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Article CommentarySpecial Article

Commentary: Interventions Based on Learning Principles Can Supplant Seclusion and Restraint

Robert Paul Liberman
Journal of the American Academy of Psychiatry and the Law Online December 2011, 39 (4) 480-495;
Robert Paul Liberman
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    Table 1

    Stepwise Behavior Analysis of Aggression

    Identify antecedents of aggression or of stimuli correlated with the behavior's onset. An example is when a patient becomes frustrated and angry when staff members refuse his unreasonable requests.
    Specify the aggressive behavior in operational terms so that all will agree when it occurs (e.g., shouting threats and expletives with fists clenched, angry facial expression, and shoving or hitting).
    Note the immediate consequences of the aggression that may be inadvertently maintaining it. Staff members can congregate in a show of force and speak to the patient in a soft tone of voice, reassuring him that he will be all right if he de-escalates by sitting down and relaxing.
    Inventory the patient's social, personal, and cognitive strengths and deficits and conduct a survey of personally relevant reinforcers for him. Reinforce the patient's positive qualities, using reinforcers that are appropriate to his values and preferences while ignoring provocative behavior.
    Identify alternative ways of reducing anger and aggression in the current and future episode. Implement positive programming, differential reinforcement for behavior other than threats and anger, and social skills training to improve the patient's ability to express his frustration in words and to ask staff members to explain how and when he can have his request honored.
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    Table 2

    Examples of Behavioral Interventions for Reducing Aggressive and Destructive Behavior in Children, Adolescents, and Adults

    Positive programmingPlanned and scheduled activities that are pitched toward successfully engaging the patient in appropriate behavior can displace frustration, angry interactions, and various types of aggression. Abundant reinforcement should be given to the patient for interacting appropriately in the activity.
    Differential reinforcement of alternative, competing, and other behaviorsStaff gives social and tangible reinforcement to the patient for any behavior or interactions that are not aggressive or preludes to aggression. In practice, reinforcement is delivered after a specific interval has passed without aggression. For example, a person with frequent aggression might be on an every-15-minute schedule for reinforcement, with the time between reinforcements gradually lengthened as the frequency of aggression declines.
    Stimulus controlA special location or signal is established when a patient engages in abusive, threatening, or obscene talking, and the patient is instructed to go to that location when such behavior occurs. The person remains in the designated area for as long as the provocative behavior continues. The individual is typically ignored during this time, but as soon as the intolerable behavior ceases, the patient returns to the planned and scheduled activities, during which social interactions take place and abundant reinforcement is given for appropriate behavior. In this technique, the special location becomes the stimulus for inappropriate behavior, and the environment in the rest of the unit or classroom gradually loses its stimulus value for the unacceptable behavior. A feasible and effective stimulus-control procedure is time out from reinforcement, in which the stimulus is a chair situated at the end of a corridor facing the wall. Patients can use this procedure for self-control and cooling off by taking a time-out when experiencing anger, arousal, or frustration. On a psychiatric unit for aggressive patients, this stimulus-control procedure was successful in reducing and eliminating violent behavior in 74% of the patients.
    Contingent observationPatients who demonstrate anger and verbal abuse or engage in destructive acts are instructed to sit quietly for a predefined period on the perimeter of a group activity. They watch peers and staff interact in appropriate ways and benefit from vicarious learning.
    Overcorrection and teaching interactionThis technique combines instructional control with social skills training. A patient who is assaultive or destructive of property is instructed to make amends in an excessive, or overcorrecting, manner. A patient who breaks a chair is given some duct tape and is required to patch and fix the chair and also polish or dust all of the other chairs in the area. Then, the patient meets with a clinician, who asks the patient to identify the reasons for the destructive behavior. A collaborative behavioral analysis of the situation is done, in which antecedents and consequences of the aggression are examined for their role in the untoward event.
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Journal of the American Academy of Psychiatry and the Law Online: 39 (4)
Journal of the American Academy of Psychiatry and the Law Online
Vol. 39, Issue 4
1 Dec 2011
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Commentary: Interventions Based on Learning Principles Can Supplant Seclusion and Restraint
Robert Paul Liberman
Journal of the American Academy of Psychiatry and the Law Online Dec 2011, 39 (4) 480-495;

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Robert Paul Liberman
Journal of the American Academy of Psychiatry and the Law Online Dec 2011, 39 (4) 480-495;
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    • Abstract
    • Unintended Consequences of Efforts to Reduce or Eliminate Seclusion and Restraint
    • One Suit Does Not Fit All: Linking the Person to the Treatment
    • Learning-Based Behavior Therapies Reduce Aggression
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