Operant Techniques

The basic underlying principle of operant techniques is quite simple: their aim is to reinforce desired behaviour while undesired behaviour is extinguished or punished. A prime example of a (usually inpatient) treatment based on operant principles is the token economy. In a token economy, the therapist distributes so-called tokens for occurrences of desired behaviour (like for example brushing teeth, being timely, conducting a conversation, cleaning the room) with the aim to reinforce this behaviour. Tokens are chips that function as secondary reinforcers. The patient can exchange the tokens for various objects (such as money or sweets) and favours (such as a walk outside the clinic or watching television). The main advantage of tokens is that they can be handed immediately following the desired behaviour. Undesired behaviours (like crying, staying in bed all day, arguing) do not generate tokens, which causes these behaviours - according to the principle of extinction - to extinguish. The direct application of reward and punishment was shown to be effective in a wide variety of patient categories, including children with behavioural problems, schizophrenics and mentally disabled people. Nevertheless, the practical utility of tokens remains paramount.

An important study by Paul & Lentz (1977) documented the random assignment of nearly 100 chronic psychiatric patients to a token economy unit, a milieu therapy unit, or a traditionally organized unit (Paul & Lentz, 1977). The token economy unit was most effective, resulting in more discharges and less prescriptions of medication than in each of the other units. Despite its demonstrated efficacy, the interest in token economies has strongly waned over the past years. This may be partly attributed to the dramatic decrease in the average length of stay of inpatient units and the associated development of ambulatory rehabilitation programmes less suitable for the establishment of token economies.

In the field of substance-abuse treatment research, token economies (voucher-based incentives) are regarded as a promising treatment intervention (Higgens, Alessi & Dantona, 2000). Biochemically verified abstinence from recent drug use is rewarded with vouchers exchangeable for retail items meeting a predetermined therapeutic goal. This voucher-based incentive is often combined with an intensive behavioural treatment known as the community reinforcement approach (CRA) developed by Hunt & Azrin (1973). In their overview of research on the voucher-incentive approach, Higgens, Alessi and Dantona (2000) conclude it to be effective in the treatment of cocaine dependence and a promising treatment intervention regarding other substance-use disorders (alcohol, marijuana, nicotine and opioid dependence). However, the effectiveness of this type of intervention has been tested mainly in specialized research clinics and its usefulness in everyday drug-abuse treatment practice remains to be seen (Emmelkamp & Vedel, 2006).

The behaviour therapy approach to depression is based on the assumption that depressive symptoms originate from a deficit of reinforcement for constructive and pleasant behaviours and that depression will remit to the extent the reinforcement of those behaviours increases (Lewinsohn, 1975). Behavioural approaches attempt to change behaviour in order to secure an increase of positive reinforcers. According to this view, depressive cognitions (like, for example, 'I am worthless') are the result of depressed mood and these cognitions change as a result of changing behaviour and the increase of reinforcers.

Treatments derived from Lewinsohn's theory encourage the patient to participate in constructive and pleasurable activities. Activities that patients used to enjoy but ceased doing are now scheduled as homework assignments. Activities are ordered in a hierarchical fashion. Less challenging activities are scheduled first; more challenging activities follow later on in treatment. A number of studies have investigated whether this reinforcement of pleasant and constructive activities would, by itself, lead to a decrease in negative affect. The evidence demonstrated that the increase in pleasant activities indeed gave rise to mood improvement (Emmelkamp 1994). Another way to achieve reinforcement from social interactions is social skills training, which is discussed later.

Rehm (1977) proposed a self-control model for depression that offers a framework for integrating the cognitive and behavioural models (Rehm, 1977). Rehm endorses the importance of reinforcement in depression but posits that reinforcement is not limited to external sources. People can also reinforce themselves, independent of their environment. According to Rehm, the depressed mood and inactivity of depressed patients is the result of negative self-evaluations, reinforcement deficits and excessive self-punishment. Self-reinforcement and self-punishment can take place in behaviour and in thought. His self-control programme for depression consists of six weeks' training in self-registration, self-evaluation and self-reinforcement. Patients are required to complete diaries to register the positive activities they carry out each day (self-registration). During the self-evaluation phase, the therapist emphasizes realistic goal setting. Patients have to select specific and achievable sub-goals and they are subsequently required to judge their progress on a numerical scale (self-evaluation). Next, they receive instructions how to reward themselves when they achieve one of the subgoals (self-reinforcement). This programme has been shown to be effective with mild to moderately depressed patients, although it is not clear which ingredients of the programme are critical for the observed effects (Emmelkamp 1994).

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