murder of therapy

 

The Murder of Therapy: Why Clients Don’t Get Better

Dr. Steven Bell

Berry College

Abstract

This is an article describing and analyzing my four months working as a

psychologist using behavior modification in the Occupied Territories known as the

West Bank, Palestine. While I speak of two families and two children, this is done

to make the story easier to tell. Actually, I worked with several families and

multiple children. I discovered the power and challenge of a collectivist culture to

applying learning theory principles. The work of Professors Nathan Azrin (Azrin,

1974), Richard Foxx (Foxx, 1982), and Marc Gold (Gold, 1974) was basic to my

therapeutic approach.

Introduction

Why don’t folks get better? If one takes Herbert Spenser’s advice and

modifies for psychologists working with folks from very different cultures you get:

“There is a principle which is a bar against all information, which will keep you in

everlasting ignorance – that principle is contempt prior to investigation.” In my

case the Murder of Therapy was partial unawareness of the Arab culture.

How do I get your attention when so many other legitimate needs demand

your time and resources? Sadly one option might be to take the advice of Michael

Corleone in Mario Puzo’s, The Godfather. “Keep your friends close. Keep your

enemies closer.” If you are a Jewish or Christian: there are 1.57 billion Muslims in

the world.  If you are Muslim, Israel has one of the most powerful armed forces in

the world with a high probability of possessing and the capability to deliver over

100 nuclear weapons. This is an area of the world about which you might wish to

know a little bit more.

One of the things which did not get my attention was my concept of Truth. It

was the greatest barrier to my understanding what appeared to me to be completely

irrational behaviors on the part of Palestinian families, namely, blocking

therapeutic plans to change children’s inappropriate behaviors. I learned more

concretely about the power of culture to be a counter force to a successful

therapeutic continuum.

Culture

Cultures are typically divided into two somewhat discrete categories:

Collectivist and Individualist (Grief, 1994). While relatively large numbers of

individuals vary from the norm, generally, people in individualist cultures, such as

ours in the USA emphasize personal achievement at the expense of group goals.

Collectivism and individualism deeply pervade cultures. I simply took my culture’s

stance for granted as the standard of Truth. In the USA, our deeply ingrained

individualism can be illustrated by our aversion to car pooling – forcing us to

reward it by creating High Occupancy Vehicle lanes in large cities.

In a Collectivist culture each person is encouraged to conform to do what is

best for the group. The family’s obligations for the common good are seen as more

important than the rights of individuals – in my experience the rights of mothers to

have some private life away from family obligations. In extreme conditions

wanting to be independent or stand out is seen as shameful. Everyone must rely on

others (nuclear family first) for support.

During my Sabbatical and Rotary International Grant period I was working

in the Collectivist culture of the Israeli Occupied Territories, getting my chance to

be a full-time Counseling-School psychologist again.  Mostly, given the

populations I was serving, I used a form of behavior modification (BMod)

(D’Zurilla & Goldfried, 1971) known currently as Applied Behavior Analysis

(Gresham, Gansle, & Noell, 1993). It varies from other therapeutic methods by

emphasizing the visible and measurable over the psycho dynamically oriented

emphasis on the invisible. Given the limitations of the two individuals’ insight and

associational ability, I decided to change the behavior rather than the thoughts.

Besides, as has been demonstrated with Cognitive Maps (Eden, 1992), if you

change the outer behavior, the brain’s associations change as well.

Behavior Modification principles

  • The Law of Readiness (Herrnstein, 1970), which says there are

 

optimal times to teach and learn new behaviors; for example, using

 food as reinforcers during meals.

  • The Law of Effect (Thorndike, 1927), wherein the consequences

 

of a behavior strengthen or weaken the probability of its

reappearing. If a behavior is reinforced, the likelihood that it will

reoccur increases; for example, getting a snack after using the

appropriate language by naming it.  If a punishment follows a

behavior, the likelihood of the behavior reappearing is lessened;

for example, getting the silent treatment after you hit your brother

  • The Premacke Principle (Danaher, 1974), where first, one

 

withholds the things or opportunities the person normally finds

rewarding. Then getting them is made contingent on the desired

behavior, for example, Fadi loved walking with his grandmother

and sitting on the porch swing with his grandfather.  So we allowed

going for a walk with grandmom or swinging on the porch with

grandpop only when he asked using the appropriate language.

  • Task analysis (Gold, 1974), wherein a complicated multistep

 

process is broken down into manageable increments. For example,

getting dressed.

The rationale for my using behavior modification rather than a cognitive

behavioral approach is that the participants were essentially nonverbal; were not

cooperative and had little insight. Also Behavior modification is more than twice

as effective as psychotherapy in general: with a success rate as high as 80% –

(Stern, & Golden, 1977) symptom substitution notwithstanding. In traditional

therapy 1/3 of the people are likely get worse or to put it another way: you are as

likely to get better if left alone.

Role of family

It is well know that any form of therapy is enhanced or inhibited by the

cooperation or noncooperation of the “family”. Yet, my Individualistic orientation

blocked my complete understanding of the power of family in the Collectivist

culture. And herein lay the root of my challenge:  to focus my time and skill –

teaching primarily the mothers – how to change her child’s behavioral repertoire.

This challenge was made even more insidious because I took for granted my

Individualistic culture and was thus not familiar enough with the ground rules of a

Collectivist culture. It was not until I realized the entire family – – which is a lot of

people in this fecund society – – had to be brought in as stakeholders for success to

begin and be sustained. Imagine a room full of parents, both sets of in-

laws/grandparents, a smattering of uncle, aunts, nephews, nieces and cousins all

yelling and interrupting each other in a language I barely understood.

Role of Mother

Complicating behavioral therapy was a lack of resources taken for granted in

the USA. Infuriatingly, in the West Bank, there are many egregious, dedeveloping

forces insidiously and systematically at work (Ilan, 2006): a 43 year military

occupation blocking free movement in a multitude of ways within the country,

interfaith religious tension, and a government based on tribal rather than

democratic principles and, of course, piled on – a drought. The lack of a strong

central government has meant there are no public laws allowing the education of

handicapped children and youth.

Therefore, these disabled individuals must stay at home. Thus, the

responsibility for education, counseling, therapy and for behavior change falls on

the family – namely, the mother, but as I was soon to discover – the power was

distributed into the nuclear and even extended family. Often times the mother

found herself overwhelmed with the duties to her husband, aged parents, aged in-

laws, unmarried children, married children, grandchildren, extended families ties

and then all the responsibilities of running the home. Consequently, she became

estranged from the best interests of her handicapped children. Much like the adage:

“it’s hard to remember you were sent to drain the swamp when you are up to you

neck in alligators,” the mother often was simply unable to carry out the therapeutic

intent of a well developed straightforward behavioral plan – – defaulting to giving

reinforcers intermittently often without the child’s compliance and doing for her

children rather than making them do for themselves.

While using Applied Behavior Analysis with two families and their children

I eventually realized the power of the Collectivist cultural of which I (coming from

an individualist culture) was virtually unaware, in spite of two years studying Arab

culture and language with face-to-face tutors. The fact that in spite of daily Rosetta

Stone lessons, which drove my colleagues and wife out of their minds, my Arabic

wasn’t terrific and their English (which was many times better than my Arabic)

confounded our plans. On one occasion I told a mother that she should ask for

compliance only three times before removing the reinforcer. The mother heard

“the child should say the target word three times before getting the reinforcer.”

Imagine how frustrating that was for the mother and the child.

The fact that there were no schools to help meant I was working in each

family’s home two times a week for several hours per session. I was able to see the

mother, often the father and occasionally some members of the extended family

interact with the two children.

Culture

In the Collectivist culture of the Arabs in the West Bank, one can easily find

multiple generations of a family living in a layered “wedding cake” of a

multistoried house. The first floor would house the in-laws, the second the nuclear

family and the third the unmarried bachelors. There are certainly some wonderful

advantages to this intergenerational living arrangement of grandparents and

grandchildren living together. Our individualist culture could relearn a lot about

honoring our senior citizens. I saw no nursing facilities or retirement homes in the

West Bank.

A disadvantage in this culture is that Mom is often by-passed, ambushed and

undercut by the well meaning father, siblings, grandparents and extended family –

creating a major therapeutic challenge to the required tight behavior-reward

system. These other stakeholders routinely ignored the rule of withholding

reinforcers, e.g. snacks, walks, etc. contingent on behaviors such as language to

express wants. It was not until I realized the power of the nuclear and extended

family that my work with two moderately disabled adults began to be successful.

Fadi’s Language

Fadi is a five-year-old boy who lost language at about a year and a half. He

is solitary by choice and demands a high degree of order and consistency (he must

walk on a certain side of the side walk to a certain distance). If one of his steps

crosses “his” line in the cement, an ear piercing tantrum could last 20 minutes. He

seems incapable of communicating with other people even when dire events are

impinging on his life. Over a period of about five minutes, I saw him completely

defenseless and silent as he was pummeled by two-year-old half his size.

His mother, Ghada, had agreed to only allow him to have a biscuit or a cup

of tea when he used words to ask for them. The grandparents nodded in agreement

that going for a walk or swinging would also be contingent on Fadi asking. We

even were willing to accept “bidi” (I want) for any of the three reinforcers namely:

going for a walk, swinging and/or getting snacks. After two weeks of restricting

these “luxuries”, no breakthrough occurred. One day his sister reported Fadi said

“duda (ant)” so following the principle of “take what the client gives you” we

surrounded him with: a jar of ants, pictures of ants to color, clay to mold into an

ant. Yet, no progress beyond the one occasion of one word – “duda” was made. I

was befuddled. No snacks, walks or swings for two weeks, yet no words were

being said. The Law of Effect was not working.  Or so it seemed. Where were

Edward L. Thorndike and B. F. Skinner when I needed them? Low and behold, at a

family gathering, with head down, Grand mom admitted how badly she felt for

poor Fadi so she was going for walks anyway. Emboldened, Grand pop revealed he

was pushing Fadi on their outside swing without Fadi having to ask! The plan was

going down in flames.

One of the rules of parenting, teaching and counseling is this: if a desired

behavior is within the repertoire of the person then push. If it is not within the

repertoire it would be cruel to withhold rewards. The trick is to know whether you

have before you a “can’t” client or a “won’t” client. The mother and I we betting

and hoping Fadi was a “won’t”.  As of this writing, now three months later, my

efforts to discover if Fadi’s case was a “can’t’ or a “won’t” have been stymied by a

lack of communication.

Jamla’s activities of daily living

The next cultural issue is highlighted by the second family with a twenty-

six-year old moderately disabled adult daughter. Here, in this case, beside the ever

present, extended-family-ambush is the increased amount of grieving a mother in a

collectivist culture experiences. In this highly matriarchal society, she believes

herself to be responsible for the entire family throughout their life spans (and

before) or so it seems. Their failure is her failure and shame.

Basma and I worked on two issues: language development and creating

multistep task analyses for: getting dressed; doing laundry; taking the dinner plate

from table; not hitting her brother or niece; and using the toilet independently. We

were using real power and leverage: favorite foods, having dessert, a drive in the

car or watching TV. Further, we got rid of her childhood puzzles and beads

replacing them with magazines appropriate to young adults (fashion magazines,

make up, sport and muscle magazines).We used traditional learning principles:

Focus on tomorrow, not yesterday (Boker la ams). Accepting successive

approximations (Skinner, 1963) toward the terminal goal, then demanding more.

And most importantly – being consistent.

Basma is not the first parent experiencing guilt, anger, exhaustion, and

misplaced sympathy (Kubler-Ross, 1972), ; unknowingly handicapping her grown

daughter by allowing inappropriate behavior.. Yet, by the absence of consistently

applied consequences the family was creating a young adult who resisted training

and responsibility. Jamla was allowed to point and grunt to get any foods outside

of her reach. Her dinner plate was removed for her. Her laundry was done for her.

She was often helped up the steps from her basement apartment to the dining area

on the second floor. In both instances I was to discover the family was

handicapping her growth by doing for her what they should have been

encouraging her do for herself. Here’s an example: one day, Dad spent (wasted?)

an hour trying to get her up the steps to the second floor for dinner including

manually moving her legs up the first few steps. We were in the process of setting

up a laborious, intensive, many-step task analysis when I suggested we all go

upstairs for dinner and leave her alone leaving the natural consequence of being

hungry to work. Mom and Dad (while being watched by the mother-in- law) were

concerned (near hysteria) that if they didn’t get her upstairs immediately, she

would literally starve to death. I pleaded for their forbearance asking them to wait a

few minutes more (several times) and it was reluctantly given (each time). Hearing

Jamla’s cries, a glum and silent dinner began. Ten minutes later, lo and behold, on

her own she came up the steps and joined us. “Bravo, Jamla rang out!! What else

can she do if we don’t do for her?” Once they realized it was a “won’t”, here’s

what else

  • progressing from grunts and points to a first word and in two weeks,

 

five word sentences

  • taking her plate, silver ware and glass from the table

 

  • staying seated at the table throughout dinner

 

  • not hitting her three-year-old niece

The mystery unmasked: Conclusions

Why don’t folks get better? There are many challenges to being a counselor,

teacher or psychologist with any person. One of the greatest challenges working to

change anyone’s behavior including your own, is reflecting over and over:

  • Jumping to conclusions

 

  • Is the problem behavior it a “can’t” or a “won’t”?

 

  • Are the steps in the plan too great thereby overwhelming the person?

 

  • Is the plan working?

 

  • Could outside forces be blocking change? I am fifty pounds overweight. I eat

       while watching TV. I tried to move the TV from the kitchen. My kids

       objected.

You must understand (and understanding is the hardest part) we all live in a

culture…it could be family, their extended family, their community, church,

mosque, synagogue, country or even Facebook. This environment if collective can

have more power to shape someone’s behavior than their own the best intentions.

A sad example is the culture of Generational Poverty (Payne, 1996), which can

crush the hardiest spirit. Remember the peer groups with whom you experimented

as a teenager. When your parents told you, “birds of a feather flock together”, they

may have been rightly worried as they understood the power of the group.

When I came to the Arab culture with only my truths, neglecting theirs, I met the

enemy and he was me.

References

Azrin, N. (1974). Toilet training in less than a day (3rd ed.). Simon & Schuster.

Greif, A. (1994). Cultural Beliefs and the Organization of Society: A Historical

and Theoretical Reflection on Collectivist and Individualist Societies. The

Journal of Political Economy, 102 (5), 912-50.

Danaher, B. (1974). Theoretical Foundations and Clinical Applications of the

Premack Principle: Review and Critique. Behavior Therapy, 5 (3), 307-24.

D’Zurilla, T. J., Goldfried, M. R. (1971). Problem Solving and Behavior

Modification. Journal of Abnormal Psychology, 78 (1), 107-26.

Eden, C. (1992). On the Nature of Cognitive Maps. Journal of Management

Studies, 29 (3), 261-65

Foxx, R.M. (1982). Increasing Behaviors of Persons with Severe Retardation and

Autism. Research Press, Champaign, IL

Gold, M. (1974). Overview: Try another way. (Video). Retrieved from

http://www.mnddc.org/extra/marc-gold1.html.

Gresham, F. M., Gansle, K.A., Noell, G. H. (1993). Treatment integrity in applied

behavior analysis with children. Journal of Applied Behavioral Analysis, 26

(2), 257-63.

Herrnstein, R. J. (1970). On the Law of Effect. Journal of the Experimental

Analysis of Behavior,13 (2), 243-66.

Kubler-Ross, E. (1972). On Death and Dying. Journal of the American Medical

Association, 221 (2), 174-79.

Pappe, I. (2006). The Ethnic Cleansing of Palestine. Oxford, England:

Oneworld Publications Limited.

Payne, R. K. (1996). A Framework for Understanding Poverty (4th ed.). Highlands,

TX: aha! Process Inc.

Skinner, B. F. (1963). Operant Behavior. American Psychologist, 503-15.

Stern, M. R., Golden, F. (1977). A Partial Evaluation of an Introductory Training

for Psychiatric Nurses. American Journal of Community Psychology, 5 (1),

1-22.

Thorndike, E. L. (1927). The Law of Effect. The American Journal of Psychology,

39 (1), 212-22.

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Published in: on November 12, 2010 at 5:35 pm  Leave a Comment  

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