Identifying and Using Reinforcers to Enhance the Treatment of Persons With Serious Mental Illness

The late 1950s and early 1960s witnessed a revolution in the treatment of severely mentally ill inpatients. Antipsychotic medications substantially reduced their symptoms, and their improved clinical status held the promise of their being able to live in less restrictive, lower-cost community settings. However, the transition to community living required more than symptom reduction; community living skills had to be improved and inappropriate behaviors eliminated.

In this context, reinforcement therapies flourished. A reinforcer is defined as any material item, consumable, activity, person, or social event that increases the strength or frequency of the individual's behavior on which it is contingent.

Three decades later, behavior therapies that use positive social reinforcement, such as social skills training and family interventions (1), have become more popular while the more classic reinforcement therapies, such as use of a token economy—a structured treatment in which desirable behaviors are rewarded with tokens that are exchangeable for valued goods or activities—have virtually disappeared.

Why have token economies been abandoned? As a corollary, what is the current role for reinforcers in treatment and rehabilitation programs? Below we address these questions and propose a method for identifying reinforcers and including them in the planning and implementation of treatments.

Effectiveness of reinforcement therapies

With more than 200 studies describing the benefits of reinforcement therapies in psychiatry, empirical support for such treatments is substantial (2,3,4). Among these studies, one of the best designed was that of Paul and Lentz (5), who found that an inpatient token economy was significantly superior to milieu therapy or customary care in reducing aggressive and other bizarre behavior and increasing community living skills to nearly normal standards.

Although clinicians conducting skills training and behavioral family therapies use reinforcers as part of their treatment, reinforcement therapies are otherwise seldom used in contemporary mental health settings. Several factors account for this disuse. The initial surge of clients from inpatient settings into the community was not matched by increases in budgets, which are vital for augmenting rewards and incentives beyond those customarily available in community mental health settings. Shortage of qualified staff also impeded the proper use of reinforcement therapies (6). However, reconceptualizing reinforcement therapies as providing empowerment to clients whose treatment can be promoted through individual choice of incentives is consistent with contemporary stakeholder values. In addition, the importance of effectively engaging, maintaining, and motivating clients to participate actively in treatment highlights the value of explicitly including reinforcers in assessment and rehabilitation.

For most people, expending effort to attain a goal is initiated and sustained by the perceived value that will be added to one's life if the goal is achieved. Value is often imputed to money, prestige, leisure-time activities, happiness, praise and recognition, satisfying work, and warm and supportive relationships. Although psychotropic medications, skills training, intensive case management, and other modalities of psychiatric treatment can be considered means toward attaining "value-added" lifestyles, clients themselves must see the benefit or value of such goals.

Because serious and persistent mental illnesses can be associated with neurocognitive impairments, apathy, motor retardation, and lack of insight (7), extrinsic reinforcers that are valued by clients may be helpful in engaging and maintaining them in treatment. For example, the participation rate in a treatment program for mentally ill clients with comorbid substance abuse was improved with extrinsic reinforcers such as priority and personal assistance in applying for Social Security Disability Insurance and Supplemental Security Income, access to housing vouchers, and representative payee services that ensured the monthly availability of housing and food (8).

With the restrictive environments of the old mental hospitals no longer relevant, practitioners providing services in community settings must make their programs more rewarding for clients if they are to succeed in engaging and sustaining them in treatment. Effective rewards must be tailored to the individual, and hence a wide range of rewards should be available to appeal to the diversity of individuals who are eligible for services. Rewards can include bus passes, certificates of accomplishment, eating out in restaurants, praise, money, and even time off from having to attend program services (4). Moreover, each client may respond to any given reinforcer in entirely different ways — "One man's meat is another man's poison." For instance, Mitchell (9) could distinguish clients who were motivated by social interaction and praise from those who found such stimuli aversive.

To maximize rehabilitation efforts, one must first set, with the client's active participation, the goals to be achieved. Once desirable and realistic long-term and short-term goals have been set and are clear for both the client and the clinician, the motivational requirements for each goal are addressed. Reinforcement becomes useful when clients have difficulty seeing the value of the goal, believe their efforts will be too costly or difficult, or lack the conviction that success is possible. Whenever lack of motivation seems to be an obstacle to treatment, a reinforcer survey offers a useful option for identifying rewards that may help treatment planning and promote therapeutic progress.

Reinforcer surveys

Reinforcer surveys are interviews or questionnaires that list numerous objects, persons, activities, and settings and then assess the client's perception of the value of each item. The surveys help identify the type of reward that might be useful for motivating the client; the frequency, intensity, or duration of the reward; and the relative differences in "motivational weight" of these prospective rewards.

Reinforcer surveys have been designed for mentally disabled clients, and their usefulness has been empirically documented. We assessed the validity of a reinforcer survey with hospitalized mentally ill persons by conducting a behavioral experiment to determine whether the participants would respond more on a task requiring effortful activity when the consequences or rewards were selected as highly desirable in contrast to rewards that were identified as less desirable. The results (data not shown) demonstrated that even persons with serious and persistent mental illness predictably "worked" more for rewards that had been verbally endorsed as having more value, validating the practice of tailoring rewards with a reinforcer survey.

Among the surveys applicable for use with mentally disabled clients, the Reinforcement Survey for Adults by Clement (10) has appeal for practitioners because of its clinical relevance, user friendliness, and large scope of possible reinforcers. In using this survey, the respondent is asked to list the people, places, things (hobbies and comestibles), and activities that the respondent prefers, performs most often, or for which increased frequency would be desirable. If the respondent is unable for any reason to provide reliable answers to a reinforcer survey, family members, professional or nonprofessional caretakers, or others who have substantial knowledge of and contact with the client could readily complete the survey. Samples of the Reinforcement Survey for Adults and other reinforcer surveys are available on request from the second author.

Conclusions

We can use reinforcers to motivate and help our clients achieve greater success in psychiatric rehabilitation, whether it be by offering cookies after rehabilitation groups, cheering after a nicely done role play in social skills training, or presenting a special certificate of accomplishment when their long-term goals are reached. Ultimately our goals in using reinforcers are to help people find the internal motivation to improve their condition and to feel they have control and power over their illness, and to empower them to collaborate actively in their treatment. However, to be effective, reinforcement must be connected to the needs, preferences, and values of each client. Identifying reinforcers for use in motivating clients is necessarily an empirical process; consequences of behavior are reinforcing to the extent that they increase or strengthen the behaviors on which they are contingent.

Motivational assessments and reinforcer surveys are useful tools in planning treatment and in detecting changes over time in clients' goals and motivational needs. Reinforcers, if properly assessed and delivered, can optimize the value of treatment in the clients' eyes and can increase their acquisition of skills, attainment of goals, and feelings of self-efficacy. In the current era of individually tailored treatments and consumer empowerment, reinforcement therapies and motivational strategies will surely regain their therapeutic significance.

Dr. Lecomte is assistant professor of psychiatry at McGill University in Montreal, Quebec. This paper was written while Dr. Lecomte was a postdoctoral fellow in psychology at the Intervention Research Center for Psychosis at the University of California, Los Angeles (UCLA). Dr. Liberman is director of the center and professor of psychiatry in the UCLA department of psychiatry and biobehavioral sciences, where Dr. Wallace is professor of medical psychology. Address correspondence to Dr. Liberman at the department of psychiatry and biobehavioral sciences, 300 UCLA Medical Plaza, Box 956967, Los Angeles, California 90095 (e-mail, rpl @ucla.edu).