Consider the Consequences

I recently participated in a team meeting in which staff were attempting to decide how to handle a behavioral infraction committed by a client participating in a structured therapy program. This client had already received the stated consequence for the infraction, but the question on the table was whether he would be allowed to graduate from the program on time or would be asked to complete additional treatment before becoming a graduate. The recent behavioral problem had led some staff to worry that the client had failed to meet the spirit of the program, and graduation was considered a carrot which would be used to motivate the client to follow program rules.

One staff member voiced concern that the client would not recognize the impact of his actions without additional consequences. Other staff argued that since the client had already received a consequence for the infraction and a change in his scheduled graduation had not previously been identified as a possible outcome of his behavior, adding this consequence was inappropriate.

So who was right?

There may not be an objectively “right” answer, but this experience reminded me of the importance of incorporating the most fundamental principle behind all behavioral and cognitive therapy into our work as therapists: contingency management. In other words, attending to the consequences of behavior and using those consequences to shape desired outcomes.

As behavioral and cognitive therapists, conceptualizations of our clients should include a focus on the contingencies shaping their behavior, and our interventions should directly target the behaviors we (and they!) want to increase or decrease.

So what does this look like in practice? First, it requires an understanding of some basic principles of behaviorism. There are two ways that consequences can function for a client.

Reinforcement is a consequence that encourages more of a given behavior. If my client completed her homework assignment, I will attempt to reinforce this behavior by praising her. “This is so great! Look at all the hard work you did on this! I really appreciate your efforts.” I am trying to increase the likelihood that she will continue to complete homework assignments in the future by applying a specific consequence that I believe she will find enjoyable: praise. Note that instead of adding an enjoyable consequence (praise), I could also remove an unpleasant consequence in order to reinforce a behavior that I’d like to see more of. For example, I might have an agreement with my client that if she completes her homework assignment, I will ask her to complete two exposures during our session instead of our usual three. Bringing in a completed homework assignment means that I will remove an experience that she perceives to be unpleasant from our session, which reinforces continued homework completion.

Punishment is a consequence that encourages less of a given behavior. If my client frequently arrives late to our sessions, I could attempt to punish this behavior by asking the client to complete a chain analysis on the chain of events that led up to him arriving late. In other words, I could attempt to reduce the frequency of his late arrivals by applying a consequence I believe he will find unpleasant. Alternatively, I could also attempt to remove an enjoyable consequence in response to his lateness, in order to punish the behavior that I would like to reduce. For example, if I normally allowed a few minutes at the beginning of session for the client to check in about his experiences throughout the week prior to getting into the the session agenda, I could let him know that we would not have that time when he arrives late.

To summarize, reinforcers increase the likelihood of a behavior occurring again while punishments reduce the likelihood of a behavior occurring in the future. You can either add a consequence to reinforce or punish (positive reinforcement or positive punishment) or you can remove a consequence (negative reinforcement or negative punishment). Here, “positive” and “negative” don’t refer to valence (good or bad) – they refer to addition or subtraction. Here’s a summary:

 

Reinforcement

Punishment

Positive

Adding a consequence which results in increased likelihood of a particular behavior Adding a consequence which results in decreased likelihood of a particular behavior
Negative Removing a consequence which results in increased likelihood of a particular behavior

Removing a consequence which results in decreased likelihood of a particular behavior

One thing that’s important to note is that your choices around how to reinforce a behavior you want or punish a behavior you’d like to reduce or eliminate depend on the client’s interpretation of your chosen consequences. For example, in the example of positive reinforcement above, I suggested that I could offer my client praise in order to reinforce her homework completion. But this will only work if my client finds praise to be enjoyable and therefore reinforcing. If she feels uncomfortable when she is praised, then praise will actually function as a punishment for her and would serve to diminish the likelihood of her completing homework in the future, since she will try to avoid being praised. This is why it’s very important to understand how your client experiences various consequences. You might have a hypothesis based on your experience in the world (“people enjoy praise”, “many clients dislike completing chain analyses”), but you’ll need to test this hypothesis with your individual client.

I once had a client who had been experiencing depression following a romantic breakup. In an attempt to reinforce getting out of the house, I asked her to engage in a pleasant activity (positive reinforcement), and we agreed that she would go see a movie that weekend. At our next session, I was eager to hear whether she had followed through on the assignment. She heaved a deep sigh and told me that although she had gone to a movie, it had been very difficult for her to sit through the entire thing. It turned out that during their relationship, the client and her partner had frequently gone to the movies together, and being in the theater actually made her feel more depressed and alone. Rather than the reinforcement I was seeking, this experience actually served to punish the client for getting out of the house (positive punishment)! I had assigned a generic “pleasant activity” without assessing its impact for this particular client. Let my mistake be a lesson: generate a hypothesis about how a consequence will function, but make sure to test that hypothesis with your specific client.

As I hope has been made clear, a focus on consequences is important not only for behaviors within the therapy session (attendance, homework completion, appropriate interpersonal behaviors with the therapist) but in the client’s daily life as well. Movement toward the client’s goals can be addressed by utilizing principles of contingency management to selectively reinforce and punish behavioral choices. For example, if your client’s social anxiety contributes to isolation and loneliness, you might help him set up a contingency around social engagement. Perhaps the client could receive a small reward for each person with whom he initiates a conversation throughout the week (positive reinforcement), such as the opportunity to watch a favorite television show or eat a favorite snack.

The hope is that natural contingencies will eventually take over. For example, the client might eventually experience a reduction in anxiety around others after having a series of enjoyable conversations; this reduction in anxiety would serve to reinforce greater social engagement (negative reinforcement). However, in the initial stages of treatment, talking to people might serve as a punishment for the client, due to increases in his anxiety (positive punishment). Your goal as the therapist is to facilitate artificial contingencies (those that are not inherently part of the situation, such as receiving the opportunity to watch a funny show after initiating a conversation) in such a way that you can overcome the initial period of discomfort until natural contingencies begin to take effect.

Some of the standard activities that we ask clients to do as part of behavioral and cognitive therapies serve as contingencies that have been shown to be generally effective for many people (e.g., activity scheduling, graduated exposure exercises,  behavioral activation). However, as cognitive behavioral therapists, we have the capacity to utilize behavioral principles in an individualized way that goes beyond what is written in a treatment manual. Using the basic principles of reinforcement and punishment, we can tailor treatment to each individual client and their needs, all within the framework of behavioral and cognitive therapy. So what behaviors would your clients like to increase or decrease in their lives? What behaviors would you like them to do more or less of within your sessions? How can you use reinforcement and punishment based on each client’s unique likes and dislikes to establish contingencies that will lead to more of the behaviors you want and less of those that are decreasing your clients’ quality of life?

 

One thought on “Consider the Consequences

  1. Pingback: Right? | The Therapist's Guide

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