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Introduction

Positive behavior support is used to change behaviors that are problematic. Problem behaviors are reduced by using strategies that can be reinforced by including shaping, chaining, and fading. These methods are used to promote the overall success of the behavior. Replacement behaviors are also used to discourage negative patterns. Voucher-based incentives is an example of positive behavior support using reinforcement of appropriate behaviors. This intervention has been applied with individuals with substance abuse and has proven to decrease their dependency. Vouchers could be exchanged for points that can be exchanged for money. Higgins, Alessi, and Dantona, (2002), found that over the course of a few weeks, the participants improved a lot. This is an example of the efficacy of positive behavior support used in substance abuse settings.

Theory

Applied Behavior Analysis (ABA) is a theory that uses reinforcements, either positive or negative, to alter certain behaviors. While some behavior analysts suggest that ABA and positive behavior support are one in the same, others argue that positive behavior supports will be damaging to the field of ABA (Tincani, 2007). Positive behavior support is an approach that improves quality of life, and helps clients be successful in reaching goals to reduce problem behaviors in a socially acceptable manner (Carr et al., 2002).

Evidence

Cognitive Orientation to Daily Occupational Performance (CO-OP) is a unique approach in the rehabilitation of executive dysfunction in the patient’s daily life in which the clients set their own personal goals (Dawson, et al., 2009). The stress on goal setting as motivation is a useful way of having clients identify and attain goals (Froude, 2017). In a study conducted by Froude, the CO-OP strategies that were implemented allowed the clients to achieve their goals evidenced by the improvements in their COPM ratings. The “do” portion of the process is paramount since it allows the the client to carry out the action and perfect the task, or similar tasks.

Higgins et al. (2007) explored two approaches to determine how abstinence in drug use can be supported. The first approach, community reinforcement approach (CRA), developed sessions for patients to be taught skills for replacing ineffective behavior. The patients rationalized the consequences of using cocaine. In addition, they explored safer activities. The second approach used was a voucher program. The authors hypothesized that increasing the value of the vouchers would decrease the use of cocaine. The authors found that their hypothesis further supported the use of a voucher program.

Case Study

Gigi Brown is a 26-year-old woman attending medical school at Florida International University. She has been abusing alcohol for over two years, since beginning the program, due to the high demands and the stressors that come with it. Lately, she has been binge drinking everyday as a way to cope. She wakes up craving a drink, and has to have one in order to go to sleep. She has been experiencing debilitating hangovers that have led her to miss various school and family gatherings, causing her parents great concern. Gigi’s binge drinking is also negatively affecting her school attendance, as she does not wake up on time or feeling well. She has become very self conscious about her academic performance and is constantly comparing herself to her classmates. Gigi is currently on academic probation due to her poor grades which are having a negative impact on her academic life. She has recognized how much her alcoholism is taking over her personal and professional life and has made the decision that she wants to stop drinking. Gigi was referred by the school counselor to see an occupational therapist in order to help her reach her goals.

Intervention Plan

Problem Statement:

Edie’s health and social participation is limited by her challenging behaviors (i.e.drinking).

Short-Term Goals:

1. Client will implement the “no drink jar” reinforcement strategy for every day she does not have a drink within 2 weeks to improve her health and overall well-being.
2. Client will independently verbalize an effective positive replacement behavior that is appropriate when provided with 2 different social scenarios (i.e. a bar vs. family barbeque) in 2 sessions to improve her social participation.
3. Client will apply a positive replacement behavior when attending a happy hour in 3 sessions to improve social participation.

Long-Term Goals:

1. Client will demonstrate zero instances of challenging behavior (i.e drinking) as evidenced by a clean urine screen by discharge.
2. Client will independently continue applying 3 strategies (1. positive reinforcement 2. alcohol free home and 3. positive replacement behavior) to reduce drinking behavior for 4 months in order to improve health and well-being.

Intervention Format:

Individual

Setting:

Edie will meet with the occupational therapist in the university clinic for 1 hour 2x per week for 4 months.

Supplies:

N/A

Agenda:

• Therapist meets and builds rapport with Gigi (10 min)
• Therapist conducts interview and develops Gigi’s occupational profile (15 min)
• Therapist educates Gigi on positive replacement behaviors for her challenging behavior  (10 min)
• Therapist and Gigi discuss positive reinforcement behaviors (10 min)
• Therapist discusses methods for Gigi to change her environment (10 min)
• Therapist will provide a summary of the session and elicit feedback (5 min)

Documentation

S: Client states she’s been abusing alcohol in order to deal with the stressors from the medical school program she is in. She’s been missing school and family gatherings from the effects the alcohol is having on her.

O: Client verbalized her challenging behaviors were influencing her health and social participation in a negative way. The therapist educated client on positive behavior reinforcement which can be used to teach a behavior in order to replace negative behaviors. Client then discussed methods for Gigi to change her environment, and how she’s going to utilize this strategy on a daily basis. Client committed to practicing positive reinforcement behaviors 5 out 7 days in the upcoming week.

A: Client demonstrated improved knowledge in positive behavior reinforcement evidenced by discussion and feedback during session. She reported feeling more positive about reducing her drinking behaviors and attendance in school. She will benefit from positive behavior reinforcement in order to replace these challenging behaviors independently.

P: Client will continue positive behavior reinforcement in order to decrease urges of challenging behaviors to increase her social participation. Continue to enhance tx activities when necessary. Client is to see OT 2x per week for 4 months.

References:

Higgins, S., Alessi, S., Dantona, R., (2002). Voucher-based incentives, a substance abuse treatment innovation. Addiction, 27(6), 887-910. Doi:10.1016/S0306-4603(02)00297-6

Higgins, S. T., Heil, S. H., Dantona, R., Donham, R., Matthews, M., & Badger, G. J. (2007). Effects of varying the monetary value of voucher-based incentives on abstinence achieved during and following treatment among cocaine-dependent outpatients. Addiction, 102(2), 271-281. doi:10.1111/j.1360-0443.2006.01664.x

Tincani, M. (2007). Moving forward: Positive behavior support and applied behavior analysis. The Behavior Analyst Today, 8(4), 492-499. doi:10.1037/h0100635