11. A Hypothetical Case Study in Interaction Therapy
In an effort to illustrate the mechanics of the interaction therapy approach, a hypothetical case study follows. (The reader who prefers actual case material should consult Appendixes 6 and 7 for verbatim transcripts of the first session with the R family and with the K family.)
In our hypothetical case study, the therapist receives a request of service for Greg, a 10-year-old child. The mother is on the telephone and wants the therapist to see the child alone. The covert, or even overt message is that “Greg is sick, and the rest of the family is not.” At this point, the therapist explains that in order to deal with Greg’s problems, it is very important to have both Greg and his parents participate in the therapy sessions. (Had the main presenting complaint been deviant behavior between Greg and a sibling, then the sibling would also have been asked to participate in the therapy sessions.) The usual response, with varying degrees of reluctance, is that the three of them will come to the initial session.
The therapist in interaction therapy only works with the “identified child client(s)” and the parents. The rationale for this approach stems from this investigator’s experience in observing the unwillingness of the identified child’s siblings to participate positively in the therapeutic process. This unwillingness of the siblings is usually due to their lack of motivation, by a prior conditioning process, in helping the identified child client and also due to the siblings’ low priority for helping Greg, as opposed to some “fun” experience, e.g., “missing out” on a baseball game or going swimming, by having to attend a “boring therapy session to cure crazy Greg.”
The initial session starts, as explained previously, with Greg and his parents. The therapist asks these family members what brings them there, in order to elicit the information necessary to establish the nature and extent of the problem behavior(s). The parents usually respond with statements such as “Don’t you have the information on the chart?”; or by responding more directly and giving some “abstract” or generalized set of complaints, e.g., “Greg doesn’t listen, doesn’t pay respect, steals from us, cuts classes all the time, should do his chores without having to be told a thousand times, is driving us up the wall, has to learn to behave.” These complaints about Greg are termed as “abstract” or “generalized” because they do not refer to specific, objective, and clearly observable behaviors, but rather comply with parental attitudinal variables. As in any other behavior therapy intervention, the first goal of the therapist is to assess what the situation is by ascertaining what the antecedents or consequents are that are probably or likely maintaining the deviant behavior(s).
After the therapist has spent some 20 to 30 minutes gathering the baseline data while listening to complaints, and consequently reinforcing this inappropriate or deviant behavior of the clients by the mere act of the therapist’s listening to the complaints, then the therapist proceeds to the next step. The next step in this process is to summarily ascertain the motivation for change on the part of each of the clients. This assessment of the motivation is done by simply asking each of the family members the following or similar questions: Are you interested in working towards making this a happier family? Are you willing to compromise, and even sacrifice, in order to make this a happier family? If all the clients involved respond affirmatively (this investigator has yet to experience a family member’s “no” response), then the therapist proceeds to the following stage.
The next stage of the process involves a modification of the approach used in reaching contractual agreements by Jacobs (Note 5). The contracting technique, as presently used by this investigator, begins by giving the family members paper and pens: a set for the parents, and another for Greg. These family members are asked to enumerate five, highly specific behaviors that Greg would like to see his parents change (Greg’s task), and that Greg’s parents would like to see Greg change (parents’ task). The therapist explains to the family members that what they write down may include: (a) behaviors that are to be decreased in frequency; (b) behaviors that are to be established; and/or (c) behaviors that are to be increased in frequency. Once the two lists of five behaviors each are compiled, all present in the session collaborate in the rewriting of the statements. This rewriting of the items is done so that each statement reflects and represents an unmistakable, objective, and clearly observable set of behaviors. This rewriting is a crucial step in the process of interaction therapy since it forms the basis for the items of the therapeutic exchange contract. Also the process of rewriting the statements is to be carried out without discussion concerning the causes or the content per se of the statements. As an example, the task of rewriting “don’t get loaded” would preclude discussion on the effects of alcohol, and on the reasons why the person has become conditioned, to a greater or lesser extent, to consume alcohol. Rather, the discussion is controlled and directed by the therapist in order to arrive, for example, at the revised statement, “Do not hit me when you are under the influence of alcohol,” or whatever the family member who advanced the statement would consider an important first set of behaviors to be modified in the resolution of the presenting difficulties.
The rationale for specifically precluding any discussion extraneous to the process at hand, namely, the behavioral specifications of objectives, is twofold: (a) to be efficient in terms of time, thus being able to deliver the full content of the first session in approximately 1 hr; and (b) to avoid any further, unintentional reinforcement, by the therapist, of the maladaptive verbal behavior patterns exhibited by the family members.
During the process of writing a contractual agreement in interaction therapy, a specific behavior is sometimes cited, such as “stop smoking,” that almost invariably gives rise to early failures in the therapy process. This situation of failure is basically due to the person’s inability to control, without a deconditioning process, highly reinforced behaviors. In such instances, this investigator has simply stated to the family members that the behavior is too difficult a target goal for the initial phase of the program. This investigator then elicits from the family members some form of compromise that can be successfully implemented, such as “don’t smoke in the bedroom.”
This investigator, on the other hand, has accepted items such as “don’t yell,” although this behavior has not been qualified as to specific times or circumstances. In such an instance, the therapist usually elicits some examples of past yelling experiences, between the family members, in order to make sure that all the family members agree on their conceptualizations of “yelling.” If there is no agreement among the different family members, then another definition of the deviant behavior is sought. If another definition is not found within a reasonable period of time, the behavior or statement is not included in the list for the contract presently being created.
Continuing the process to reach a contractual agreement, once the family members have their lists of five objective statements that have been rewritten so as to insure specificity, then the lists are exchanged. Greg receives the list that his parents wrote, and Greg’s parents receive the list that Greg wrote. The therapist then instructs the family members to choose three out of the five items from the rewritten list of behaviors that they are willing to change. Both parents must choose the same items, and both must be in agreement with which items they choose. Greg also has to choose three items from the rewritten list. If Greg were attending the sessions with a sibling, then the children would have to write and choose their items in unison, just as their parents did.
The therapist instructs the family members that the behaviors they choose can be the ones easiest for them to change, and also that the behaviors they choose are to be the ones that they agree to enact or to change for a period of one week, regardless of what the other family members’ compliance with the contract is. The therapist formalizes the contract procedure by requesting the family members to sign the individual contracts. At this point, the therapist also asks each of the family members to copy the three behaviors on which they have agreed to work on a 3″ x 5″ card that the therapist supplies and jokingly advises them that “the card is to be carried on their person at all times, except when sleeping or bathing.” Once the behaviors have been written down on the cards, the therapist collects and keeps their signed contracts. The next procedure is to have the family members share with one another which items they chose.
The rest of the first session is spent explaining to the family members the daily meeting, or family council, during which the family members are to assess their compliance with the contract, as well as to list all the positive or fun things that have occurred during each day. During the family council, which is to last approximately 15 minutes, the discussion should center on the assessment of each item of the contract. This assessment is to be carried out in an evaluative but nonjudgmental manner; that is, if the family members cannot agree on whether or not the behavior is being complied with, then that occurrence of the behavior is not to be included or tallied in that particular time period. The family members are instructed to the effect that the data thus collected during their daily meeting is to be entered on the Interaction Assessment Form. (The reader is referred to the Materials section of this study for a more comprehensive treatment of the Interaction Assessment Form and the instructions to be followed during the family’s daily meeting.)
Toward the end of the first session, the therapist reviews the different instructions to be carried out by the family members during the following week, and he/she makes the usual arrangements for the next visit, typically one week after the first session.
In the beginning of the second session, the therapist receives the Interaction Assessment Form, which has been completed as part of the family’s homework. The family members, at this point, often seem discouraged or disappointed, in varying degrees, with their own performance during the preceding week. To counteract the negative feelings the family members may have about their compliance with the contract and the program, the therapist gives these family members as much verbal, positive reinforcement as practicable, regardless of the actual levels of performance. If the family members performed any of the assigned tasks, then they receive full verbal, positive reinforcement. Typical phrases used by this therapist include: “Fantastic!” “I am very pleased with all of you!” “Very few families get so many pluses in one week!” “As a matter of fact, I can only recall three families that have been able to do as well!” This intervention of the therapist gets the family members ready to discuss the events that went well during the preceding week, as well as to talk about the fun or positive behaviors experienced by the family. Of course, the verbal, positive reinforcement by the therapist also reinforces compliance with the program.
To ascertain over-all feelings of the different family members, this investigator uses a bipolar scale from 0 to 10. The highest number in this scale, 10, indicates maximum satisfaction on the part of the individual family members with the over-all performance of the family, or with any more specific behavior.
The second part of the session is spent dealing with any difficulties the family members may have experienced during the preceding week. For example, an item in the contract, or a procedure, may still require further explanation or some specific technique of behavior modification may be necessary to use. This latter would be the case if, for example, Greg was not getting good grades at school, forgetting to do his chores at home, forgetting to make his bed, and fighting with his peers. To this effect, some technique of behavioral management can be implemented.
As an illustration, one such technique is a point system designed after the one described by Patterson (1971/ 1975), which can maximize Greg’s receiving some positive reinforcement for performing the desired behaviors, which in turn would condition (teach) Greg to produce the behaviors desired. Of course, the reinforcement Greg receives would be contingent upon his producing the desired behaviors or their approximation, as in any schedule of operant conditioning shaping with positive reinforcement. Also, the reinforcement would be graded in such a way as to give Greg more or higher quality reinforcement for a better performance.
An example of the application of this technique is provided in Appendix 1, where a contract sheet, modeled after Patterson’s (1971/1975) multiple behavior contract sheet, is used to record the target behaviors and the points for each, as well as the consequences for the total daily performance in terms of points. Such a program for Greg would entail: (a) the parents communicating with Greg’s teacher and requesting that the teacher give Greg a daily letter grade that best describes Greg’s performance, class preparation, and attention for each school day; (b) preparing a card on which the teacher can note Greg’s grade for the day; (c) allowing Greg to be responsible for this card: if he loses it or forgets to ask his teacher for a grade, then he gets an automatic “0” for his behavior that day (the parents would then proceed, in case of loss of the card, to prepare a new one); and (d) signing the contract (see Appendix 1) and posting it in a public place, such as on the family’s refrigerator door.
The data collected through such a behavioral contingency management program would be plotted in a graph such as the one found in Appendix 2. The plotting of this data serves as a visual indicator, both to the therapist and to the family members, of the effectiveness of the program.
Almost any technique of behavior modification can be implemented, on a need basis, in order to effectively modify deviant behaviors exhibited by children. This investigator has found that almost invariably some combination of a positive reinforcement technique with a mild aversive contingency can effectively curb or modify most behaviors. The specific techniques that this investigator has found most efficient include contractual agreements on behavioral contingencies such as the one previously described, and which appears in Appendix 1, and also the time-out from reinforcement procedure to be discussed.
Training in the time-out procedure, as practiced by this investigator, starts with a brief explanation of the procedure itself and proceeds, with (in this case) Greg’s cooperation, with a demonstration of its practical application. The parents also participate in the process by practicing the verbal behaviors required in the implementation of the time-out, while Greg practices the performance of the requests. The parents are given specific verbal statements to use, such as, “Greg, time-out, please, for 5 minutes.” Also after a time-out is completed, the parent is to say, “Greg, your time-out is over. Thank you.” This investigator suggests to the family members that the time-out should be given as soon as the deviant behavior is exhibited, and it should be carried out by Greg standing with his face towards a blank wall. In the initial stages of training, or when Greg seems to be “dragging his feet” to the time-out location, the parents are instructed to count, in a continuous manner “1001, 1002, 1003,” at which time the next contingency applies.
In such a case when Greg has not arrived at his prearranged time-out location, or when he is still producing deviant behavior during the time-out, the parent is instructed to state, “Greg, your time-out starts again, this time for 10 minutes. Thank you.” The aversive consequence is doubled (but only once).in order to increase the likelihood that Greg will comply with future first instances of the request. In the event that the doubling of the time-out period is not a sufficient deterrent of the deviant behavior, the parent is then instructed to state, “Greg, you are now in a 24-hour restriction. You may now leave your time-out area. Thank you.” The parent is further instructed to leave the area in order to stop reinforcing Greg’s deviant behavior.
The restriction procedure involves the prearranged withdrawal of positive reinforcers such as TV, soft drinks, chewing gum, desserts, or play for a period of 24 hours. During the restriction period, Greg may receive additional time-outs or start a new restriction, contingent on his exhibiting deviant behaviors. To prevent a possible abuse of the restriction procedure, which would in turn defeat its purpose, Greg’s parents are instructed to have an additional restriction start from the time that the most recent deviant behavior occurs and not after the present restriction is completed.
Examples of actual schedules of time-out from reinforcement can be found in Appendixes 9 and 19. The schedule found in Appendix 9 is an earlier version of the time-out procedure as used by this investigator. It was written by Mr. and Mrs. M, following the instructions of this investigator, and reportedly applied by these parents to all their children, although Kevin was their only child attending the therapy sessions. The schedule of time-out from reinforcement found in Appendix 19 was developed by this investigator to be used by Mr. and Mrs. K with their two children, Bob and Cathy. At the present time, this investigator is using the K family schedule of time-out with most families because of its ease in application.
Other techniques that have been used by this investigator in interaction therapy are the ones directed at resolving differences of opinion between parents and children by using verbal reinforcers, successive approximation (shaping), and/or graduated modeling (Bandura, 60 1969). As an example, Greg might want to buy an expensive toy, and his parents are not willing to spend the amount of money involved. In this case, the therapist would strive toward finding some solution that would be acceptable to all involved and, at the same time, help the family members learn through practice how to resolve issues of this nature, and similar ones.
One other effort can be made in helping family members, and especially parents, learn how to generate behavior modification programs on their own, without the direct aid of the therapist. The technique used by this therapist involves requesting the parents to mail order from the publisher Patterson’s (1971/1975) book entitled Families. This book explains to parents the application of learning-theory principles for the modification of children’s behavior in the family setting. By the time families receive this book (it is not available in bookstores), they have already had an opportunity to experience behavioral changes in the family, which in turn maximizes their reading and using the book by themselves. This approach is a reversal of the approach of most other behavioral family therapists, notably among them Patterson himself, and his collaborators at the University of Oregon and at the Oregon Research Institute (Patterson et al., 1975).
Termination of interaction therapy is less structured than any of the other stages of the process. Termination is usually quite dependent on how the family feels about whether or not they can successfully handle the daily variety of situations by themselves without further help from the therapist. It is also possible that the family may require periodic “booster” sessions to reactivate some aspects of the program. Another way to handle the process of termination is by staggering the therapy sessions in such a way that the family feels some support from the therapist, although the family members are doing the work mostly by themselves. Follow-up sessions are also scheduled to ascertain the effectiveness of the program and to determine whether the family members still report being satisfied with the situation in their family.
Most families are seen for a few sessions, typically making a maximum of about 12 sessions of 1 hr each that they are seen in therapy. Sessions are held at the therapist’s office. No other contacts are usually made (e.g., home visits), thereby keeping professional involvement almost par with the actual number of therapy sessions.
© 1976 Angel Enrique Pacheco, Ph.D., C.Psych. All Rights Reserved.
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