Shaping Behavior: Contingency Management Strategies

Consistent with the DBT model, contingency management procedures are central to our program. To use these strategies effectively, however, clinicians must be well versed in the principles and application of learning theory (e.g., classical and operant conditioning). In essence, contingency management strategies are designed to reinforce adaptive behavior and extinguish maladaptive behavior. Their application is based on the knowledge that the consequences of a behavior (e.g., people laugh when I tell a joke) influence the probability of the behavior occurring again in the future (e.g., more joke telling). Thus, it is possible to increase or decrease the frequency of a behavior by influencing its associated consequences. In the previous example with Daniele, when she hesitates to take off her sunglasses, the therapist looks down at her notes as an aversive contingency (e.g., the consequence of keeping your sunglasses on during the therapy session is decreased attention from the therapist). Contingency management strategies may be subtle, as in a slight withdrawal of warmth (e.g., sitting back from the client or shifting to a more serious tone of voice) or more overt (e.g., directly talking about life- threatening ED behaviors when they occur). The selection of what strategy to use when is dependent on the therapists intimate knowledge of what is reinforcing to a particular client. What works for one client may not work for another. Likewise, what works for one client in one circumstance may not work for the same client in a different circumstance. For instance, withdrawal of warmth when a client refuses to talk about a therapy-interfering behavior will be more effective with an individual who craves attention and affection from the therapist than someone who dislikes such attention and prefers more distance. It may take some time to determine what contingency will shape a given client's behavior.

Take for example our experience with Jill, a young woman who presented with an 8-year history of anorexia nervosa, binge-purge type, and comorbid borderline personality disorder with recurrent episodes of self- injury. Before her participation in the DBT program, efforts to change Jill's symptoms were largely unsuccessful. In particular, her self-injury often resulted in discharge from standard ED programs, which felt that they were not equipped to manage her multiple problem behaviors. During the initial commitment phase with Jill, she quickly developed a strong attachment to her individual DBT therapist and often requested more time with her beyond their weekly 50-minute sessions. In an effort to shape the client's behavior, the pair agreed to the following contingency: For every full week (e.g., 7 consecutive days) the client abstained from engaging in any self-injurious behavior, she would “earn” an extra 20 minutes with the individual therapist. If she engaged in self-injury, however, she would only have their 50-minute session, at least half of which would be spent completing a detailed chain analysis of the targeted behavior (an aversive contingency for the client, who disliked speaking about self-injury). At the time of this writing, Jill has not engaged in any episodes of self-injury in 14 weeks. She attributes her willingness and ability to meet this goal to a highly reinforcing contingency.

All people are shaped by the behaviors of others and the environment that surrounds them. DBT requires that therapists remain mindful of how they influence their clients and how their clients influence them and use that information to guide treatment planning. For example, in reviewing a case in our consultation team, we realized that one of our therapists had decreased her focus on explicitly targeting weight gain (e.g., following up on weekly weight goals, weighing the client at the start of each session, conducting a chain analysis of episodes of restriction) in her sessions with a client with anorexia. We discovered that the therapist had been influenced by the client's behavior of either crying or dissociating every time the subject was broached. Similarly, one of our dieticians recognized that, as a result of a patient's angry outbursts and hostility, she had stopped addressing episodes of therapy-interfering behaviors during meal times (e.g., tearing apart food in small pieces, ongoing negative comments about her meal plan). To be clear, from a DBT standpoint, such behaviors are not regarded as manipulative; rather, they are understood as the client's best efforts (albeit maladaptive) to get their needs met (e.g., to not gain weight or follow their meal plan). As with all people, clients' behaviors are merely the result of a lifetime of learning and reinforcement. If people respond by backing away or decreasing their emphasis on change when the client cries, dissociates, or becomes angry, then the client will likely continue to engage in these processes to get his or her needs met. DBT therapists observe and describe the behavior nonjudgmentally and use it as data to help move the client closer to his or her treatment and life goals:

Therapist: Ah, so I notice just now you reacted with an angry comment when I asked you not to cut your food into small pieces [uses behaviorally specific information nonjudgmentally].

Jill: (glares at therapist and has an angry tone of voice) Don't tell me what to do. I'm eating my food just fine.

Therapist: (with softness and directness) Yikes. When you stare at me like that it really makes me want to back off [nonjudgmental, radically genuine response targeting therapy-interfering behavior]! Hmmm. I know your goal in coming into this program was to be able to go out with your friends and not feel like your eating disorder took center stage. I'm assuming that is still your goal... yes? [commitment strategy of linking to prior commitments; refrains from making assumptions about the clients behavior.]

Jill: (reluctantly) Yes.

Therapist: OK. Good to know. So my commitment to you is to help you meet that goal, which means observing and describing [therapist generalizes mindfulness skills] times when you engage in ED behavior during meals. Is there a way we can do that together without you shooting daggers at me with your eyes? [said with irreverence and a slight smile; therapist targets motivation and commitment.]

Jill: Fine (huffs but refrains from breaking her food into smaller pieces and instead takes a bigger bite).

Therapist: You rock. Now, as you finish, tell me more about that movie you saw last night [reinforces adaptive behavior and moves on].

Weekly Goal Sheet

Given the importance of contingency management with this population, we developed a weekly worksheet (see Figure 16.1) to be used collaboratively by client and therapist. The worksheet is organized around the treatment hierarchy and prompts clients to set concrete and achievable goals in each of the targeted areas (e.g., a weight goal, a therapy-interfering behavior goal). For each goal, clients are also asked to identify a corresponding contingency and reward. Therapists are recommended to help clients set their own contingencies. In our experience, and once clients have been fully oriented to these procedures and how they will help the client meet their life goals, clients are far more skilled and knowledgeable about what will shape their own behavior then therapists are.

In our program, the weekly goal sheet is completed in a 90-minute goalsetting group at the end of each treatment week to prepare clients for the week ahead. Clients are instructed to complete the worksheet to the best of their ability before the group. If they have not done so, it is treated as a therapy-interfering behavior and named as such. Clients are free to discuss all the goals in the group with the exception of their weight goals, which are reviewed and discussed in greater detail with the individual therapist and treatment team as needed.

Key Points in Contingency Management Procedures

1. Orient the client. A therapist is more likely to help the client make changes when he or she fully understands and buys into the goals and procedures. DBT is a comprehensive therapy with many moving parts; therapists sometimes forget to explain to clients why they are doing what they are doing. Transparency is an integral part of the DBT model. Before using contingency management strategies, it is important to teach clients about learning theory, thoroughly explain the rationale for using contingencies to change behavior, and link the use of these strategies to their treatment and life goals. It is also essential to orient clients to what will happen when they do not want to follow a contingency (see Point 3). In our program, we first use a

Sample Client Goal Plan

Figure 16.1. Sample Client Goal Plan

blend of commitment and dialectical strategies to increase the clients willingness to meet the contingency. If a client is still unwilling to follow through, despite our best efforts, we nonjudgmentally name the behavior as therapy interfering, and clients may not return to the program until they have met with their individual therapist to discuss motivation and commitment issues and complete a chain analysis.

2. Be collaborative. Ideally, contingencies are the result of a cooperative, nonjudgmental conversation between therapist and client. Even in situations in which there are program limits (e.g., a client must gain 1-2 pounds per week on an inpatient unit), helping the client identify what might work for him or her in a given circumstance is important. The idea here is to link contingency management procedures to the clients goals. For example, with Jill a therapist might explicitly connect the plan of reinforcing adaptive behavior with more therapist contact to the clients larger goal of developing stronger, healthier relationships in general. Of particular note is the use of the consultation-to-the- client approach, discussed earlier. Identifying needs, setting concrete goals, and learning to be accountable are skills that therapists need to help clients master. Clients with multiple problem behaviors are often less skilled at organizing multiple competing demands and problem solving in ways that help them build a life worth living. The weekly goal group and corresponding goal worksheet target such skill deficits and help clients take greater responsibility for their actions and their lives.

3. Follow through. The therapist must follow through on a contingency once it is set. Often, clients want to change or forego their contingency in the heat of the moment. This response is normal for everyone. It is incredibly difficult to change well-ingrained habits (e.g., smoking, procrastinating, swearing), and people often do not like to meet the contingencies when they struggle (e.g., they put off putting money into the “swear jar” like they said they would). The therapist's job is to hold patients to their contingencies. In our program, we set goals with corresponding contingencies and rewards (see Figure 16.1) at the end of each week. Clients are oriented to the fact that the contingencies set on Friday are held and cannot be changed until the following Friday, at which time we will review the effectiveness and suitability of the plan.

4. Know your limits and when to flex them. In the example of Jill, it was within the therapist's limits to extend her sessions with the client by 20 minutes when she met the goal of no self-injury for the week before. Therapists (and clinical environments) will differ with respect to limits. Some therapists would not be able or willing to extend a session. Choosing contingencies requires awareness of one's own limits as well as the limits of the therapeutic milieu, when applicable. Some contingencies may be beyond the control of the client and therapisl. For example, on an inpatient ED unit, the program contingency for not meeting the weekly 1- to 2-pound weight goal for several weeks might be to add a nasogastric tube. Likewise, natural contingencies are at play. A client who chooses not to gain weight might lose the ability to return to college because of medical instability, or a client who decides to withhold information about symptoms from his or her therapist might face the natural contingency of burning out the therapist or treatment team (e.g., the therapist feels frustrated with the client; the team starts to feel that they are not able to effectively treat the client). A strong consultation team will help each of its members to set contingencies with their clients that will reduce (not add to) burnout as well as support therapists when they flex their limits to help shape a client behavior.

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