Reinforcement Therapy: Short Cut to Sanity?

EIGHT years ago, Jane S. listened numbly to voices from what she called the "optimological world." They told her to wear heavy clothing in summer, to avoid bathing or speaking to people and never to leave Illinois' Anna State Hospital. For 27 years, she had been considered an incurable schizophrenic. Today, Jane lives in a small town working as a companion to an elderly woman. She shows no sign of ever having been a mental patient.

Jane's rescue from the subhuman existence of a mental-hospital ward is one of several hundred dramatic improvements that have been achieved by a relatively new--and hotly debated --technique known as reinforcement therapy. Unlike psychiatric techniques which seek to deal with deep-seated causes of a patient's psychosis, reinforcement therapy concentrates on controlling and guiding everyday behavior. Its basic principle is that the residual signs of normality in an insane person should be encouraged by praise and applause--in effect, reinforced and taught with the help of tangible rewards.

Sugar-Coated. The principles that underlie reinforcement therapy go back to Russia's Ivan Pavlov, whose classic experiments with salivating dogs first proved that human and animal reflexes could be conditioned. His theories were expanded by the greatest living exponent of behaviorism, Harvard Psychologist B. F. Skinner, who demonstrated that rats, pigeons and even men are influenced by the consequences that their actions have. This principle, the reinforcement therapists insist, applies also to mental patients previously thought to be beyond psychiatric help.

In one early experiment, Psychologist Ivar Lovaas of U.C.L.A. tried out reinforcement on a small group of vegetable-like psychotic children who were capable of no other utterances than guttural noises in their throats. Lovaas waited until they were hungry, then gave them a taste of sugar-coated cornflakes. Next, he held up a few flakes before the children and waited for them to make a sound. When they did, he immediately gave each of them another flake and said "Good!" After a few more attempts, he pressed their lips together, demonstrated the sound of "mmmm" and rewarded the children with praise and cereal when they imitated him. In several weeks of painstaking work, the children learned to make several sounds, then combinations of sounds and finally words before getting their rewards. Although their illness has not disappeared, most of these once "hopeless" children are now functioning at the level of five-year-olds.

Neatly Dressed. An even more challenging experiment in reinforcement therapy was begun eight years ago by Psychologists Teodoro Ayllon and Nathan Azrin at Anna State Hospital. In a ward of 46 chronic female schizophrenics and mental defectives, they exposed patients to the pleasures of cigarettes, television, a choice of roommates, social events and even walks around the hospital grounds. Then they announced that, henceforth, patients would have to "buy" everything except regular meals, a bed in the least desirable room and their prescribed medicines. They could earn metal "tokens" to make purchases simply by demonstrating normal behavior. Attendants then began handing out tokens for the largest amount of useful behavior that each patient could manage at the time.

For some women, merely appearing neatly dressed for breakfast was enough to start their tokens; patients who had spent all day in a rocking chair were paid to get up and observe a job being done, then paid a little more for helping to accomplish it, and then obliged to pay rent for the chair. Withdrawn patients were paid for speaking to others.

Soon 30% of the patients were able to earn tokens for working six hours a day in jobs such as laboratory assistant or clerical worker. Just as important, unrewarded behavior--including tantrums and imaginary conversations with spirits --declined drastically. As they saved up tokens for such expensive items as trips to town, most patients began to exercise the "normal" mental processes of choice and thinking ahead.

Most of the original Anna State patients increased their ability to work usefully within the ward; 21 of them have been discharged and are in "halfway houses," being cared for by their families or living on their own. For them, no tokens are required. Says Azrin: "The natural satisfactions of this world take over. The jobs the patients do and the friends they make keep it going."

Comparable rescue rates have been recorded in most of the 50-odd other U.S. institutions that are now using reinforcement technique. In the not too distant future, Azrin believes, "virtually all state mental-hospital patients can be discharged into sheltered halfway-house care." Reinforcement therapy has also been used with apparent success to treat alcoholics, autistic children and even unhappily married couples. Leonard Krasner, a pioneering reinforcement therapist at the State University of New York's Stony Brook campus, predicts that "within ten or fifteen years, many of the present techniques of psychotherapy will generally be acknowledged to be archaic, ineffective and inadequate."

Firmly Established. Most mental-health experts still need to be convinced. For one thing, the exhaustive follow-up studies required to assess the possible limitations of behavioral therapy are just beginning. Psychiatrists wonder how thorough and long-lasting any behavioral treatment--reinforcement or otherwise--can be. To them, "sick" or unusual behavior is a sign of underlying psychosis; no matter how many external symptoms are extinguished, they fear that the deeper problem will keep rising to the surface. Reinforcement experts answer that they have yet to see such "symptom substitution" in their patients.

At a more practical level, behaviorists concede that reinforcement techniques have not so far been fully effective in teaching the full range of skills needed to cope with many daily strains. Some reinforcement experts go further and admit that behavior therapy probably cannot replace other techniques completely. Allen Bergin, a Columbia University psychologist says that "the behavioral therapist can handle a few things quite well. But what can he do when a totally depressed, alienated person comes into his office and bemoans the purposelessness of his life?"

Still, the practical results are hard to dismiss, and the behavioristic approach has become a sustained, potent challenge to the dominance of Freudian-influenced psychiatry. Azrin contends that "the promise that these techniques have shown in the mental hospital justifies their being tried out in every other area." In his more whimsical moments, Azrin likes to think that behavior therapy will eventually follow the paradigm of progress once proposed by Charles F. Kettering, inventor of the first successful electric automobile self-starter. "First they tell you you're wrong, and they can prove it," said Kettering. "Then they tell you you're right, but it's not important. Then they tell you it's important, but they've known it for years."

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