My Approach to Behavior Therapy
Rees Chapman, Ph.D.
When I was in graduate school, I found myself ideologically opposed to behavior therapy. For me, it wasn't therapy, but dehumanizing manipulation. To apply Watsonian principles - called "The Behaviorist Manifesto," useful in directing rats to run through mazes - to the human condition seemed inherently wrong, as anyone familiar with John Watson's "Little Albert" experiments on an eight month old child could understand. BF Skinner took his "radical" theories, which were applicable for rats in operant conditioning chambers and pigeons guiding missiles, and generalized them to child-rearing; this seemed to completely miss the point of being human. As a fledgling therapist in masters practica, I refused to conceive of my cases in any way that involved concepts of reinforcement or conditioning.
Years later, I was providing therapy for a young man with traumatic brain injury, who had essentially no capacity for insight or self-actualization. Client-centered, interpersonal, and gestalt therapies (with which I was most familiar) would clearly be ineffective. I'll admit to having developed an increasing sense of cynicism, in that I was beginning to think of my patient as more of a rodent than a person. So, I pirated some generic behavior chart grabbed from an old textbook on child behavior therapy, and modified it to be applicable for my patient. I don't recall any of the identified target behaviors which were to be reinforced, but I remember feeling compelled to focus exclusively on positive and desirable behaviors.
I was unimpressed with the effect of the behavior intervention on my brain-injured patient, which was actually rather favorable. What did catch my attention was the delight the parents felt seeing their grossly impaired son actually show some degree of self-control. Even more gratifying for me was the obvious brightening of his mood, the increase in his apparent self-awareness, and the expansion of his range of interaction. It seemed clear to me that the impact of positive reinforcement on him was highly beneficial emotionally, socially, and in terms of his self-esteem.
Two decades later, I use behavioral therapeutic principles regularly in my work with children. I seldom use the words behavior or reinforcement in presenting it to parents; instead, I call my behavior charts Success Sheets, and speak of calling attention to desirable actions and using incentives and rewards to empower parents and children alike.
Generally, I meet with the parents and child (or children) to create a list of positive behaviors, hoping to get suggestions from all participating. I require them to reframe negative target behaviors such as "don't lie" (replacing it with "tell the truth") and "no fighting" (instead, "good with siblings") in positive terms.
Here is an example of a Success Sheet for a nine year old child with oppositional and impulsive tendencies:
Parents are instructed to notice whenever their child does anything on the Success Sheet list of target behaviors, and to praise the activity and award it a sticker or checkmark. As behaviors occur repeatedly, many stickers or checkmarks can accumulate in individual squares for each day.
When the child wants to do anything fun or be given any treat, he/she must ask. The parents have rehearsed their response again and again, so that it is automatic: "Let's go check the Success Sheet." And when they check it together, the child counts the number of stickers or checkmarks, while the parent reminds them, for example, "see, that's when you picked up your toys in the family room without being asked." The parent then makes a decision - best arrived at through his/her intuitive judgment - whether the child has earned the activity or treat for which he/she has asked, and tells the child what has been decided. If the answer will be "no," it is best preceded by a reminder "you can earn more if you are polite and take NO for an answer." And if the child says "well, I'm really disappointed and angry, but its OK," he/she gets at least four stickers or checkmarks: one for ask before doing, one for polite to parents, one for talk about feelings, and one for take NO for an answer. Sometimes, the parent can drive home the importance of these aspects of successful self-control by declaring that the child has now actually earned the requested activity or treat.
Stickers or checkmarks are never lost or taken away. Problematic behaviors are ideally responded to with calm but clear reminders that the child knows better than to do what he/she is thinking about doing, and if that doesn't work, time outs are best. (My approach to time outs is somewhat unique; it is discussed elsewhere.)