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Introduction

Symptoms of those suffering with Schizophrenia are associated with motivational and volitional deficits that affect a wide range of goal directed activities. The intervention approach known as Positive Behavior Support (PBS) is used with those in need of behavioral changes. This approach focuses on promoting appropriate behaviors, while reducing problem behaviors (Sailor, Dunlap, Sugai, and Horner, 2009). The objective of this approach is to improve the quality of life of all involved by making the individual experiencing difficulty expressing him or herself, aware of the fact that there are more efficient ways of handling situations (Carr et al., 2002).

Theory

Positive Behavior Support (PBS) is based on a foundational behavioral theory. The Behavioral theory is based on the notion that the development of new behaviors is influenced by the environment. Behaviors are considered objective and measurable and, therefore, can be altered using behavioral approaches. Applied Behavioral Analysis (ABA) is a behavioral approach that is based on the Behavioral theory. It focuses on the idea that behavior change can occur through the manipulation of consequences.  Additionally, active instruction of desired behaviors can assist clients with the skills to behave in socially acceptable ways (Sailor, Dunlap, Sugai, and Horner, 2009).

Evidence

Evidence suggests that individuals suffering from schizophrenia can benefit from behavioral approaches in therapy that target problem behaviors, motivational deficits, and psychiatric symptoms. A study was conducted with 151 community outpatient participants diagnosed with schizophrenia who experienced high behavioral avoidance symptoms, in addition to other psychiatric related issues. Participants were interviewed and evaluated on a behavioral level, and results showed that there are benefits to providing external reinforcements that the participants value to modify behavior. Additionally, the study presented the importance of considering data from the Behavioral Inhibition/Behavioral Activation System Scale, that can provide practitioners with an idea of what the participant is avoiding in their environment (Reddy et al., 2014).

Case Study

Fitzroy Frederick is a 37 year old homeless man living with schizophrenia in New York City.  He was provided housing and an employment opportunity in The Fountain House, a program designed to provide assistance to individuals with mental illness. Since moving to The Fountain House, Fitzroy has experienced issues with the other residents. He has been observed yelling, swearing, and insulting his roommates. Fitzroy was referred to an occupational therapist at The Fountain House to address his issues with his roommates. The occupational therapist met with Fitzroy to conduct a functional behavior assessment to determine the function of his problem behaviors. Through interview and observation, the therapist identified exclusion from peer interactions as the antecedent to Fitzroy’s verbally aggressive behaviors, the consequence often being attention from peers. Consequently, the occupational therapist determined seeking attention as the maintaining consequence for Fitzroy’s problem behaviors. Following the assessment, the occupational therapist determined Fitzroy would benefit from positive behavior support strategies to minimize his maladaptive behaviors and introduce more appropriate attention seeking behaviors.

Intervention Plan

Problem Statement

Fitzroy demonstrates an inability to appropriately initiate social interactions, often engaging in maladaptive attention seeking behaviors, affecting his social participation.

Long Term Goals

1. Fitzroy will demonstrate a decrease in inappropriate behaviors by 80% when excluded from peer interactions during session within 8 weeks for social participation.
2. Fitzroy will use 5 appropriate behaviors to initiate social engagement, when excluded from peer interactions during session within 8 weeks for social participation.
3. Roommates will withhold attention to Fitzroy when engaging in inappropriate behaviors 80% of the time during session within 8 weeks for social participation.

Short Term Goals

1. Fitzroy will demonstrate a decrease in inappropriate behaviors by 50% when excluded from peer interactions during session within 2 weeks for social participation.
2. Fitzroy will use 2 appropriate behaviors to initiate social engagement, when excluded from peer interaction during session within 2 weeks for social participation.
3. Roommates will withhold attention to Fitzroy when engaging in inappropriate behaviors 50% of the time during session within 2 weeks for social participation.

Intervention Format

Group session

Setting

Fitzroy will meet with the occupational therapist for group sessions at the Fountain House for 60 minutes 1 time a week for 8 weeks.

Supplies

None

Agenda

• Meet with Fitzroy and group members to further develop rapport (5 min)
• Educate peers on PBS strategies (10 min)
  • Not attending to Fitzroy’s inappropriate behaviors
• Set expectations for Fitzroy in appropriate behaviors (5 min)
• Complete cooking activity (30 min)
• Debrief (10 min)

Documentation

S: Client stated, “My roommates always leave me out, and I hate it” when asked about his social engagement with his roommates.

O: Client participated in a 60 minute group OT session with emphasis on positive behavior supports. Initially, peers were educated on PBS strategies, withholding attention to client’s inappropriate behaviors and providing attention contingent on appropropriate initiations.  Fitzroy and his peers engaged in a cooking activity in the kitchen. When the activity began, first the roommates worked together to gather items needed to complete the cooking task, excluding Fitzroy. Fitzroy was given one verbal cue to appropriately ask to be included. He disregarded the verbal cue and began to yell at roommates for a duration of 15 minutes. Roommates were able to withhold attention following inappropriate behaviors exhibited by Fitzroy 10% of the time. Fitzroy’s yelling escalated when roommates withheld attention.

A: Client’s need for one verbal cue to ask to be included in the activity indicates inability to initiate appropriate social interactions independently. Client’s decision to disregard the verbal cue and yell at roommates for excluding him, also demonstrates a need for further intervention on PBS strategies to use appropriate behaviors for social engagement. Roommates’ ability to withhold attention for inappropriate behaviors indicates their understanding of PBS strategies. However, roommates withholding attention for only 10% of the time also indicates need for more practice. Client’s inappropriate behavior escalating when roommates withheld attention is the result of an extinction burst, further confirming attention as the maintaining consequence.

P:  OT treatment indicated 1x per week for 60 minutes for 8 weeks. Engage client in highly interactive therapy to target appropriate attention seeking behaviors and minimize/eliminate maladaptive attention seeking behaviors.

References

Carr, E. G., Dunlap, G., Horner, R. H., Koegel, R. L., Turnbull, A. P., Sailor, W., … & Fox, L.
(2002). Positive behavior support: Evolution of an applied science. Journal of positive behavior interventions, 4(1), 4-16.

Reddy, L. F., Green, M. F., Rizzo, S., Sugar, C. A., Blanchard, J. J., Gur, R. E., Horan, W. P. (2014). Behavioral Approach and Avoidance in Schizophrenia: An Evaluation of Motivational Profiles. Schizophrenia Research, 159(1), 164–170.

Sailor, W., Dunlap, G., Sugai, G., and Horner, R. (2009). Handbook of positive behavior
support. New York: Springer.