off his arms. He subsequently told the staff he wore
the weights "for an hour". He, in fact, did no exercises.
Bob remarked later in the study that "he rarely smoked ciga-
rettes after supper anyway" implying that his self-reward
contract for this behavior was meaningless and indicating
somewhat the attitude he had toward the study.

Bob: Behavior 2 (Range of Motion)

Of some importance regarding this behavior pattern is
Bob's short-lived attempt at ranging his left arm at the out-
set of the SR period. But again, Bob did not follow through
on having someone record his activity on the chart posted on
the wall at his bedside. Most of Bob's "no performance" times
were spent either sleeping or visiting with his family. It
is interesting to note that during this phase of the experiment,
Bob described to the researcher his antics designed to fool
the observer assigned to monitor his behavior. Bob also
suggested that the researcher should get "the spy off his back".
It was obvious that Bob knew he was being observed and this
seemed to irritate him. However, the situation at the Center
was such that unobtrusive observation of Bob between 4 and Sp.m.

was very difficult. As noted, he spent a great deal of time in

121

in his room during this time and the only way to observe him
necessitated going in his room. Of course, this destroyed
some of the unobtrusiveness, but probably had little to do
with Bob's cooperation.

Bob: Behavior 3 (OT Inactivity Time)

 

In one of the more interesting segments of the study,
Bob was asked to time himself during his therapy period in
his morning OT. He was given a wooden box, approximately
4x4x10 inches, in which an electric clock was placed with an
electric switch mounted next to the face of the clock. When-
ever Bob was stationed in OT, the OTR placed the clock within
his reach and he was instructed by the OTR to "punch in" or
"punch out" as he worked or rested. The system had its draw-
backs, however, for Bob was not an accurate or compulsive
time keeper. He would occasionally "forget" to activate
or deactivate the clock despite the OTR's reminder. In addi-
tion, the self-reward contract was not clearly worked out.
In this case, since the entire SM-SR program was under direct
supervision of his OTR, Bob was not really given an opportunity
to set his own reinforcement or standard for behavior 3. The
therapist, an active antismoking campaigner, suggested to Bob
that if he worked 20 minutes (of a 30-minute period) he could
have a cigarette break in the hallway (Bob often suggested he
wanted to smoke in the therapy area). This "contract",of
course,violated a basic assumption of self-reinforcement,
establishing the standard and the reward himself. It proved

to be quite ineffective; Bob often did not arrive at ll:003.m.,

122

and would often not get positioned at his OT station for
another few minutes. Therefore, the likelihood of his attaining
the 20 minute goal was practically non-existant. Furthermore,
since Bob ate lunch in the same room immediately after his OT
session, he usually had no time to accomplish the reward even
when he earned it. When these factors were pointed out, the
therapist agreed to a change and told (again a violation) Bob
that if he worked for 20 minutes he could terminate his p.m.
therapy early. This new reward was also an externally imposed
reinforcement, since Bob was not part of the decision-making
process, but the reinforcement seemed appropriate in that Bob
had been leaving his afternoon therapy sessions prematurely.
Observations in the SR period Show the highest amount of
dispersion among these scores. This would seem to indicate
that the SR treatment had some effect on Bob's behavior,
although the specific effect is not clear. His constant nega-
tive reference made about the timing task was perhaps indicative
of his interest (or lack thereof) in the project as well,
although Bob was supposedly unaware of the fact that this was
part of the ongoing research. The daily presence of the
"unobtrusive observer" in Bob's therapy hour and the contract
was perhaps a tip-off to the relationship to the study, however.
It is interesting to note that the E period activity level
was higher than any of the previous periods. Although no
definite conclusions can be reached, we can speculate whether
doing away with the clock and the self-reward contracts, or
possibly the removal of Bob's Halo brace on day 41 and the

subsequent increase in physical movement potential, influenced

123

his overall activity level. The change in OT performance might
also reflect Bob's slow adjustment to his limitations with a
corresponding realization for the need to change his pattern.

It is finally of interest to point out that Bob's primary
activity in OT during the study included sanding a board
(biceps, triceps strengthening), assembling and disassembling
activities (finger strengthening) and performing active and
passive range of motion exercises. Of particular interest
is that Bob's average activity percentage when sanding was only
.265. At the same time, when Bob was forced, because of a
one-to-one situation, to produce in exercising, his activity
level rose to an average of .515. ‘This would seem to indicate
that social interaction and personal contact seemed to increase
the activity level for Bob and might provide a clue to a major
reinforcer overlooked in Bob's situation. Although some of
the variability within this behavior is due to the specific
activity occuring each day, it seems that the range of activities
was dispersed throughout the study and hence can not explain a
total performance profile for a period. The only activity
which seemed to increase over time was the hand and finger
activities which were directly related to the return of that
function with Bob's stay at the center. The use of the hands
and fingers, of course, was very reinforcing for Bob, and their
increasing mobility was important for Bob's long-range recovery.
He seemed to work more intensely to improve his skills in this

area, particularly toward the end of the study period.

124

Bob: Across-Behavior Summary

 

From studying Bob's three behaviors, it seems evident that
his behaviors were obviously not effected to any great extent
by the treatment. Although there was an effect noted during
the SR period for behavior 2 (ROM), the effect was short-lived,
while the 3rd behavior (OT) resulted in a greater dispersion
in scores during the SR period. The results do not seem con-
clusive in favor of the implementation of SM or SR in Bob's
case. Although there was a significant improvement in behavior 3
over the time of the study, the improvement might have been a
function of either greater physical strength and mobility or
the removal of what might have been perceived as an aversive
experience--the threat of contracts. At any rate, several
potential confounding factors are evident in this last behavior.

Doug: Behavior 1 (Range of Motion)

 

The within-behavior analysis of Doug's range of motion
activities shows a decisive change in behavior at the outset
of the SR period. It is noteworthy that on only one occasion
in the SM period Doug did perform his ranging exercises. This
was undoubtedly a reaction to the observer's periodic checking
with Doug on whether the data was being recorded and Doug's
antagonism at having to defend his behavior. Part of the
lack of performance in Doug's case might have been related to
some peer group pressure he seemed to feel. For example, his
observer noted that when Doug chose to do his exercises he would
do them in a secluded spot out of sight of his room-mates or

he would do them in a hasty manner when no one was around.

125

The realization that the ranging activity was an activity none
of his early adolescent room-mates had to perform may have

made Doug feel embarrassed or less than adequate. His SM period
comments that he did them "later" and that the scheduled time
(3:30-4:00) was a "busy time" were indicators of his reluc-
tance to engage in such an activity.

As far as the SM period was concerned, Doug was unwilling
to initiate the self-recording. The researcher often made the
daily record after Doug had become involved in an alternative
activity. As for the SR period, Doug was most copperative in
setting an acceptable minimal standard (45 exercises). One
suggested alternative reinforcement suggested by the researcher
was quickly accepted by Doug. He established that he would
do 45 exercises before going to arts and crafts, music or game
time scheduled daily at 4:00 p.m. Doug always "cashed in" on
his reinforcements. The value of the range of motion exercises
to Doug however,seemed to diminish as soon as the reinforcement
period was finished thereby implying the value of the rein-
forcement, but a lack of carryover of the principle when it
was no longer required. The intrinsic reinforcement of range
of motion exercises apparently did not outweigh the potential
aversive effects which might derive from his peers as Doug
chose not to continue the existing reinforcement contract.

Doug: Behavior 2 and 2a (Travel Time and Pushes)

 

This phase of the study was interesting in that Doug, who
until the time of the study seemed to be quite clumsy and apa-

thetic as he wheeled his chair down the hall, made great

126

improvement in his strength and dexterity. Although Doug's
timed performance steadily improved from the B through the

SM period, one noticeable effect of the SM phase was the
decrease in variation about the slope and the joint descent

of slope for both the pushing behavior and the timed behavior,
implying a greater concentration on the task behavior, similar
to Sue's situation. Because of the continual decline during
the SM phase for each behavior and the subsequent levelling off
of both the number of pushes, and time during the SR period,
significance was not achieved. As was pointed out, however,
Doug may have reached his ultimate physical potential at the
end of the SM period and further improvement might have been
impossible.

As for the SM period Doug was very excited and motivated
to make the run in "one minute". After he had accomplished
that goal he noted that he wished to reduce the number of
pushes. His enthusiasm was carried over into the SR phase
where Doug projected a continued improvement both in the time
and number of pushes. All went very well with the exception
of day 35 when Doug was given a different wheelchair. The
change produced an immediate decrease both in his rate of speed
and dexterity. However, immediately thereafter Doug regained
his skill and speed and reached the lowest score for the study.
The self-monitoring and graph was attended to each day by both
the observer and Doug since Doug was aware of the joint moni-
toring. As for the reinforcement--a can of pop--Doug usually
got one. He passed it up on a few occasions saying that "it was

too cold for a cold p0p". No other reward was substituted;

127

however, the intrinsic reward of "winning the race against
time" was undoubtedly sufficient to keep Doug intent on the
activity and he needed no further reinforcement. In fact, on
a few occasions, Doug made a second "run" to try to improve
his performance level.

Doug: Behavior 3 (OT Activity Time)

 

As was noted in Chapter 3, this behavior was chosen by
the researcher because Doug seemed to spend a great deal of
time daydreaming or watching others around him in the busy OT
area. The data show that Doug's overall baseline performance
improved over time due primarily to the 3rd phase of the B
period. We note that in the SM period the slope was reversed,
although the mean activity level of the SM period was higher
than in the previous 3 baseline periods. Doug was relatively
hard on himself in the self-timing program, the very observa-
tion made by Bandura and Perloff (1967). He would often turn
the clock off even if he was actively performing in therapy.
These untimed activities were not as goal directed as playing
a game, building block towers or exercising with the therapist,
and there did not seem to be a carryover of the concept that OT
can also mean sitting unsupported on a mat for several minutes
or for picking up parts of a game which is a means to muscle
strengthening.

As we consider the specific activities occuring within
Doug's OT sessions, it was noted, as in Bob's behavior 3, that
Doug's activity level drOpped during the relatively direction-

less sanding days (average percent of activity .35) while OT time

128

spent playing games resulted in an average active percentage
time of .64. The final major time block of OT was spent in
independent goal directed hand activities with an average
percentage of activity being .78.

This observation of activity re-emphasizes the point made
earlier that apparently patients do work harder at those
activities in which there is an immediate reinforcement, such
as putting a plastic model together, or making a tower of
styrofoam or wooden blocks. It also seems to indicate that
although selected activities may be necessary for increasing
strength or range of motion, patients may need an alternative
experience immediately thereaften particularly a very rein—
forcing event such as a social time with the therapist or
other enjoyable activity. As in Bob's case, the SM for Doug's
behavior was done by the OT with the patient's knowledge. A
sheet was kept, but in an inconspicuous place, on which was
recorded Doug's time recorded by the electric clock. Although
Doug daily reported his time verbally, he was only reminded
of his overall performance between the SM and SR phase when he
was given his average recorded time for the SM period. He then
set his own standard for the SR phase. His Olympic-like goal
was to "work" for 35 minutes at therapist-assigned activities,
after which he could choose to do an activity he enjoyed in
the OT area. This goal was reached four out of eight days, with
two other days falling just two minutes shy. This fact does
not appear on the actual data, since the maximum observation

time was 30 minutes. In this case, as in Doug's other behaviors,

129

it appears that auto-recording was not particularly reliable.
Furthermore, it was not evident to the observers that Doug
proceeded to his preferential OT task after reaching his goal
in the assigned task, implying that the self-reward contract
and feedback might not have been too effective in this situa-
tion probably due to the time element.

Doug: Across Behavior Summary

 

From the data collected on Doug's three behaviors, it
seems that there are certain findings to be emphasized. First,
although the actual number of significant results due to treat-
ment is low, there acre some effects due to treatment. It is
obvious that SM did stabilize behaviors 2, 2a, and 3 somewhat.
Had the SM results been more accessible to Doug, one might
speculate on how much more behavior 3 might have changed.

The SR technique had a noticeable effect on behavior 1, and in
both 2 and 2a it at least seemed to keep the behavior at a
plateau. With better devised reinforcers for the third behavior,
it is felt that this behavior might have showed continued im-
provement. Overall, it would appear that with some slight
changes, the SM and SR programs would be a good possibility for
promoting behavior changes in Doug.

Personal Data Analysis

 

The personality differences among the three subjects and
their participation in the program will be considered in this
section. In reviewing all the statistical tests, Sue had six,
Bob two, and Doug four significant differences across treatments.

Despite the fact that this is not a large number for any patient, it

130

should be determined whether there are some readily apparent
differences between the personality characteristics of the
patients which might explain the differences in performance.
Tables 5-1 and 5-2 provide some points for consideration.

We note in Table 5-1 that the scores obtained on the locus
of control instrument differ only by 3 points. These scores
are very close to the average scores of 22 patients who had
previously taken the test. Based on the correlation of the
RAS to Rotter's Opinion Survey, the average locus of control
tended toward the external direction. This set of scores seems
to correspond to the observation found by Wendland (1972)
regarding the tendency of recently disabled patients to be
more externally controlled. This also seems to fit the idea
that those persons confined to institutions feel they lose a
certain amount of personal freedom. It iS~a little surprising,
given Seeman and Evan's (1962) findings,that Sue's scores were
in the external direction since she was very knowledgable and
interested in her condition.

The Self-Evaluation Questionnaire, the state-trait anxiety
inventory, results (Table 5-1)shows that Bob claims the least
amount of state anxiety while Sue had the least amount of
general or trait anxiety but the highest variability within
state scores. This corresponds very well with observed be-
haviors that Bob was low keyed and Sue was highly emotional.
Doug scored the highest on both subscales, as might be expected
considering his youthful age and his physical condition. He also
scored slightly higher on both subscales than did 15 other

persons in the Center tested on the same measure. Again,

131

Table 5-1

Comparative scores of the 3 patients on each

of 3 tests administered

 

Avg.Pt.
Sue Bob Doug Data
REHAB. ATT.
Survey
(Locus of Control) 17 16 14 14.5(22)
STAI
Average Scores 32.6/ 30.0/ 34.5/ 33.93/
(S/T) 23.50 31.25 39.75 38.26
(6) (4) (4) (15)
STAI 20-48 31-43 30-43 20—61
Range 23-25 25-44 37-46 21-54
EPPS: (percentile)
Ach 88 29 37
Def 27 52 25
Ant 4 70 77
Sue 46 50 63
End 32 l 3

Age
(4) Refers to number of completed protocols

 

76

Table 5-2

96

L
‘1

Average Staff Rating of Patient Activity Level

 

Avg.Pt.
Sue Bob Doug Data
BEHAVIOR RATING
Scale Score 32.25 21.25 28.50 22.54
Total Rank 2/13 8/13 4/13 (19)

( ) Refers to number of completed protocols

132

considering his age, his physical status, and uncertain prog-
nosis, this higher level of anxiety may be quite understandable.
It is interesting to note that these scores in general reflect
a lower average than the norms presented for the STAI. This
seems a little unusual, but may in fact reflect the attitude

of the center, the nature of the Center, or a very unique
relaxed group of people.

The Edwards Personal Preference profiles provide probably
the most helpful information. The data are interesting,
particularly as one looks at Bob's and Doug's scores on the
Endurance, Autonomy, and Achievement subscales where we see
very low scores on Endurance, but high on Autonomy and Achieve-
ment. In the same test, Sue's Endurance and Achievement scores
are much higher than Bob's and Doug's. It would be expected,
and was noted, a greater involvement and participation in her
treatment program which may help to explain her overall in-
terest in her program.

The results on the Incomplete Sentence and Research
Questionnaire seem to parallel the researcher's subjective
feelings about the patients in the study. Sue and Doug both
responded with comments which reflected a high level of under-
standing and feeling of interest with the experiment. Bob's
Incomplete Sentence test showed a great deal of disenchantment
with some of the concepts of the study like having "observers"
or "self-reward contracts" and an overall feeling that the
study was not particularly beneficial to him. His Research

Questionnaire results supported this attitude.

133

Finally, on the Patient Behavior Rating Scale (Table 5-2)
we find a total of 13 distinct ranks. It is noted that Sue
was rated by the staff as more active than all but one other
patient in the center. Doug ranks 4th out of 13 and Bob ranks
8th. This would seem to confirm that Sue was a very motivated
patient and a hard worker. Doug was somewhat less motivated
and Bob ranks in the lower half in terms of his activity level.
This again corresponds with the subjective rating of the par-
ticipants in the study. Sue, by far was most cooperative and
interested, with Doug less committed, but still considered
interested. Bob, on the other hand, seemed to pass the
research tasks and concepts off as meaningless.

The personal data collected provides some information
about the types of persons involved. All tended to think
others had some control of their reinforcers. Sue appeared
far more goal oriented and willing to stick to tasks than
did the two males in the study. In addition, it appeared
that although Sue was more excitable, she showed a consistently
low trait anxiety profile throughout the study. The varia-
bility in scores presents interesting and thought provoking
questions. Because of the small sample, further analysis
would not be useful, although these basic observations can

only provide the basics for further investigation.

Chapter VI

Summary, Discussion, and Implications

This dissertation attempted to extend the theory regarding
self-directed reinforcement programs to the medical rehabili-
tation setting. Applying the intensive case study approach to
a multiple baseline design, four hypotheses were tested. The
first question asked was whether the utilization of auto-
recording (SM) of selected patient behaviors affected the
occurrence pattern of the behavior over a pre-treatment
baseline. The next questions tested whether the utilization
of self-directed reinforcement program (SR) for the same
behaviors caused a change in the behavior pattern over a pre-
treatment baseline period and the self-monitoring period.
Finally, the question was addressed whether the SM and SR
treatment effects produced any long-term effects on the
behavior as measured by comparing the pre-treatment baseline
period with the post-treatment extinction phase.

Three patients were selected for the study from the total
adult and young adult inpatient population of Mary Free Bed
Rehabilitation Center, a comprehensive medical rehabilitation
center in Grand Rapids, Michigan. Each patient was asked to
define his/her goals for treatment with the rehabilitation
staff. Based on these goals and other behaviors noted, three
behaviors were selected by the researcher which could be
measured and observed during the study. In two individuals,

a single behavior was divided into two component parts resulting
in a total of 11 observed behaviors.

134

135

The multiple baseline procedure began with external
monitoring of the three behaviors of the three patients for
a 9-calender-day period without informing the patient of the
behaviors being observed. The patients were then told about
one behavior which was being observed. They were instructed
in the process of auto-recording and asked to monitor this
behavior themselves for 9 calender days. Once this 9-day SM
period was completed a second conference was held with the
patient to establish a standard for that behavior for the third
9-day segment. The patients were asked to decide on some rein-
forcement directly under their own control and which they
were willing to administer pending their accomplishment of
the established standard of behavior. At the same conference
the patients were introduced to Behavior 2 and the self-
monitoring technique for that behavior.

After the third 9-day period, the patient was placed on
an extinction program with no standard required and no rein-
forcement related to performance of the first behavior. At the
same time the patients were informed of the 3rd behavior being
observed and asked to monitor their performance on that
behavior. A standard and a reinforcement for successful com-
pletion of behavior 2 was also established at this time.

Again, after 9 days, a conference was held with the
patient and researcher. At this conference behavior 2 was
placed on the extinction program and standard of acceptable
performance and suitable self-controlled reinforcement
selected for behavior 3. Finally after 9 additional days (or

45 cumulative study days) the patient was told there was no

136

further need for monitoring or rewarding performance of any
behavior, although external observations continued 9 days more.
Fifty-four calendar days were used by each.subject and the
entire study took 79 days to run.

The statistical analysis applied to the behavioral data
utilized a trend analysis of the median slopes of each separate
period. This technique projects the trend line of the
accumulated data points into each succeeding time period with
the binomial test applied to each set of data. By comparing
the actual dispersion of the data with the projected data, a
test of the significant differences was calculated across
treatments within each behavior. By comparing results across
behaviors some implications were derived.

Summary of Results

 

The statistical analysis of the results showed no partic-
ular consistency in terms of the four tested hypotheses. There
seemed to be a trend in that those behaviors which traditionally
occured in the participant's life, things such as timed acti-
vities,were more influenced by the self-monitoring process.
Those activities which traditionally did not need to occur in
the person's life, such as specific exercise programs, were
more positively affected by the self-reinforcement. Those
activities for which there was an immediate reinforcement pre-
cluded the need for self-reinforcement. The overall effect of
the total treatment from a dynamic analysis standpoint showed
that the treatment was significant for one behavior of one

individual. Further analysis of the dynamic trends however,

137

seemed to provide some explanation for the lack of significant
differences post-treatment when compared to pre-treatment
baselines. The lack of significance seems to be attributed

to the lack of baseline stability and the physical plateau
effect, wherein the individual physically reached the maximal
performance level.

The assessment of the descriptive data that was collected
showed that the patients tended toward the external locus of
control, with major differences on the personality measures.
The outcomes on the external measures seemed to correspond
to the researcher's subjective opinion. The participant's
selection of reinforcers also seemed to be closely related to
the performance on the corresponding behaviors. Those rein-
forcers which were regularly utilized prior to the study seemed
to provide the greatest incentive during the SR phases in the
study as well. Those reinforcers that were casually suggested
or not meaningful produced little behavior change.

Discussion

 

In reviewing the procedures and results of this study, there
are several issues which need further exploration. These issues
relate to the theory as applied in the study, the method of
conducting the study and the overall results of the study. It
is anticipated that a review of these issues will aid in the
interpretation of the study results.

At the outset, a major issue relative to the premise under
which the study was conducted needs clarification. All of
the patients in the study were told they were part of a research

project. Although the behaviors selected were for the most

138

part directly related to the patient's rehabilitation treatment
program, the entire process was seen by the patients more as

a research project than a method of patient treatment. As

the patients moved from one phase to the next in the study

they were informed of the change in that manner. The instructions
for each new phase were generally couched in a stage-like man-

ner as Opposed to being related to changes occurring within a
monitored or rewarded behavior.

Given this type of orientation a slightly different eval-
uation of the overall results might seem possible. In particular,
one might question the liklihood of the direction of Hypothesis 4
as it was stated. This hypothesis anticipated an extinction (E)
period performance at a better level than the pre-treatment
baseline (B) performance. Since the patients were told they
no longer needed to record or reinforce the behavior during the
(E) period, one would speculate that this might serve as a cue
for them to drop the technique employed. In this case, then,
the results which showed a drop in performance level after the
SR period would confirm a treatment effect as much as an in-
crease after a no-treatment baseline (B) period. This seemed
to occur with some regularity as previously noted, and adds
credibility to the effectiveness of the treatment.

Along the same line of the procedures used in the study,

a review of the system employed during the study shows that,

in fact, there was a diversion from a true self-control process.
At the outset, although the patients were asked to state their
respective goals for treatment, they had no choice in the spe-

cific behaviors chosen related to the goals. Although the

139

rationale for not allowing this choice is somewhat defensible
in terms of the questions addressed and the control desired
in the study, further research is needed wherein the patients
have options on behaviors they might wish to improve upon or
change. Furthermore, if the self-control process is to be
most effective, it would seem reasonable in a study of this
nature to give the patients free rein in decision-making about
when they might be ready to move from one phase to another.
At some arbitrary point later in the study, the researcher
might indicate that although the data collected to that time
was sufficient for the research project, the patients could con-
tinue to monitor the behaviors or reinforce appropriate levels
of the behavior as long as they wished. An external monitoring
system could continue to monitor the behaviors into this extinc-
tion phase. It would seem in this case that a control behavior
might be selected and externally monitored throughout the study
or one might consider concentrating on one behavior at a time
through all phases before initiating another behavior into the
study. This, of course, is the multiple baseline approach as
used in this study but extended over a longer period of time.
Related to this issue of self-control, another interesting
and intriguing question is the value of the behavior to the
person and the continuation of that behavior over time. In a
rehabilitation setting, this becomes a crucial question in that
patients are daily learning the extent of the limitations im-
posed by their disability and are gradually adjusting themselves
to these limitations. Therefore, a goal or behavior chosen

early in the rehabilitation process may become meaningless

140

as the patient realizes the extent of the limitations or as

the behavioral goal is accomplished. In this study there were
some goals stated by the patients which became valueless as the
project continued simply because the physical re-development

did not occur as wished. In this case, behaviors related to the
accomplishment of the goal became valueless and interest was

soon lost in performance of the behavior. In other cases, the
patients accommodated themselves well to the goals and the re-
lated behaviors became meaningless when the goals were accom-
plished. This might have been more of a problem had the patient
selected specific behaviors at the outset of the study as opposed
to goals. Since the behaviors chosen were related to the stated
goals, but also related to other implied goals,realization of

the goal or the inability to reach the stated goal did not
entirely diminish the value of the related.behavior. Nevertheless,
future studies must contend with this issue of the meaningfulness
of the behavior chosen for self-control when assessing the effect
of self-control techniques.

Still another issue to consider in the development of this
type of study is tied in to reinforcements. It has been stated
earlier that reinforcement is considered in two separate con-
texts in this study. The first, self-reinforcement, is directly
related to the act of controlling specific reinforcements
obtained as a result of maintaining an acceptable standard
of behavior. The second, locus of control, is related to the
individual's perception of whether such control actually exists.
In implementing a self-control program it seems imperative that

the entire staff must be made aware of the self-control process

141

from self-suggestion through self—reinforcement. Incorporated
into this training is the need to train the staff in reinforce-
ment theory. If the patients are to be given responsibility

for their own behavior, it becomes imperative that the environ-
ment become reinforcing for these individuals. If, in fact,
self-control is seen as an effective means of promoting rehab-
ilitation behaviors, the staff must understand their role in
reinforcing the patient's behaviors related to self-control in-
cluding identification, monitoring, standard setting and rein-
forcement. This becomes especially important for consideration
for those individuals who perceive the locus of control as being
external, or not under their own control. These individuals
usually expect reinforcements from the external environment and
their behavior patterns are such that they solicit these rein-
forcements from significant others in the environment. The

staff must be made aware of this potential behavior pattern of
the patients and must be taught that reinforcement of appropriate
attempts at self-control is an important adjunct to the devel-
opment of an internal locus of control and self-directed behavior
change.

Finally , a comment is in order with respect to this study
in relation to the comments by Friedlander (1974) and Wright
(1972) discussed earlier. One of the qualifying reasons for
conducting a study in self-control in rehabilitation was based
on the practicality for patient care and applicability for ex-
isting staff to use. It is felt that applying the principles of

self control in a medical rehabilitation center is both prac-

142
tical and applicable. The advantages provided to the patient
include the prospect for more time actively spent in therapeu-
tic activity outside of the regularly scheduled therapy sessions,
the potential for a shorter stay and reduction in treatment cost.
For the staff, the practical applications of the self-control
ideology seem obvious. The staff can spend more time on actual
instruction in therapeutic procedures rather than a much more
time consuming treatment observing. By teaching many of the
patients the skills of self-control, the staff hypothetically
should have more time to spend in the establishment of self—
reinforcement contract contingencies with the patients, and should
then have more time to spend with the more severely disabled
in the treatment setting. In this way the staff can become
coordinators of patient activity as opposed to the primary care
specialist they function as now for every individual patient.
This would seem to promote effective time and energy utilization
in the medical rehabilitation setting especially when time is
limited and funds equally limited.

Limitations pf the Study

 

 

Despite all the careful planning for a study such as this,
several unplanned for problems occurred. There were some dif-
ficulties which need comment for the benefit of those who might
wish to replicate the study.

A problem which was described on several occasions is that
associated with the trend of the baselines of several of the
behaviors. White (1972, a) described a baseline period as
ideally that "condition in which data collected during a spe-

cified period of time reflect stability and or predictability

to a degree which allows . . . changes to be discriminated" (p. 11).

143

In this study the baseline periods often reflected a
trend which precluded the likelihood that any significant
differences would occur. That is, had the researcher ex-
tended the baseline in some cases until the behavior stabilized,
the test for effects due to treatment might have been more
meaningful. A5 White notes, however, extending the baseline
does add time to the study which often is not permitted within
a particular study.

A second potential difficulty encountered in the study has
to do with observer anonymity and unobtrusiveness. Because
of the physical structure of the rehabilitation center, it
was often impossible for observers to remain out of the line
of sight of the patients. This was particularly a problem
with Bob. His reaction to having someone tag along to watch
whether he performed his behavior was that it was a relatively
juvenile experience. The use of fellow patients on the nursing
ward to observe did not work either, since so many patients
had varying schedules and their skills of external monitoring
were questionable. The use of staff for monitoring or counting
was found, by direct experience, to be unpredictable. In
addition, with the daily presence of observers in a relatively
stable hospital-like environment, the patients soon became
aware of the relation of the observers to the study.

A third problem in this study has to do with the method
of including the staff in the study. Only three staff members
were directly involved to any degree, two orderlies who
usually cared for Bob and were informed of Bob's exercises

and recording needs and one OTR who worked with Bob and Doug

144

eSpecially on their OT behaviors. It was unfortunate that the
staff in general were unable to follow through on some of the
specific observations or recording of behaviors. Having this
option might make the observation process a little less
noticeable and perhaps make the staff slightly more aware of
the benefits of this type of program and behavior level of

the patient. In addition to the monitoring issue, additional
training of the OTR in the principles of self-reinforcement
and standard setting would be an example of a necessary im-
provement in the study.

Another basic improvement in this study would have to do
with establishing a better self—monitoring program, particu—
larly with the more physically involved patients. Not only
does the method of staff presentation of non-intrinsically
reinforcing behavior requirements (range of motion eXercises,
for example) need improvement, but so does the method of
recording the activity. Perhaps some sort of stamp or other
method for recording which involves gross hand functioning
rather than fine finger dexterity would increase the patient's
interest in the behavior being observed and might influence
the accomplishment of the behavior. Furthermore, having the
chart readily visible to the patient also provides a subtle
but effective reminder to patient (and staff) for specific
behavior cues.

Finally, as we noted in the procedure section, this study
was designed to test the effects of SM and SR on selected
patient behaviors. Because of the small number of patients
used, the results can not be generalized to the patient popu-

.knion as a whole. Hence, the results of this study can be

145
used only to stimulate further questions and research. They
can in no way be used to describe the effects the treatment
had on the total medical rehabilitation population.

Implications for Future Studies

 

The kinds of data obtained in this study raise several
questions which could form the basis for future studies in
the field of rehabilitation. The data gathered in terms
of the day-to-day patient observations, the personality
characteristics of the patients and the effects of the treat-
ment, the characteristics of the patients and their rehabili-
tation activity expectations, the differential effects of
the SM and SR treatments for specific behaviors all seem to
be worthy of further study.

For example, one could hypothesize that an internally
controlled patient might perform very differently under a
self-directed reinforcement program than would the externally
controlled individual. Although it is questionable how many
inpatients in a medical rehabilitation setting feel they have
control over any reinforcers, the different outcome anticipated
from an internal and externally controlled patient might well
be worth exploring, however,as Bellack (1975) also noted.

Another interesting phoenomenon in this study was the
extremely low scores obtained for both male patients on the
endurance subscale of the Edwards Personal Preference Survey.
One might speculate on the overall profile of the EPPS for an
inpatient medical rehabilitation population and the differences
that might occur between medical rehabilitation patient norms
and the general population norms and what effect this might

have on the treatment program of the patients.

146

A third question which might be addressed in future studies
has to do with the issue of observable goal attainment and
therapeutic activity. That is, if patients seldom, if ever,
see any increase in strength, endurance, or overall ability
because of their specific treatment regimens, one must question
the likelihood that the related behaviors will continue to be
produced. On the other hand, if the patients were filling in
a chart daily showing their progress in the ability to perform
some activity which in and of itself seems to have no value,
immediate reinforcement of seeing that they can exert 14 pounds
of pressure instead of 12, that they can place 16 pegs in
small holes in 19 minutes when a week before they could only
do 8 in the same length of time might seem important. The
need for immediate concrete feedback to the patient in all
phases of medical rehabilitation seems absolutely essential
if the patients motivation is to be raised. Considerable
more work needs to be done in this area.

As the study results showed, the use of self-monitoring
techniques seemed to be a sufficient incentive for the
patient to improve those behaviors for which there is an in-
built reinforcement. At the same time SR was shown to be
more effective in changing those behavior patterns for which
there was no immediate specific or measurable result as an
outcome of the activity. This seems to be perhaps the most
meaningful outcome of the study. Further study might Show
that for those behaviors for which there is a reinforcement
obtained as a direct result of performing the behavior, self-

monitoring may be the only necessary tool to change the likelihood

147

of that behavior. On the other hand, those behaviors for
which there is no direct reinforcement may need a self-
administered reinforcement program to maintain the behavior.
This would be an extremely worthwhile study and would add
substantially to the work being done in the field of self-
controlled behavior.

Finally, in the light of these study results, it seems
as though carefully designed SM and SR treatment programs do
seem to influence patient activity levels. It is quite
clear that the SM activity could promote more independent
activity for the patient. A SR program should be the result
of a combination of the review of previous performance levels
and the application of the contingency management concept for
rehabilitation activity planning. With the results and
recommendations of this study in the field of medical reha-
bilitation, it would seem that if patients could internalize
and practice the art of self-controlled behavior the nature
of the work of each rehabilitation staff member would change
dramatically. The patients would seemingly demand less
attention from the staff thus allowing the staff the oppor-
tunity to more selectively reinforce appropriate behaviors
while assisting the patients in establishing self-reward
contracts and teaching new, related behaviors.

It seems that the potential for the application of the
technique of self-controlled behavior modification has
potential benefits for the population of medical rehabilitation

patients. Undoubtedly it will not be an easy system to

148

inaugurate in any treatment center, since the concepts of
"patient" and "medical staff responsibility" and "patient
independence" are often antithetical in nature. The staff's
needs for patient dependence and the traditional dependency
roles of the patient will be the major hurdles to overcome in
establishing what could be a very innovative and invigorating
approach to rehabilitation medicine. It is hoped that this
research will form the basis for further work in the appli-
cation of self-directed behavioral principles in rehabilitation
and the increased level of understanding of behavioral science
principles on the part of staff and patient alike.

In Retrospect

 

Having completed this research it is imperative that some
general feelings be shared. The process from idea germination
through design considerations into the actual study was a long
and frustrating one. Conducting the actual research was un-
doubtedly the most rewarding in that the participants and
staff provided a considerable amount of positive reinforcement
in terms of their overall interest in the study and cooperation
in the daily details. The analysis of the data although
challenging was somewhat frustrating in that the problems as
they have been noted began to influence the results and made the
outcome appear less satisfactory than when first conceived.
Nevertheless a sense of pride exists now that it is all over
and the product is complete.

The initial feelings about the potential for self-controlled

behavior have been solidified through this experimental program.

149

It appears that by the development of appropriate self-
monitoring techniques and the careful application of appro-
priate and meaningful reinforcers a wide variety of medical
rehabilitation inpatient behaviors can be brought under the
direct control of the patients themselves. The skill of the
individual staff in encouragement of independent activities
rather than the reinforcement of dependent patterns of behavior
will make this kind of program most appropriate in a medical
setting. For many it will mean a massive change in perception
of health care roles; for some it will mean a welcome relief
from the frustrations of dependent patient patterns. Most
importantly it will mean a personal challenge for the_indi-
\ddualswdth a disability to begin to apply again the principle
of being in control of their own destiny as they carry out

the daily activities of their rehabilitation.

REFERENCES

150

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APPENDIX B
FORMS

170

B - 1
SCHE THOUGHTS ON BEHAVIORAL OBSERVATION

ATTENDANCE: It is absolutely essential that records be kept DAILY of patient
behaviors. It is imperative that someone be able to observe the behaviors on
a scheduled basis. If you are unable to meet your scheduled observation period,
notify me as soon as possible!! (office: 459-2837: Home: 949-8957)

ACCURACY: Accurate reporting is essential for this study. It is very easy to
allow your mind to wonder as you observe others, especially after the first
few times. Concentrate on the assignment at all costs, since inaccurate observ-
ations will make the study useless.

INTERACTION: In many cases it may be very tempting to interact with the persons
being observed. Interaction is fine AS LONG AS it doesn't detract from the
occurrence of the observed behavior or in any way influence it. The change
in observations then is not because of the individual, but because of what
you did (and that's a "no-no").

UNOBTRUSIVENESS: If at all possible, make yourself a 'wallflower' while you are
observing. Make the recording instruments as inconspicuous as possible. Using
paper and pencil to record tally marks is as legitimate as counting with a
counter, and is even better if the sound of the counter is too noticeable.
Mingle with other patients if necessary to get a better position to observe.

RECORDING: Always record your observations BEFORE TURNING YOUR COUNTER OR WATCH
back to zero.

OBSERVE THE TIME: In addition to accuracy, time will usually be a majoy factor
to be observed. If the time for observing is from 7:00—7:30, please make sure
that you observe that time!

RESEARCH JOURNAL: Note any particular things which seemed to affect the observed
behavior, such as a specific activity which prevented the occurrence of the
behavior, or any other unusual activity going on at the time.

TIME KEEPING: Keep a log of the time you spent for reimbursement purposes.

QUESTIONS: Don't assume anything in this project. If you have questions about
anything, ROLLER RIGHT AWAY! To delay may be costly, either in terms of
inaccurate reporting or inaccurate observing. Stay in touch and don't feel
embarrased...I'LL be embarrased if the data isn't right when I present it for
my doctorate!

Thanks for being the help I know you will be to me. This is an important project

for me and your help will be most important!

171

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172 page #

B-3 RESEARCH JOURNAL

DATE COMMENTS

 

 

APPENDIX C
INSTRUMENTS

173

-1
C REHABILITATION ATTITUDE SURVEY

TO THE PATIENT: The following statements are not a test. There are
no right or wrong answers. We are asking that you respond to the
statements as you feel about them. Your answers will be anonymous
but will help the staff at Mary Free Bed to understand hOw patients
feel about things. To answer, just put an X through the "T" if you
agree with the statement or through the "F" if you disagree.

T F 1. American hospitals would be in much worse shape if it
not for the trained medical staff they have.

T F 2. I am proud when I do things for myself.

T F 3. Others usually know what is best for me.

T F 4. Knowing what is happening is not important in treatment.

T F 5 There is a direct connection between how hard I work and

the progress I make in therapy.
6. A good patient is one who does what the staff tells him.
7. I have often found that what is going to happen will.
8. My return to health is entirely in the hands of others.
9. I feel nervous when asked to make decisions about treatment.
Knowing what my problem is helps me to manage my program.
11. I am afraid of doing too much in therapy right now.
12. If given the Opportunity to control my life, I would accept.
13. I am totally at ease with my present situation.

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14. At this moment I can change the extent to which my disability
affects me.

15. I am not sure that the patient care team will do what they
are supposed to do.

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’11

T F 16. "Eat, drink, and be merry for tomorrow who knows" reflects
how I feel right now.

T F 17. I feel that the nurses know what is best for me.

T F 18. Right now I feel there is nothing whiCh can help me to
do things any better.

I F 19. I feel that I am able to control my treatment program.
T F 20. I am regretful about what has led me to my present situation.

I F 21. Trying to control what happens to me right now doesn't
seem to be paying off--it's hardly worth the effort.

T F 22. Being able to know ahead of time what will happen in
therapy doesn't affect how well I do.

T F 23. A good patient is one who makes sure the staff understands
his situation even though the staff may find it annoying.

I F 24. Many of the unhappy things in peoples lives are partly due
due to bad luck.

AGE

C-1
25.
26.

27.
28.
29.

30.

31.
32.
33.

34.
35.

36.
37.

38.
39.

40.

174

Right nOw I feel that I am in control of my life.

It is important for me to know where I am, what is
happening and what may happen in any circumstance.

I am most pleasant when allowed complete freedom of activity.
I feel tense about what is happening in my treatment.

Knowing what my problem is cannot help me to manage my
program any better.

I feel most content when I am permitted to make my own
decisions.

I feel totally to blame for what has happened to me.
No matter how hard I try I cannot improve my condition.

Most patients don't realize the extend to which their
rehabilitation is influenced by accidental happenings.

I prefer to have the staff tell me what to do.

Trying to control what happens to me isn't worth the
effort, it doesn't pay off.

Right now I feel totally helpless.

Where I am right now is a function of my own doing--1uck
or fate has little to do with it.

I get jittery feelings when asked to think about my future.

Trying to change any part of my program is useless,
patients opinions don't really seem to count.

In the long run, patients are in control of their program.

SEX DIAGNOSIS

 

 

C-Z

Patient's name

Rater's name

175
PATIENT BEHAVIOR SCALE

Unit Date

Title

 

Indicate by placing an x before the statement which is most indicative of the
above named patient for each of the following comments, based on your observations
of the patient.

1. The

The

2. The

The

3. The

The

4. The

The

5. The

The

6. The

The

7. The

The

8. The

The

9. The

The

10. The
The

11. The
The

12. The
The

13. The
The

14. The

The

patient
patient

patient
patient

patient
patient

patient
patient

patient
patient

patient'
patient'

patient
patient

patient
patient

patient
patient

patient
patient

patient
patient

patient
patient

patient
patient

patient

or activity

patient

follows treatment recommendations.
seldom follows treatment recommendations.

seldom needs prodding to get activities done.
usually needs prodding to get activities done.

rarely requests help more often than is necessary.
often requests help more often than is necessary.

follows directions for treatment.
does not follow directions for treatment.

works for extended periods of time on tasks.
fails to work on a task for any reasonable period.

5 attitude is usually positive.
3 attitude is usually poor.

abides by hospital rules and regulations.
violates hospital rules and regulations.

seldom becomes upset by failure or lack of progress.
often becomes upset by failure or lack of progress.

usually complains about tasks that are given.
seldom complains about tasks that are given.

works constantly on therapeutic activities.
rarely works on therapeutic activities.

reports regularly for appointments.
often fails to show up for appointments or is late.

sometimes says or does things that are self-defeating.
rarely says or does things that are self-defeating.

is usually friendly and agreeable.
is often unfriendly and disagreeable.

never comments in an uncomplimentary manner on the work
of the staff.
frequently comments in an uncomplimentary manner on the

work or activity of the staff.

15. The patient often speaks to others.

The patient rarely or never speaks to others.

The patient takes pride in the progress of therapy; that is, shows
progress or talks about progress to others.
The patient takes no pride in the progress of therapy; that is, shows

nothing to others nor talks about progress to others.

Behavior Scale, page 2 176

17. The patient pays attention to the therapy and progress of others.
The patient pays no attention to the therapy and progress of others.

18. The patient makes no worthwhile suggestions about treatment.
The patient makes some worthwhile suggestions about treatment.
19. The patient seldom accepts constructive suggestions from the staff.
The patient usually accepts constructive suggestions from the staff.
20. The patient participates in the activities around him.
The patient rarely participates in the activities around him.
21. The patient often volunteers information which is helpful.
The patient never volunteers any information which is helpful.
22. The patient is usually interacting with one or more patients.
The patient usually spends time alone.
23. The patient rquests to follow through on ward orders.
The patient ignores ward order recommendations.
24. The patient often plays cards, games, etc. with other patients.
The patient rarely plays cards, games, etc. with other patients.
25. The patient initiates activity for themselves.
The patient waits for others to start him on an activity.
26. The patient is usually playful and good humored.
The patient is seldom playful and good humored.
27. The patient is usually busy with something.
The patient seems to have a lot of inactivity.
28. The patient seldom becomes upset if something doesn't suit him/her.
The patient often becomes upset if something doesn't suit him/her.
29. The patient takes pride in personal appearance.
The patient takes no pride in personal appearance.
30. The patient asks for things to do when not occupied.
The patient never asks for things to do when not occupied.
31. The patient does not have to be pressured to get to appointments.
The patient has to be pressured to get to appointments.
32. The patient never wants to lie in bed during the daytime more than is required.
The patient usually wants to lie in bed during the daytime more than is required.
33. The patient makes positive suggestions when problems arise.
The patient seldom makes positive suggestions when problems arise.
34. The patient seems interested in nothing.
The patient seems interested in everything.
35. The patient does not need to be directed to an activity.

The patient would sit all day if not directed to an activity.

Name

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

177

INCOMPLETE SENTENCES BLANK

 

Complete these sentences to express your real feelings about the

study you have been part of while a patient at Mary Free Bed.

sure to make a complete sentence.
The study I was part of
Rewarding my own behavior
During the study
The whole idea
Charts and graphs
Keeping a daily record of behavior
I don't think
Making deals about my behavior
My greatest desire
The thing I would like to do
Observers
Self-given rewards
Observing and counting
Three goals I have
I feel
The thing I liked best about the study
Sometimes
I am very
I do best
What pains me
The only trouble
If I had a chance
Now that it's over
In the future

I want to know

Be

Name

True

True

True

True

True

True

True

True

True

True

True

True

True

True

True

c-4

False

False

False

False

False

False

False

False

False

False

False

False

False

False

False

1.

10.

11.

12.

13.

14.

15.

178

RESEARCH QUESTIONNAIRE

Date

The following statements are to be answered either True if you agree or
False if you disagree.

They are related to the study you were part of.

Just recording the amount of a certain behavior I do helps to
make me do the behavior better or more often.

By requiring that I wait to do something I like to do until
I do something that is required or suggested will probably help
to make the required behavior happen more.

Rewards are something which we only get from others, we can't
give ourselves rewards.

I felt that keeping a record of the number of times or amount
of time I spend doing something was not important to me.

The idea of rewarding my own behavior meant that I should do
a certain thing before I could do something I would rather do.

Giving myself a few minutes rest in therapy for every so many
minutes I worked in therapy would be an example of rewarding
my own behavior.

I felt I understood the "Self—Reward Contracts" I made during
the study.

I felt that the behaviors I watched for the study were related
to my goals I had for myself.

I don't see how “making a deal with myself" will help me to
change how much I do of some behavior.

I don't need to "make a deal with myself” to do something I
don't particularly want to do, but which is important.

Having a snack, smoke, or some other enjoyable thing BEFORE
doing some recommended behavior will increase the possibility
that I will do that behavior later.

I was interested in what the study was all about.

I feel the Self-Reward Contract assisted me in doing more of
the behaviors than I would have done without any contract.

Having observer(s) around was the main influence that made me
do the suggested behaviors rather than my own incentive.

I might use the idea of a Self-Reward Contract on my own.

 

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