Contemporary Issues in Behavioral Therapy - Cautela, J. & Ishaq, W

Contemporary Issues in
Behavior Therapy
Improving the Human Condition
APPLIED CLINICAL PSYCHOLOGY
Series Editors:
Alan S. Bellack
University of Maryland at Baltimore, Baltimore, Maryland
Michel Hersen
Nova Southeastern University, Fort Lauderdale, Florida
Current volumes in this Series
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Henry D. Schlinger, Jr.
CASEBOOK OF THE BRIEF PSYCHOTHERAPIES

Edited by Richard A. Wells and Vincent J. Giannetti
CLINICAL PSYCHOLOGY SINCE 1917

Science, Practice, and Organization
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CONJOINT BEHAVIORAL CONSULTATION

A Procedural Manual
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CONTEMPORARY ISSUES IN BEHAVIOR THERAPY

Edited by Joseph R. Cautela and Waris Ishaq
FUNDAMENTALS OF BEHAVIOR ANALYTIC RESEARCH

Alan Poling, Laura L. Methot, and Mark G. LeSage
GUIDEBOOK FOR CLINICAL PSYCHOLOGY INTERNS

Edited by Gary K. Zammit and James W. Hull
KEY CONCEPTS IN PSYCHOTHERAPY INTEGRATION

Jerold R. Gold
SEXUAL BEHAVIOR
Problems and Management
Nathaniel McConaghy
SOURCEBOOK OF ADULT ASSESSMENT STRATEGIES

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THERAPEUTIC CHANGE
An Object Relations Perspective
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Contemporary Issues in
Behavior Therapy
Edited by
Joseph R. Cautela
Behavior Therapy Institute
Sudbury, Massachusetts
and Harvard University Health Services
Cambridge, Massachusetts
and
Waris Ishaq
University of Oregon
and Pacific Behavioral Sciences Center
Eugene, Oregon
Springer Science+Business Media, LLC

Library of Congress Cataloging-in-Pub1ication Data
Contemporary issues in behavior therapy : improving the human

condition / edited by Joseph R. Cautela and Waris Ishaq.
p. cm. — (Applied clinical psychology)
Includes bibliographical references and index.
ISBN 978-1-4757-9828-9
1. Behavior therapy. 2. Clinical health psychology. 3. Mental
health promotion. I. Cautela, Joseph R. II. Ishaq, Waris.
III. Series.
[DNLM: 1. Behavior Therapy. 2. Behavioral Medicine.
3. Psychotherapy. 4. Social Work. 5. Philosophy, Medical. WM 425
C7615 1996]
RC489.B4C673 1996
616.89' 1 4 2 — d c 2 0
DNLM/DLC
for Library of Congress 96-18531
CIP
ISBN 978-1-4757-9828-9 ISBN 978-1-4757-9826-5 (eBook)

DOI 10.1007/978-1-4757-9826-5
© 1996 Springer Science+Business Media New York

Originally published by Plenum Press, New York in 1996
Softcover reprint of the hardcover 1st edition 1996
10 9 8 7 6 5 4 3 2 1
All r i g h t s r e s e r v e d
N o p a r t o f t h i s b o o k m a y b e r e p r o d u c e d , s t o r e d in a r e t r i e v a l s y s t e m , o r t r a n s m i t t e d i n a n y f o r m o r
by any m e a n s , electronic, mechanical, p h o t o c o p y i n g , microfilming, r e c o r d i n g , or o t h e r w i s e ,
without written permission f r o m the Publisher
To the memory of my mother, a loving, caring person who
believed in me
-JRC
In loving and fond memory of my deceased wives Shahenshah,

Qamar Sultan, and Waseema, my work on this book is dedicated
to Julie and Joseph R. Cautela, Gerald R. Patterson, the authors
whose works are featured in this handbook, and the men and
women at Plenum, all of whose combined efforts have made this
project possible; and to my sons, daughters, and grandchildren,
who went out of their way to engineer my environment for it to
provide reinforcement for my own work on this book
-WI
Contributors
Jacob Azerrad • 19 Muzzey Street, Lexington, Massachusetts 02173
Grace Baron • Department of Psychology, Wheaton College, Norton, Mas-

sachusetts 02766
William M. Beneke • Department of Social and Behavioral Sciences, Lin-

coln University, Jefferson City, Missouri 65102-0029
Dawn M. Birk • Eastern Montana Community Mental Health Center, 2507

Wilson Street, Miles City, Montana 59301
Joseph R. Cautela • Behavior Therapy Institute, 10 Phillips Road, Sudbury,

Massachusetts 01776, and Harvard University Health Services, Cambridge,
Massachusetts 02138
Carl D. Cheney • Department of Psychology, Utah State University, Logan,

Utah 84322-2810
Lacey O. Corbett • Behavior Therapy Associates, 208 Sandwich Street,

Plymouth, Massachusetts 02360
Nancy J. Corbett • Behavior Therapy Associates, 208 Sandwich Street,

Plymouth, Massachusetts 02360
Richard Garrett • Graduate Center, Bentley College, Waltham, Massa-

chusetts 02154
R. Douglas Greer • Teachers College and Graduate School of Arts and Sci-
ences, Columbia University, New York, New York 10027
Michel Hersen • Center for Psychological Studies, Nova Southeastern Uni-

versity, Fort Lauderdale, Florida 33314
viii CONTRIBUTORS
Waris Ishaq • Department of Anthropology, University of Oregon, Eugene,

Oregon 97403, and Mental Health Paraprofessionals Training Division, Pacific
Behavior Sciences Center, 2581 Willakenzie Road, Eugene, Oregon 97401
Albert J. Kearney • Action Therapies, 7 Carmen Circle, Medfield, Massa-

chusetts 02052
Christopher King • Department of Clinical Neuropsychology, Bryn Mawr

Rehabilitation Hospital, Malvern, Pennsylvania 19355
Jeffrey Kupfer • Mediplex of Holyoke, 260 Easthampton Road, Holyoke,

Massach usetts 01404
Glenn I. Latham • Department of Special Education, Center for Persons

with Disabilities, Utah State University, Logan, Utah 84321
Brady J. Phelps • Department of Psychology, South Dakota State University,

Brookings, South Dakota 57007-0997
Douglas H. Powell • Harvard University Health Services, Cambridge, Mas-

sachusetts 02138
Daniel L. Segal • Department of Psychology, University of Colorado at Col-

orado Springs, Colorado Springs, Colorado 8093.3-7150
Jennifer L. Twachtman • Braintree Hospital Pediatric Center, 751 Granite

Street, Braintree, Massachusetts 02184
Jerome D. Ulman • Department of Special Education, Ball State University,

Muncie, Indiana 47306-0615
Jerry G. Vander Tuig • Cooperative Research, Lincoln University, Jefferson

City, Missouri 65102-0029
Vincent B. Van Hasselt • Center for Psychological Studies, Nova South-

eastern University, Fort Lauderdale, Florida 33314
E. A. Vargas • Department of Educational Psychology and Foundations,

West Virginia University, Morgantown, West Virginia 26506
Julie S. Vargas • Department of Educational Psychology and Foundations,

West Virginia University, Morgantown, West Virginia 26506
Foreword
Many undergraduates choose to become psychology majors because of their

interest in understanding and helping themselves. Afterward, some of those
students shift their focus to understanding and helping others and go on to
graduate school. In graduate school, they may choose to either pursue research
in order to expand our understanding of human behavior or engage directly in
helping people, using knowledge gleaned from basic and applied research.
Early in his undergraduate studies, Joseph Cautela chose to pursue train-
ing in basic research, while at the same time actively expanding his clinical
knowledge and skills by working as a psychiatric aide. He continued to build
on his clinical experiences while studying for his doctorate in experimental
psychology at Boston University. I am fortunate to have had the opportunity to
serve as his thesis advisor.
In this volume, Dr. Cautela teams up with Waris Ishaq, who is known for
his work and dedication to improving the human condition. The range of
topics and the roster of eminent contributors in this volume is equal to the task
to which so many of us have dedicated our lives-that of improving the quality
of living and enhancing our environment. This book is a welcome and signifi-
cant contribution to these broad issues.
LEO REYNA
Port Lauderdale, Florida
Preface
Unfortunately, many current psychosocial and environmental problems hinder

our quality of life and threaten our very survival. Terrorism, street crime, wars,
and diseases that are difficult to eradicate are some of the factors that instill fear
in much of the world's population. Often, the fear is accompanied by feelings of
helplessness, while the problems continue to exist at the individual, socio-
economic, political, and environmental levels. Individuals from many disci-
plines are needed to help solve the problems and execute the strategies needed
to implement the solutions.
A significant purpose of this handbook is to demonstrate that social sci-
ence is already at work to alleviate human suffering on both the micro- and
macrolevels. Another important contribution of the book is that it presents a
set of behavioral principles and strategies that are effective in modifying unde-
sirable behavior.
This book attempts to present the ray of hope that psychosocial and
environmental events that adversely affect the human condition can be mod-
ified by professionals from such disciplines as philosophy, education, health
psychology, behavior therapy, and social psychology. These disciplines are all
represented in this volume.
Contents
1. Introduction ......................................... 1
Joseph R. Cautela
I. BEHAVIORAL MEDICINE
2. Medical Nonadherence: A Behavior Analysis ............. 9

Carl D. Cheney
3. Covert Conditioning in Behavioral Medicine: Strategies for
Psycho-oncology ...................................... 23
Lacey O. Corbett and Nancy J. Corbett
4. The Nature of Walking: A Foundation for the Experimental
Analysis of Orientation and Mobility .................... 45
Jeffrey Kupfer
5. Treatment of Substance Abuse in Older Adults . . . . . . . . . . .. 69
Daniel L. Segal, Vincent B. Van Hasselt, Michel Hersen, and
Christopher King
6. Behavior Analysis and HIV Prevention: A Call to Action. .. 87
Grace Baron
7. Improving Eating Habits: A Stimulus-Control Approach to
Lifestyle Change ...................................... 105
William M. Beneke and Jerry G. Vander Tuig
8. Memory Rehabilitation Techniques with Brain-Injured
Individuals ........................................... 123
Brady J. Phelps and Carl D. Cheney
xiii
XIV CONTENTS
II. EDUCATION
9. Acting to Save Our Schools (1984-1994) ................ 137

R. Douglas Greer
10. A University for the Twenty-First Century ................ 159

E. A. Vargas
1l. The Primacy of the Initial Learning Experience: The

Incredible Gift of Learning ............................. 189
Jacob Azerrad
III. DEVElOPMENTAL DISABILITIES
12. Improving the Human Condition through Communication

Training in Autism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 207
Jennifer L. Twachtman
IV. SOCIAL ISSUES
13. The Social Relevance of Applied Behavior Analysis and

Psychological Intervention Strategies . . . . . . . . . . . . . . . . . . . .. 235
Waris Ishag
14. From Aircrib to Walden Two: B. F. Skinner and Cultural
Design .............................................. 261
Julie S. Vargas
15. Perspectives on the Problem of Poverty ................... 279
Jerome D. Ulman
V. CLINICAL APPLICATIONS
16. Behavior Therapy-Generated Insight ..................... 301

Douglas H. Powell
17. Some Applications of Behavioral Principles to Sport and
Exercise Enhancement ................................. 315
Albert J. Kearney
18. Training the Client to Be Empathetic .................... 337
Joseph R. Cautela
CONTENTS xv
Vi. DEVElOPMENTAL CONSIDERATIONS
19. The Making of a Stable Family ......................... 357

Glenn I. Latham
20. Putting the Gold Back in the Golden Years ............... 383
Dawn M. Birk
VII. PHILOSOPHICAL ISSUES
21. Wisdom as the Key to a Better World 403

Richard Garrett
22. Afterword ........................................... 421
Waris Ishaq
About the Contributors ................................... 425
Index ................................................... 433
1
Introduction
Joseph R. Cautela
Unfortunately, there are many undesirable circumstances that degrade or de-

stroy the human condition. These circumstances include child abuse, domestic
violence, poverty, communicable diseases, violence, war, drug addiction, terror-
ism, prejudice, psychological disabilities, medical illnesses, developmental
problems, homelessness, intractable pain, and fragmented families. While these
deplorable conditions are present-day concerns, they have probably always
been with us. Although the general nature of the problems, for example, do-
mestic violence and war, remains the same, there are some important differ-
ences between the circumstances of the present and those of over 50 years ago.
While war has always been with us, at no time has civilization unleashed such
devastating weapons and the possibility of complete annihilation of all human-
ity. The breakdown of the nuclear family appears to be a more frequent and
devastating problem nowadays. While many communicable diseases have been
for all purposes completely eradicated, we are threatened by the human immu-
nodeficiency virus (HIV), which does not appear to be running its course like
the Black Death of the Middle Ages, but is gradually affecting a greater portion
of the population and appears to be developing more resistant strains. While
drug abuse used to be confined to certain portions of the population, it is
currently a severe problem across ethnic and socioeconomic lines. Violence in
the streets and terrorism now threaten the psychological and physical security
of everyone even here in America.
There are advantages of living in present-day society relevant to the above
Joseph R. Cautela • Behavior Therapy Institute, 10 Phillips Road, Sudbury, Massachusetts

01776, and Harvard University Health Services, Cambridge, Massachusetts 02138.
1
2 1 • INTRODUCTION
dangers. Medical advances in the treatment and prevention of many diseases

have been extraordinary. Pain control has advanced to such a stage that almost
all pain can be controlled to some extent. Imagery techniques such as X rays,
CAT scans, MRIs, and PET scans have revolutionized diagnosis and treatment.
Cardiac and cancer medication and surgery save thousands of lives each year.
Not only have there been medical advances to improve the human condition
but within the discipline of psychology there has been theoretical speculation,
experimental, and other empirical research to improve the human condition.
Empirically based psychological and behavioral procedures have been vali-
dated in the treatment of depression, developmental disability, headache, irrita-
ble bowel syndrome, panic disorder without agoraphobia, posttraumatic stress
disorder (PTSD), obsessive-compulsive disorders (OCDs), social phobias, and
problematic parental behavior (Ollendick, 1995, p. 82). In addition to alleviat-
ing suffering of the human condition on an individual basis, attempts have been
made to deal with improving the human condition on a more global social
level. Such areas include conflict resolution and violence (Goldstein & Huff,
1993), response to air disaster (Jacobs, Quevillon, & Stricherz, 1990), stress in
the workplace (Keita & Jones, 1990), improving environmental quality (Cher-
ulnik, 1993), and youth unemployment (Petersen & Mortimer, 1994).
This handbook indicates how psychological analysis and methodology
can improve the human condition, either on individual problematic behavior
or on general, socioeconomic levels. The subtitle, "Improving the Human Con-
dition" deserves definition, but it was difficult to discover any explicit defini-
tion of "human condition" despite much research. However, in keeping with
the purpose of the text, we chose one of Webster's definitions. We define
"humanist" as "a person who is devoted to human welfare; one who is marked
by a strong interest in or concern for man" (Webster's, 1976, p. 1100).
In this regard, B. F. Skinner is an example of a true humanist. In 1972, he
was the recipient of the "Humanist of the Year Award." In his later years,
Skinner was constantly concerned with increasing the welfare of humankind by
arranging contingencies of positive reinforcement. Not only was he concerned
with the present welfare of mankind but also with the survival of the species
(Skinner, 1987). In fact, Skinner's earlier interest in the survival of mankind is
reflected in an article he wrote for The Humanist, in 1972, in which he defined
a humanist as "one of those who, because of the environment to which he has
been exposed, is concerned with the future of mankind" (Skinner, 1972, p. 19).
While we do not claim to have the definitive definition of the human condition,
we have developed a working definition that reflects the purpose and contents
of this book. We define "human condition" as the psychological and physical
state of an individual. The psychological and physical states can be concep-
tualized as being on a continuum of a degree of psychological and physical
well-being.
• INTRODUCTION 3
CHARACTERISTICS OF IMPROVING THE HUMAN CONDITION
Interaction of Physical and Psychological Effects

The field of behavioral medicine assumes that the physical and psychologi-
cal states of the human condition interact with each other (Chapters 2-8). The
attempt to modify organic dysfunction can involve direct manipulation such as
in the treatment of cancer (Chapter 3) and dysfunctional walking (Chapter 4).
Behavioral medicine is also concerned with the manipulation of psychological
variables to the influence and prevention of organic pathological states (Chap-
ters 2 and 6).
Education and Improving the Human Condition

There is a consensus that education of an individual or the masses will
improve the human condition (exceptions being the teaching of problematic be-
haviors such as stealing and using drugs). The educational system in the United
States has been under constant negative criticism, and there have been many
suggestions for improvement such as increasing expenditures, decreasing class-
room size, increasing school hours, improving teacher quality, inventing better
technology, and introducing new pedagogical approaches. Chapters 9, 10, and
11 offer innovative pedagogical approaches. Chapter 6 emphasizes a behavioral
approach in the education of HIV prevention, but also presents therapeutic
approaches based on learning principles.
Developmental Considerations in Improving the Human Condition

In some individuals, improved human condition is limited and hampered
by physiological abnormalities. Those with developmental disabilities require
special methods and procedures to improve the human condition (Chap-
ter 12).
In general, the elderly (65 years and older) are more apt to experience
psychological and physiological factors that adversely affect the human condi-
tion. For this age group, the sense modalities do not function as well as they did
in their earlier years. The reinforcements experienced through vision, smell,
and hearing are usually reduced. Certain physical functions become difficult if
not impossible. The elderly are more apt to have physical illnesses that hinder
mobility and locomotion. Pain is often a pervasive problem. In the older elderly
(75 years and older), cognitive abilities decline somewhat, and they are apt to
experience more social isolation. Financial problems can limit sources of rein-
forcement and result in inadequate nutrition (Cautela, 1981). Despite what
appear to be almost inherent limitations, the elderly can be taught and helped
to improve the human condition. In Chapter 20, Birk offers encouragement for
improving the human condition in the elderly.
4 1 • INTRODUCTION
Spread of Effect
Improving the human condition of an individual (including oneself) im-
proves the human condition of others. An obvious example would be that of a
father whose illness improves, which then enables his children to worry less and
now gives them more freedom to spend time improving their own human
condition. In successfully treating agoraphobics, I have noticed how the family
dynamic can change to decrease family dysfunction (Chapter 18).
levels of Improvement of the Human Condition

Improving the human condition can take place at different levels. An
individual picking up litter on the street can affect the environment, though
perhaps not as much as protecting the ozone layer or the rain forest. Doing
individual therapy on panic disorders may not improve the human condition as
much, in the long run, as research on panic disorders. Paying a person a
compliment can have an effect on improving the individual's human condition,
even if only temporarily. On the other hand, curing a client of a panic disorder
may have a longer-lasting effect on the individual's human condition. A con-
cerned excellent teacher will improve the human condition of her pupils, but
perhaps reorganizing the educational system will have a greater effect (see
Chapter 10). Another example of level difference is counseling an individual on
domestic violence compared to trying to influence legislation, writing books,
and conducting panel discussions on television on this topic. Besides compas-
sion and care for someone with HIV, developing effective HIV education
awareness programs (Chapter 6) will affect more individuals.
Social Factors and the Human Condition

Chapter 13 discusses the social relevance of applied behavioral analysis.
Chapter 14 emphasizes how appropriate cultural design can improve the hu-
man condition.
The quality of life near or below the poverty level is certainly not likely to
be adequate. Poverty affects educational opportunities; access to health care
systems is often limited or not at all available. Fear is a constant factor since
violence is often a real threat in urban poverty areas. Chapter 15, on perspec-
tives on the problem of poverty, analyzes the welfare system in the United States
and suggests remedies and alternatives. Not only does Ulman consider the
multitude of factors that influence economic status, he also presents a behav-
ioral model on how to eliminate obstacles to decreasing poverty.
Clinical Treatment and the Human Condition

While it seems obvious that the purpose of therapy is to improve the
human condition of the client, there is often a spread of effect, increasing the
human condition of significant others. There are two main arguments that seek
1 • INTRODUCTION 5
to deprecate the effects of therapy on the human condition. The first holds that
most of the time therapy is not effective or is not worth the time, effort, and
money for the meager benefits achieved. The other argument holds that the
only real solution that will have any impact on an individual's human condition
is to work on a macro level by trying to modify the socioeconomic and educa-
tional systems of a society.
As to the first argument: On an anecdotal level, we clinicians have ob-
served some of our clients become free of crippling anxiety through psychologi-
cal therapy (where drugs have failed), thereby increasing the quality of their
lives. We also have experienced how stress reduction procedures utilized in the
workplace have reduced organic symptomatology and maintained employ-
ment. There are many more examples that psychological therapy can improve
the human condition (see above examples of empirically based and validated
psychological and behavioral procedures). While it is logical that the human
condition of more people will be enhanced by modifying environmental fac-
tors, there will always be certain clients who will need individual therapy. Also,
what do we do while waiting for a new cultural design to become effective?
According to the psychodynamic school, insight is necessary for behavior
change. Chapter 16 presents some sound arguments and observations to dem-
onstrate that at least sometimes insight follows a behavior therapy procedure.
Chapter 18 proposes that teaching a client to be more empathetic not only
improves chances for therapeutic success but generally improves the client's
human condition as well. Chapter 17 demonstrates how behavioral principles
and procedures may be applied to enhance sports behavior. Those of us who
have worked with athletes recognize many stresses such as making the team,
getting enough playing time, anticipating competition, and being fearful during
competition. Helping athletes decrease stress in athletic-related situations cer-
tainly helps increase their quality of life.
Philosophy and Improving the Human Condition

At first glance, a chapter devoted to the philosophical approach to improv-
ing the human condition appears out of context. However, when one considers
how, through the ages, philosophers have tried to tell us how to live the good
life, what is the good life, how to avoid evil, and how to deal with despair, a
philosophical approach is not out of context after all.
Garrett, in Chapter 21, proposes that "wisdom is that understanding
which is essential to leading a good or better life and that such an understand-
ing is a key to a better world, a world in which people lead better lives." Garrett
presents sound reasoning and gives examples of human behavior that support
his assumptions.
The scope of chapters presented in this handbook indeed represents a wide
range of approaches. It is the hope of the editors that these chapters will
stimulate further theoretical speculation, research, and implementation of
strategies to improve the human condition.
6 • INTRODUCTION
REFERENCES
Cautela,]. R. (1981). The behavioral treatment of elderly patients with depression. In J. F. Clarkin
& H. G. Glazer (Eds.), Depression: Behavioral and directive treatment strategies (pp. 344-365).
New York: Garland Press.
Cherulnik, P. D. (1993). Applications of environment-behavior research. New York: Cambridge
University Press.
Goldstein, A. P., & Huff, C. R. (Eds.) (1993). The gang intervention handbook. Champaign, IL:
Research Press.
Jacobs, G. A., Quevillon, R. P., & Stricherz, M. (1990). Lessons from the aftermath of Flight 232:
Practical considerations for the mental health profession's response to air disasters. American
Psychologist, 45, 1329-1335.
Keita, G. P., & Jones, J. M. (1990). Reducing adverse reaction to stress in the workplace. American
Psychologist, 45, 1137-1141.
Ollendick, T. H. (1995). AABT and empirically validated treatments. The Behavior Therapist, 18,
81-82,89.
Petersen, A. c., & Mortimer, J. T. (Eds.) (1994). Youth unemployment and society. New York:
Cambridge University Press.
Skinner, B. F. (1972). Humanism and behaviorism. The Humanist, 32, 18-20.
Skinner, B. F. (1987). Why we are not acting to save the world. In Upon further reflection (pp. 1-
14). NY: Prentice-Hall.
Webster's third new international dictionary of the English language, unabridged. (1976). Chicago:
G. & c. Merriam.
I
Behavioral Medicine
2
Medical Nonadherence
A Behavior Analysis
CarlO. Cheney
Behavior is a difficult subject matter, not because it is
inaccessible, but because it is extremely complex.
B. f. SKINNER (1953)
THE PROBLEM
Imagine a 53-year-old man, Roy, who has a history of minor heart problems.
He suffers from hypertension and his doctor has prescribed medication to
lower his blood pressure. His doctor also suggests he schedule a medical check-
up every three months. Roy faithfully takes his medication for a few weeks
precisely on the prescribed daily schedule. As times goes by, however, he real-
izes that he does not feel any differently now than he did before, and he can also
see that the medication is costing more than he cares to pay. So, Roy conve-
niently "forgets" to take his pills, and gradually the entire routine stops. Occa-
sionally he experiences a period of mild chest discomfort but passes it off as
indigestion. After one such episode, Roy's wife makes him go to the hospital.
The nurse in the emergency room takes his blood pressure and determines that
he is supposed to be, but is not, taking his medication. Roy tells her that he
sometimes forgets to take it but promises to do better in the future. The nurse
gives him a few warnings and sends him home. Every 3 months, Roy's wife
reminds him to go to his scheduled appointment for a checkup. He takes his
medication regularly for a week before the checkup, and the doctor, upon
Carl D. Cheney • Department of Psychology, Utah State University, Logan, Utah 84322-2810.
9
10 I • BEHAVIORAL MEDICINE
examining him, considers him to be doing just fine and tells him to come back
again in 3 months.
As for Roy's pharmacist, he filled the prescription for Roy and quickly
filed his record as another one of the thousand customers he sees every month.
He does not keep track of Roy nor does he remind him to refill his prescription
once he finishes the bottle or when he is supposed to finish it. The pharmacist's
job is to supply the medication, not to nag his customers to comply. At the age
of 55, Roy dies of a heart attack. A classic scenario in the failure to adhere to a
preventive medical program.
The issue of medical nonadherence (previously called noncompliance) is
not a recent problem in health care management. Centuries ago, Hippocrates
warned, "The physician should keep aware of the fact that patients often lie
when they state that they have taken certain medicines." Adherence, or the lack
of it, exists today as a major factor in self-health-care performance (Tebbi,
1993). According to the National Council on Patient Information and Educa-
tion, 30% to 50% of all prescriptions do not produce the desired results
because patients either do not take their medications properly or do not take
them at all. It is a well-recognized problem, yet it remains a poorly under-
stood-and from a behavior science perspective-a greatly understudied topic.
Nonadherence to medical recommendations affects health care in many
crucial ways. It is estimated that 125,000 deaths occur each year in the United
States as a result of patient failure to follow a prescribed health plan. Non-
adherence also causes hundreds of thousands of unnecessary hospitalizations.
Patients return and return again to their physician for more help when, in fact,
they are not following the instructions already provided (Trick, 1993). Accord-
ing to recent statistics from the Upjohn Company, 19% (one fifth) of Ameri-
cans failed to fill a prescription given to them by a physician in the last year and
that up to 90% may self-administer medication improperly (Braus, 1993).
Nonadherence is expensive. Idle time due to illness, including hospitaliza-
tions, results in millions of lost workdays. The National Pharmaceutical Coun-
cil estimates that costs of nonadherence to prescribed treatment are anywhere
from $8 billion to $25 billion each year (Braus, 1993), and furthermore the
industry loses about 25% of its potential revenue this way (Choo, 1993).
The issue of nonadherence affects not only those who receive health care,
but those who give it as well. The most obvious outcome from not complying is
apparent treatment failure. Physicians assume that the patient is adhering to
the prescribed treatment, so that when the desired result does not occur, they
logically assume the prescribed drug or therapy is ineffective. Therefore, they
must see the patient again and will often change the prescription to stronger
medications or even recommend surgical or other radical intervention (Trick,
1993). Such patient behavior consumes the time of health care providers as well
as the resources of treatment recipients, therefore, increasing costs throughout
the health care system.
The wide range of nonadherence behaviors can manifest themselves in
terms of the serious and complex issue of fluid noncompliance in end-stage
2 • MEDICAL NONADHERENCE 11
renal disease, or it can be as simple as the administration of an oral antibiotic

for childhood ear infection. The degree to which nonadherence with a medical
regimen can be life-threatening appears to have little effect on patient behavior.
Many diagnoses with life-threatening implications have as high as 38% of
patients failing to adhere to short-term treatment plans and 43% do not adhere
to long-term prescribed regimens. More than 75% of patients are unwilling to
follow lifestyle change recommendations (DiMatteo et aI., 1993).
There seem to be few antecedent conditions that predict adherence. The
problem affects young and old patients, serious and mild diagnoses, simple and
complex regimens, all of which have significant health care cost implications.
As we approach the installation of a new national health plan, those interested
in medical adherence might wonder how much current health care costs could
be reduced if people were medically compliant. How many revisits to a physi-
cian are the result of not following orders from a previous visit? Are people
more or less medically compliant if payment for doctor visits, medications, and
so forth are a personal expense and not billed to insurance? Will adherence
improve if a national health care plan is in place for every individual, or can we
install contingencies with a plan to enforce compliance?
Trostle (1988) indicates that more than 4000 papers have been published
about medical adherence/nonadherence over the past two decades with vir-
tually inconclusive evidence regarding determinants and solutions. One major
reason for such interest is that medical nonadherence is an obviously compli-
cated, multidimensional and very important problem, and therefore it gener-
ates a great deal of analysis. In addition, the fact that the professional disci-
plines involved do not include behavior scientists further adds to the diversity
and seemingly rational but not very effective approaches to a solution.
In this chapter, I review and discuss the issue of patient nonadherence to
physicians' requests and recommendations, primarily with reference to medi-
cine self-administration. I attempt to define the problem as an overt human
behavior that is under weak contingency control. I end with some suggestions
as to how the problem might better be considered, some new ideas and direc-
tions for exploration, and possible solutions.
ANALYSIS
There are many reasons for not following a medical recommendation

because behavior is always under multiple control. Some obvious candidates
for nonadherence include previous experience with failure of a medicine to be
effective, fear of possible medication side-effects, inadequate financial means,
opposing cultural beliefs or traditions, doubt about the accuracy of the diag-
nosis and recommended treatment, ignorance, or illiteracy. People are often
"sick," and in most cases they recover with little if any medication; therefore,
getting by and trusting in "nature's way" (or chicken soup) has a certain
reasonable, if simplistic (and perhaps fatalistic), appeal.
In addition to these, I believe another, and more important, reason exists

for medical nonadherence: the lack of immediate feedback for the adherence
response. All behavior is influenced best by immediate consequences. Buying
and taking medicine appropriately may be followed by positive but often de-
layed consequences; but "may be" and "delayed" have none of the effec-
tiveness of "immediate" and "certain" meaningful consequences. When a pa-
tient takes a medicine and nothing happens right away, or even within hours,
the treatment adherence behavior is not strengthened. It is therefore not sur-
prising to a behavior scientist to observe that compliance under these condi-
tions is low.
Considering medical adherence from a behaviorological position, it is
clearly a special case of the more generic topic of prevention or illness avoid-
ance. The major issue is that the act of complying with a medical prescription,
as an illness prevention action, is most often equated with nothing immediately
happening. In terms of the behavior scientist, a nondiscriminative (no warning
signal) avoidance response is one that delays, cancels, or postpones the onset of
an aversive event scheduled to occur sometime in the future. Therefore, the
result of an effective avoidance response is literally nothing happening now or
later. Behavior is a function of its consequences, and zero consequences cannot
affect behavior.
The initial consideration regarding behavioral paradigms and where medi-
cal adherence fits in is as an avoidance or prevention issue. Avoidance is defined
as the prevention of the occurrence of an aversive stimulus by a response. In
deletion avoidance, the response (for example, taking medicine) cancels or
prevents the presentation of the aversive stimulus (e.g., onset of illness, infec-
tion, or even premature death may be prevented by following the treatment
prescription.) In postponement avoidance, the response only delays the aversive
stimulus, and therefore it must be repeated at periodic intervals. There are
medical regimens and prescription recommendations that fit into both of these
paradigms.
In discriminated (signaled) avoidance, a warning signal precedes the ap-
pearance of the aversive stimulus. Such a warning stimulus in terms of impend-
ing bad health is generally the initial condition that occasions the visit to the
physician in the first place, followed by the prescribing of the medical regimen.
In this case, by making some sort of response to an uncomfortable physical
"feeling," the organic condition is often altered and the appropriate behavior is
immediately reinforced (at the very least by the physician saying something to
the effect that the patient did the right thing). For example, having a tempera-
ture due to infection that is causing inflammation and pain and getting some
antibiotic treatment that reduces the discomfort within a few hours is clearly an
understandable contingency between the setting event, the behavior, and the
consequence.
Sidman (1953) developed the experimental avoidance procedure he called
free-operant avoidance and which has become known as Sidman avoidance. In
this type of avoidance, there is no warning signal preceding the aversive stimu-
Ius; it is simply delivered on a time-based schedule. Eventually the organism

may make an appropriate avoidance response that delays or postpones the
forthcoming stimulus or event. Each additional response also delays the next
scheduled aversive stimulus, but there is no warning stimulus that terminates
and thus no immediate feedback for the response. This is a difficult program
for a research subject to learn and equally difficult to account for experimen-
tally and theoretically. But it is clearly the most analogous to medical adher-
ence. For example, high blood pressure is called the silent sickness because it
has no warning symptoms. Moreover, the treatment has little if any discernable
effect on how the patient "feels." Such a situation provides a significant chal-
lenge for behavior management, and therefore suggests one reason why the
statistics on nonadherence are so great.
An escape paradigm is differentiated from avoidance in that with escape
there is an aversive stimulus already present, which is then terminated by the
escape response. The escape situation is called negative reinforcement because
the response is strengthened by the removal of a stimulus. If we view medical
adherence, when it occurs, as being discriminated avoidance, we could argue
that what we are really dealing with is escape from a warning stimulus. That is,
some pain or discomfort prompts going to a physician, and then this behavior
results in the termination of the uncomfortable condition contingent upon
adherence to the doctor's recommendation. It is important to distinguish avoid-
ance from escape, because with escape the controlling event is clearly the
contingent consequence of the response-the removal of an aversive stimulus-
but with avoidance there is no obvious contingent event. That is the big prob-
lem.
Research investigating the parameters of escape began in Thorndike's lab-
oratory at Harvard University in about 1886. His cat subjects were required to
escape from a "puzzle" box. There has been a great deal of controversy regard-
ing the operational and functional definitions of avoidance, aversives, and
escape throughout this century. Researchers often referred to the avoidance
paradox as, "How can the nonoccurrence of an event (e.g., footshock in a rat
chamber) serve as an effective consequence for an avoidance response?" In
other words, when a successful avoidance response occurs, nothing happens to
the organism. How can nothing, or the absence of an event, serve to control or
maintain behavior? There is evidence that avoidance responses are very resis-
tant to extinction if the subject has sufficient experience with the aversive event.
Several suggestions have been made in an effort to deal with the avoidance
paradox. Some research supports a one-factor theory and other a two-factor
account, while some research has resulted in researchers abandoning the topic
of avoidance altogether. According to one-factor theory, avoidance responses
are maintained as a result of similar escape from aversive stimuli in the past and
are most easily learned when a warning stimulus is terminated by the response.
Herrnstein and Hineline (1966) provided much of the evidence that emerged as
one-factor theory.
Mowrer (1947) promoted a two-factor theory according to which fear is
first respondently conditioned in an organism. (It is assumed that fear in this

case is aversive.) This is accomplished by presenting a noxious stimulus and
allowing the subject to both experience it and then to terminate it by making
some response. The temporal or physical parameters associated with the stimu-
lus thereafter elicit fear. The operant, which is the avoidance response (second-
factor), then occurs and is followed by escape from (termination of) the covert
aversive fear stimulus. Therefore, the immediate reinforcing consequence for
the putative avoidance, but really escape response, is termination of the aversive
fear condition (Anger, 1963). "Avoidance" of something that never happens in
the future has nothing to do with it. Nonetheless, we have usually had an
extensive history of following instructions because such behavior is often fol-
lowed by something good. We may be told, "Do a good job and there will be a
good payoff," and sure enough that has happened. But when we are told, "Do
this and nothing will happen," that is not a very viable instruction, because we
often do not do something and nothing also happens, so why do something for
nothing? This analysis requires identification of an essential contingent conse-
quence necessary to bring avoidance into the realm of understandable control-
ling variables.
The nature of what is the reinforcer in avoidance has been an issue of
discussion for decades. Some have theorized that avoidance occurs without any
reinforcing event (Fantino, 1973). Others have insisted that it is critical to
identify some contingent event. Mowrer (1947) reasoned, however, that a gen-
eral stimulus, such as fear, is complex and probably has several stimuli as its
component parts. Most researchers agree that fear has many physiological
properties and sensations that are unpleasant. Hence, any reduction of the
stimuli constituting fear could be reinforcing. A safe conclusion is that both
classical conditioning and operant conditioning seem to be involved in an
avoidance response.
It is clear from the history of medical nonadherence that fear alone, or the
amount of fear generated under most conditions, does not adequately motivate
adherence. Fear reduction might account for compliance in some instances, but
by no means does it appear to be a sufficiently persistent or effective factor. For
one reason, patients rarely, if ever, come into direct contact with the aversive
condition so as to have firsthand experience with the results of nonadherence.
In addition, behavioral extinction is always taking place whenever the "fear-
inducing" conditioned stimulus is present but the response is not made and yet
the aversive stimulus does not occur. That is, when the physician's threat, "You
had better do such and so or else," is present but without a consequence for
nonadherence, it becomes an empty and meaningless caveat. We come to ignore
such hollow warnings.
Contingent consequences are what govern behavior. This is a basic given
in behavior science. "As an experimental analysis has shown, behavior is
shaped and maintained by its consequences, but only by consequences that lie
in the past. We do what we do because of what has happened, not what will
happen" (Skinner, 1989, p. 15). What are the consequences for adherence to a
prescribed medical program designed to prevent something bad in the future?

A medical adherence response, such as buying and taking blood pressure medi-
cine, are specific behaviors that are said to avoid, delay, or cancel the onset of
an aversive event. Therefore, the immediate (and long term, as well, for that
matter) result of an effective avoidance response is nothing happening, and
"nothing" cannot strengthen behavior. The bad thing did not happen; the
avoidance response "worked," and therefore the possibility of something hap-
pening was negated. Herrnstein (1969) argues that the reduction in the molar
density of bad things due to a specific response is the reinforcer for the re-
sponse. But the absence of any consequence for a specific response is not what
maintains that behavior. I suspect that this is a major part of the reason why
there is such a poor medical adherence record.
When any behavior avoids a potential aversive event, that is, some bad
thing is prevented from happening and therefore does not occur, there is seldom
an overt concomitant response-contingent consequence. Nonetheless, behavior
is always a function of its immediate consequences, and so there must be
something that happens following a response in order for the probability of
that response to be effected (Rachlin, 1989). To be effective, a behavioral conse-
quence, be it punishment or reinforcement, must follow the specified behavior
in less than 30 sec. Behavior is continuous and ongoing, in a "stream" as
William James said, and events and reinforcers are inserted into that stream. If
you wait too long to insert consequences, then they automatically become
contingent upon different behaviors. Furthermore, as the improbability or un-
certainty of the occurrence of a consequence increases, as well as a delay in it
happening (if at all), the control that such a potential consequence might have
is dramatically reduced. If future events are both uncertain and long-delayed,
they will not exert much control over behavior. And that appears to be the case
with medical adherence: aversive consequences for nonadherence are uncertain
and delayed.
It appears that "verbal rules" are what sustain human behavior under
these conditions (Skinner, 1989; Malott, Whaley, & Malott, 1993). But be-
cause such rules are indirect-acting, they are not always very effective. If a rule
specifies a consequence that is not certain, that is, the consequence mayor may
not happen, then the rule is even less effective than one specifying a delayed but
certain consequence. For example, people understand that there is only a
chance (certainly less than 100%) that a single act of unprotected sex will result
in contracting the human immunodeficiency virus (HIV). And not only is
infection uncertain, but even if its does happen, the effect is greatly delayed and
hardly comprehensible. Besides, a person may have had dozens or hundreds of
previous unprotected sex experiences without contracting any disease, so one
more cannot hurt (so sayeth the sexually transmitted disease gambler's fallacy).
Hence, it has proven difficult to counter the immediate reinforcing effects of
unsafe sex with simply the threat of "maybe" getting HIV and then only years
"later" dying from AIDS (see Chapter 6, this volume). As a result, the transmis-
sion of HIV is epidemic (except in Cuba where persons who are HIV-positive
are quarantined), because people frequently engage in uncertain-risk and de-

layed-consequence behavior that is also immediately reinforcing. This type of
consequence arrangement, wherein there is immediate reinforcement and un-
sure but always delayed punishment, is called a contingency trap (Chance,
1994). Variance in the level of perceived importance, unclear information as to
the severity of the possible illness, and the socioeconomic status of individual
patients often present contingency traps that reinforce short-term non-
adherence in the face of delayed and uncertain cost. Compliant behavior is also
gradually extinguished as any real or assumed positive effects are small and the
savings in both dollars and effort for nonadherence soon override the threat of
possible future disaster.
SOLUTION
Suggestions for solving the problem of noncompliance are nearly as nu-

merous as reasons for why patients do not comply. The major focus of most
attempts to correct the probl~m (and why they fail) has been either education
or reminder devices. These are clearly not the crucial reasons for medical
nonadherence. Most authors who investigate this topic agree that there is a
definite need for better patient education. They especially stress patient "under-
standing" of the reasons for the specific treatment, the expected health effects
of compliance, minimizing any potential untoward side effects, and the proper
steps in the administration of the treatment (Braus, 1993; Feldman, 1993;
Irwin, Millstein, & Ellen, 1993; Tebbi 1993; Trick, 1993). In this regard,
physician-patient interaction is very important and should be ongoing, but
unfortunately it is frequently brief and inadequate (DiMatteo et al., 1993;
Feldman, 1993). Physicians often appear to assume that since their word is law,
the patient has no alternative but to comply. This perception by the physician
often leads to a foreshortening of any appropriate educational activities and
sends the patient on his or her way ignorant of what, how, and why. Physicians,
as well as everyone else, need reinforcers to follow their behavior, especially
those personalized patient educational activities that may help to improve pre-
ventive activity, such as follow-up examinations. Clearly, and paradoxically, for
a medical doctor to be effective in preaching prevention, he or she is actually
working at odds with his or her own self-interest to maintain patients. This will
probably never be a serious threat to a physician's profession, however.
Behaviorologists have shown that human behaviors are maintained by
their consequences, and when there are none or when those consequences are
sufficiently delayed, obscure, or weak, it is virtually impossible to sustain any
stable performance. Because of this, I suggest that the human behavior problem
of medical nonadherence should be recast into its proper behavioral paradigm
wherein the patient's compliance response must be immediately linked by posi-
tive reinforcement or escape from an aversive stimulus. There has to be feed-
back of some kind that results in a strengthening of the response. In the escape
situation, therefore, the immediate consequence of adherence to the medical

recommendation might actually be a reduction in an "ever-present" (covert
statement of a verbal rule perhaps) aversive condition. The aversive condition
in this case is the physician's instructions, stated in the form of a warning rule,
that if the patient does not take the medication as prescribed, they will suffer
dire, probably fatal, consequences. I submit that this is actually about all that
controls adherence now in many cases, and it does so very poorly, as the
statistics indicate. I believe the procedure is weak because, (1) the physician is
not sufficiently explicit; (2) extinction of adherence and no consequences of
nonadherence is occurring; and (3) response costs are exerting countercontroJ.
The physician recommends, that is, he or she explicitly or implicitly warns the
patient, that they should "get and take some medication or change their behav-
ior" in order to counter or reverse their organic problem. (Example, the doctor
says, "Don't smoke anymore, or you might get lung cancer and die." This is the
prescribed behavioral regimen and rule. But the patient continues to smoke,
which is noncompliance due to immediate reinforcement and improbable de-
layed punishment; besides, death is inevitable, and therefore it isn't much of a
long-term threat.)
The problem in this case, as I see it, is that the warning is most probably
insufficient. The patient does not really believe, comprehend completely, hear,
or care that bad things will or might actually happen sometime later without
compliance. Or, like Roy, they may follow the rule for awhile; but soon, as they
feel no different with or without the medicine, they "forget," or they spend
their money for more immediately tangible items.
If medical nonadherence is considered to be a nondiscriminative avoidance
issue or an escape behavior problem, it is more likely that a solution can be
generated. From the literature concerning the "theory" of medical compli-
ance/ adherence, it seems clear that most effort has gone into assessing and
discussing the problem in terms of psychological constructs. It may be that the
problem has been that most past attempts have approached compliance as a
complex and multidimensional psychological process involving such hypo-
thetical constructs and cognitions as expectations, memory, self-control, per-
sonal autonomy, desire, willingness, resistance, death wish, understanding,
knowledge, belief, trust, willpower, free agency, civil rights, and so forth. When
couched in such terms, the exact steps to intervention become confused be-
cause the controlling agent-the patient, physician, nurse, and so on-is trying
to deal with intangible mental events instead of observable and objective behav-
ior. What exactly is one to do to alter desire or willpower or belief?
I define adherence or nonadherence in behavioral terms, since the problem
is obviously one of human behavior, mainly a deficiency: people do not take
medicine as they should. I believe that medical adherence does not differ from
many other human behaviors. It is under the control of past and present
contingencies and the behavior of adherence or nonadherence is a function of
its consequences. The problem is clearly one of managing human behavior by
managing response consequences, not simply with patients, but with physi-
cians, nurses, pharmacists, family members, and society at large. It is the

environment that controls behavior and people are all part of everyone else's
environment. This approach to analysis seems clearly to be the most efficient
and encompassing method: to consider the problem from a behaviorology
perspective as a behavior management issue.
The social implications of the enormous cost of health care is indicated by
the current effort to contain them by restructuring the system. The time is right to
appropriately consider medical nonadherence with regard to health care costs
and other tragic social results. Clearly, however, it will not improve adherence by
simply fiddling with health care programs any more than individual education
performance will improve by lengthening the school day/year. The problem in
both cases lies in the management of individual behavior contingencies.
From a nurse's point of view, the problem is approached rather directly.
Nurses are generally the primary caregiver in any health care plan. They are the
ones who do much of the direct interacting with the patient and they try to do
their job within the parameters of the patient's perspectives and motives in
fulfilling the recommended or prescribed treatment. To provide efficient and
effective service, the nurse must identify nonadherence, assemble the various
factors that are assumed to have contributed to that behavior, attempt to
determine reasons, and then to generate a solution to change the behavior. The
detection, diagnosis, and attempted correction of the problem results in in-
creased work hours, increased stress-related behavior on both nurse and pa-
tient, and a decrease in cost-time efficiency (Faller, 1993). The nurse's role can
be to strengthen the actions recommended by the physician and to ascertain
what, if any, constraints or barriers exist for the patient that can be overcome
by the system (e.g., finances).
Pharmacists also have a difficult, yet vital, role to perform in dealing with
the problem of nonadherence. They must be informed of the nature and pur-
pose of the recommended treatment so as to further educate and aid the patient
in "becoming active and informed decision-makers regarding compliance with
their prescribed therapeutic plans" (American Journal of Hospital Pharmacy,
1993, p. 1077). They assist the patient in correctly filling the prescription and
refilling it at the appropriate interval, if the patient brings in the prescription. It
may be that pharmacists can be more effective in the process of managing
patient compliance to medical prescriptions than they have been. For example,
since the pharmacist has each patient's record stored in a computer, it could be
that a simple program to automatically telephone the patient when their pre-
scription should be finished and refilled would help adherence. This could be a
fully automatic operation of the computer with a prerecorded message so that
little effort on the part of the pharmacy staff would be required. The point
would be to reassert the recommendation given to the patient by the physician.
What such a program would be doing is reestablishing the "threat" that
the physician provided when he or she recommended the treatment in the first
place. The aversiveness of this "threat" is what the patient contingently escapes
by the action of adhering and complying. It is not only that by complying the
patient will therefore avoid bad things and live, it is mainly that by not adher-
ing to the recommendation they will be failing to follow the rule stated by the
physician. The immediate outcome (escape from the physician's threat) is good
when you do it and bad if you do not (the threat remains). Once the rule is
stated to the patient by the health care giver, "Follow this program or you will
die," it will always be covertly present and only needs occasional overt restate-
ment by an authority figure for it to remain at strength such that adherence
will temporarily reduce its fear-inducing effects. So what links a medical adher-
ence behavior, such as taking medicine to reduce blood pressure, is the reduc-
tion in fear that was established by the physician when diagnosing the organic
problem. A description of the statistics reporting about those who have not
followed best-practice medicine-lifestyle adherence recommendations will fur-
ther support the rule-consequence effect. Granted, this suggestion for main-
taining adherence is based on coercion and is therefore negative in the sense of
deliberately inducing an aversive condition (Sidman, 1989). However, there
seem to be few immediate positive consequences to be employed, and most
importantly the system is not working as it is; therefore, more drastic action is
called for. Nurses have time, skill, and logical constraints as do pharmacists;
but passing the responsibility buck from one service provider to the next is not
useful.
Possible immediate response-contingent activities that have probably not
been adequately tried and that may also help alleviate the nonadherence prob-
lem include (1) a visual or auditory alarm on the pill container that can only be
turned off by opening (another escape contingency), (2) pharmacists providing
a computer phone reminder, and (3) a positive reinforcer on each pill that is
pleasant (such as chocolate), so that there is both pleasant and immediate
feedback for taking it. This approach might go so far as to include an occasion-
al time-release contingency wherein something especially euphoric is released
by the pill within a few minutes of ingestion. The point is to find something
that will provide both an immediate and selective positive consequence for a
specific adherence behavior.
Reminder devices that have been used in an attempt to increase patient
compliance include prescription calendars, pill holders that specify the day on
which medication is to be taken, telephone calls to remind patients of physician
appointments or (rarely) treatment information, physician-provided instruc-
tion checklists, automatically generated reminder charts, electronic beeping
"memory joggers," and some types of "reward" systems (Trick, 1993; Raynor,
Booth, & Blenkinsopp, 1993). Education and reminder devices do have a posi-
tive effect on patient compliance; however, they do not seem to provide a
satisfactorily comprehensive or successful solution to this complex behavioral
phenomenon. The statistics reporting the magnitude and complexity of the
issue still stand as evidence of the failure to solve the problem with such
procedures. It seems clear that education and reminder devices may be neces-
sary but are not sufficient.
It turns out that the behavioral engineer needs only a limited set of princi-
pIes to call on to solve such problems. These are either response-enhancing

methods (positive or negative reinforcement) or response-reducing procedures
(punishment or extinction); so it is just the particular way they are employed
that will solve most behavior problems. I suggest the situation is best consid-
ered an escape problem and that we need to strengthen the aversive stimulus to
be escaped. The problem reduces to one of establishing a functional setting
condition (a verbal rule) that will occasion the response and then supply imme-
diate feedback for the proper action.
Unfortunately, any avoidance behavior is difficult to manage, especially
when dealing with rule-governed behavior. The control of human behavior in
general is difficult because of the many influencing factors that are often un-
known, and even when they are known they are often unmanageable. Nonethe-
less, human behavior is a subject matter that is amenable to scientific treat-
ment, it is determined by natural principles, and it is predictable (Skinner,
1953). Control of the behavior of organisms requires an objective task analysis
and the systematic application of proven, and known-to-be-functional, behav-
ior management procedures.
We need to clearly operationalize what we mean by medical nonadherence
to enable a more effective analysis of each behavioral component involved. We
also need to state some basic assumptions about noncompliance. For example,
I see compliance as a low-probability overt human behavior analyzable in terms
of an avoidance-escape paradigm. Second, such behavior needs to be viewed as
a rule-contingency relationship between physician, or other health care pro-
vider, and the patient. Third, the three-term contingency relationship must
involve the prescribing of medications or some health regimen; the patient's
behavior, whose presenting problems indicate the need for such prescriptions;
and the firmly expressed consequences of adherence and nonadherence.
SUMMARY
The problem of medical nonadherence is very important. Whatever has
been and is being done is not adequately managing the issue. Something new
needs to be tried. The problem, as I see it, has to do primarily with a failure to
define the problem properly and also to deal with the issue from an appropriate
behavior science perspective. Medical professionals, whether physician, nurse,
or pharmacist, are not behavior experts. They do not receive training in the
natural science of behaviorology, so it is no mystery why they have not solved
the medical nonadherence problem. It is a matter of ignorance by physicians
and patients and a failure on the part of behavior experts to dedicate time and
energy toward treating this serious social issue.
I suggest that nonadherence is a product of the individual's history of
reinforcement or punishment and the immediate consequences for rule-gov-
erned behavior. It is my contention that when medical adherence behavior is
considered as an active nondiscriminative avoidance response, various actions
emerge as potential solutions. The establishment of a meaningful warning

signal will turn the avoidance problem into an escape situation and more
effectively result in adherence. The issue and its behavior science treatment have
wide relevance in terms of any illness prevention behavior.
Acknowledgment. The author wishes to thank Kevin Duke, Jacqueline

Daniels, and Erin Miller for discussions and assistance in producing this chapter.
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3
Covert Conditioning
in Behavioral Medicine
Strategies for Psycho-oncology
Lacey O. Corbett and Nancy J. Corbett
INTRODUCTION
Imagery and the potential healing powers of the mind have been in existence
almost since the beginning of time. The body of research and treatment of
illness in Western medicine, however, has focused primarily on developing
biological methods designed to correct the maladies of the body through medi-
cal, surgical, and pharmaceutical interventions. In recent years, psychologists
and social scientists have become more aware of the mind-body connection
and of how covert events (thoughts, feelings, and images) can influence the
course of disease.
The use of imagery has consequently been applied by clinicians of various
theoretical orientations as a treatment intervention for a variety of illnesses that
are physiological in origin. A sampling of these procedures can be found in
several publications (Achterberg, 1985, 1992; Achterberg & Lawlis, 1984;
Achterberg, Dossey, & Kolkmeier, 1993; Samuels & Samuels, 1976). Several
institutes have emerged that are devoted to educating the practitioner regarding
the clinical application of behavioral medicine. The National Institute for the
Clinical Application of Behavioral Medicine organizations include the Society
Lacey o. Corbett and Nancy J. Corbett • Behavior Therapy Associates, 208 Sandwich Street,
Plymouth, Massachusetts 02360.
23
of Behavioral Medicine (the American Psychological Association division of

health psychology) and the Association for Applied Psychophysiology and
Biofeedback. There are many professional publications, including those pub-
lished by the Society of Behavioral Medicine. Several popular books have been
published to educate the public on self-help psychological and lifestyle meth-
ods available to intervene in modifying serious illness (Siegel, 1986; Locke &
Hornig-Rohan, 1963; Simonton, Simonton, & Creighton, 1978; Borysenko,
1987). What is missing from this vast amount of literature available on the use
of imagery to heal illness is the scientific application of the laws of learning to
modify the cause of disease.
It has been well established that the covert-conditioning procedures, based
on operant learning theory (Cautela & Kearney, 1993), follow the same laws of
learning as in overt behavior. These procedures have been successfully applied
to a multitude of approach and avoidance behaviors (Cautela & Kearney,
1986), and are increasingly being applied by a variety of behavioral clinicians
to alter the disease process (Cautela & Kearney, 1993).
The objective of this chapter is twofold. (1) One objective is to discuss the
use of covert conditioning in the field of behavioral medicine as an important
adjunct to medicine in the holistic treatment of human disorders that are
physiological in origin. Because of the extensive number of illnesses to which
the field of behavioral medicine is applicable and space limitations, this chapter
will focus on the application of covert conditioning to the field of psycho-
oncology. In spite of these restrictions, it is highly probable that the principles
herein presented can be applied to many other areas of behavioral medicine. (2)
The second objective is to suggest some possible new strategies that might spur
further research in the field of covert conditioning and behavioral medicine,
and more specifically, psycho-oncology. We assume that the reader is familiar
with the extensive existing literature in the field of covert conditioning (Cautela
& Kearney, 1986) and the clinical application of these procedures to various
medical disorders (Cautela & Kearney, 1993). Early research in behavioral
medicine has been incorporated in this chapter to show the beginning status in
this field. The most recent research included herein validates much of the early
thinking and demonstrates the progress made.
Selye (1955) speaks of dys-ease, implying that the phenomenon of illness is
related to more than the deterioration of body functions. A recent medical
study implicates anger as an immediate precipitant of heart attacks. Stress has
been associated with numerous illnesses including heart disease, colitis, hyper-
tension, cancer, and so forth (Plaut & Friedman, 1981).
The momentum that has been generated to incorporate cognitive and
emotional factors to influence and modify the disease process is irreversible. We
challenge the professional community to add a scientific, theoretical model to
the use of covert events through using the laws of learning, namely, through the
covert-conditioning procedures to increase their positive effects and conse-
quently greatly enhance the human condition.
3 • COVERT CONDITIONING 25
COVERT CONDITIONING AND PSYCHO-ONCOLOGY DEFINED
Cautela & Kearney (1993) define covert conditioning in the following

way: "Covert conditioning is a theoretical model that in addition to involving a
set of assumptions, refers to a set of imagery-based procedures that alter re-
sponse frequency by manipulation of consequences" (p. 3). The term condi-
tioning designates that the behavior change is a conditioning process. While
covert conditioning focuses on imagery, thoughts and feelings are also included
as covert processes that can be manipulated by covert-conditioning procedures;
for example, instructing a subject to say to herself, "I am not going crazy," and
then instructing her to imagine a pleasant scene or feeling relaxed and confi-
dent in a particular setting (reinforcement).
Psycho-oncology is the most recent term used to describe a multidisciplin-
ary psychological specialty that focuses on the interactional relationship be-
tween psychological events and cancer. Parameters include an analysis of the
psychosocial and psychoimmunological events. Treatment includes antecedent
conditions and target behaviors (the malignancy and its biobehavioral out-
comes) (Kaplan, 1990).
A CONCEPTUAL MODEL OF PSYCHO-ONCOLOGY

AND COVERT CONDITIONING
The nature of cancer has been conceptualized as a multiplicity of diseases

with numerous biological causative factors (Bryan, 1974). Several of these
factors attributed to the development of cancer by medical science include
genetic influence (Fraumeni, 1974), radiation (Upton, 1974), trauma and in-
flammation (Gaeta, 1974), chemical carcinogenesis (Weisburger, 1974), viruses
(Rauscher & O'Connor, 1974), and immunological incompetence (Holland,
1974; Hersy, Gutterman, & Maxligitor, 1977).
Concomitantly, numerous attempts have been made to explore and dem-
onstrate an influential relationship between cancer and psychological variables
(LeShan, 1959; Rassidakis, 1974; Babsnon, 1975). Kissen (1963) and LeShan
(1966) have attempted to identify a personality profile for the cancer victim.
Other studies have related cancer to stress and host resistance (LaBarba, 1970;
Solomon & Amkraut, 1972; Prehn, 1969) and to the loss of significant others
(Neuman, 1959; Ader & Friedman, 1964). The results of Seligman'S (1975)
work with women having abnormal Pap smears connects cancer to a feeling of
hopelessness. Other investigations lead one to believe that depression is an
influential factor (LeShan & Worthington, 1956; Goldfarb, Driesen, & Cole,
1967; Schmale & Iker, 1971; Booth, 1973). Finally, Kissen (1966), Kissen,
Brown, and Kissen (1969), and Greer and Morris (1975) contend that the
suppression of hostile feelings may determine tumor growth. More recently,
Spiegel et al. (Spiegel, Bloom, & Yalom, 1981; Spiegel, Bloom, Kraemer, &
Gottheil, 1989) (see also Fawzy et aI, 1990a,b, 1993) have presented increased
support from psychosocial interventions that appear to increase both "quality
of life" and survival duration.
Presently, many of the leading researchers (Anderson, 1992, 1994; Krup-
nick, Rowland, Goldberg, & Daniel, 1993; Rowland, 1994; Holland & Row-
land, 1989; Fawzy et aI., 1993) are proposing various research models to
address the multiple needs of cancer patients. Many of these models have
behavioral and covert components as part of the intervention paradigm. What
is still lacking is a testable model that includes covert conditioning and psycho-
immunology.
While these studies have contributed to establishing a possible relationship
between the existence of cancer and psychological variables, there has been a
regrettable lack of scientific collaboration between medicine and psychology
directed toward identifying how these psychological variables interact with
biological phenomenon to influence neoplastic cellular changes. Until recently,
a strong theoretical conceptualization has been absent. In 1976, Cautela pre-
sented a paper, "Toward a Pavlovian Theory of Cancer", to the Pavlovian
Society, and his conclusions can be summarized as follows:
The predominant oncological theories emphasize cellular behavior as a
crucial variable in cancer. Pavlovian conceptualization of the nervous sys-
tem functioning focused on the behavior of cells. Data concerning the
nature of the psychological variables related to cancer seem to indicate that
any organism in stress (too much excitation) is receiving minimal reinforce-
ment (inhibition) and may be particularly susceptible to cancer. Pavlovian
theory focuses on the relationship between excitation and inhibition. Pavlo-
vian studies indicate that organic dysfunctions were produced by manipula-
tions involved in experimental neurosis. Tumor formation has been one of
the organic dysfunctions noted. The Pavlovian model is particularly suited
to experimental tests of assumptions concerning the relationship between
cancer and various psychological variables. The ultimate goal of this model
is to develop treatment strategies derived from the Pavlovian framework
and behavior therapy that could be combined with other therapies to mod-
ify cancer behavior (p. 4-5).
While Cautela's paper focuses on the Pavlovian model of learning, a final

learning model will probably combine both classical conditioning and operant
procedures (Cautela, 1977a). The classical conditioning model has been devel-
oped in the field of psychoneuroimmunology by Ader (1981) and Ader and
Cohen (1993).
The primary purpose of this chapter is to propose a behavioral interven-
tion treatment model based on the use of covert conditioning and other behav-
ioral procedures to modify the antecedents and target behaviors and conse-
quences related to the modification of cancer.
CONCEPTUALIZATION OF CANCER AND COVERT PROCESSES
In this chapter, cancer is conceptualized as the proliferation of malignant

cells within the organism at differential rates depending on a multitude of
factors. Numerous causal variables (genetic, biochemical, viral, immunologi-
cal, and psychological) influence both one's susceptibility to the disease and the
inception and course of the disease. The influence of psychological variables is
of particular concern here.
Psychological variables are viewed as private or covert events that are
really a certain class of organic events (thoughts, feelings, and images). These
particular organic events interact in an orderly and predictable manner similar
to organic events labeled overt. Similarly, all organic events, whether labeled
private, overt, or physiological, obey the same laws of learning. Consequently,
if an organism is reinforced or punished, it will be simultaneously reinforced or
punished (probably at different strengths) in three behavioral categories: overt
behavior, covert psychological behavior, and covert physiological behavior. An
important implication of the above theoretical speculation is that the behavior
of a cell or a tumor is influenced by the same laws of learning as other behavior
(Cautela, 1977a).
An operational example of these interactions can be illustrated by hypo-
thetically expounding on the events in the life of one woman studied by
Schmale and Iker (1966), who had an abnormal Pap smear and eventually
developed cancer. A woman whose Pap smear reveals the presence of "sus-
picious" but not malignant cells in the cervix loses a loved one. She responds to
this event with feelings of hopelessness and depression. Within 6 months, these
cells have been transformed into malignant cells and she is diagnosed as having
cancer.
Using the learning paradigm outlined previously, one could conceptualize
these events in the following way: Two overt events occurred, resulting in a
decrease of reinforcement-the presence of suspicious cells and the subsequent
loss of a loved one. These losses are reviewed covertly in several possible ways
that result in a feeling of hopelessness and consequently a further decrease in
reinforcement. A close behavioral analysis would identify specific thoughts,
feelings, and images that comprise these covert events, but hypotheses regard-
ing this would include self-statements such as, "there's no use in living": "I'm
probably going to die anyway": "I can't cope by myself." Images may include
imagining the death of her loved one, imagining herself alone and without
friends, or even imagining herself dying. As mentioned above, these covert
events are really organic events that interact directly with the organism on a
physiological level. Physiologically, these responses lower the body's immu-
nocompetence by depressing lymphocyte functions (Bathrop, 1977; Kiecolt-
Glaser, 1988).
Although the above theoretical model is speculative, it has heuristic value
in light of the growing evidence relating cancer to psychological variables.
Controlled research is needed at this time to study the more specific and direct
relationship between overt organic events, covert psychological organic events,
and covert physiological events.
An essential assumption of this chapter is that overt, covert, and physi-
ological organic events interact simultaneously to influence cellular behavior;
consequently, psychological variables can influence one's susceptibility to can-
cer and the progression or arrest of the disease thereafter. A review of those
areas where imaginal (organic) events have been employed to influence cellular
behavior should help support this hypothesis. Anderson, Kiecolt-Glaser, and
Glaser (1994) have proposed a "biobehavioral model of cancer stress and
disease course." Their article reviews the research on stress, quality of life,
survival time, and psychological and treatment-related variables up to the pre-
sent. They also propose an excellent model for testing psychological interven-
tions.
Anecdotal reports exist using covert conditioning, among other behavioral
interventions, in the treatment of various organic diseases. A few are mentioned
here. Cautela (1977b) used covert positive reinforcement and other behavioral
interventions in treating a woman with severe arthritic pain. After 3 weeks, her
pain was essentially eliminated. Corbett (1993) treated a man incapacitated for
years with hemochromatosis, using covert positive reinforcement, covert ex-
tinction, and thought stopping. Target behaviors included increasing energy
and reducing fatigue, increasing activity, and increasing images of feeling
healthy. These target behaviors were successfully accomplished; a follow-up
medical exam a year later revealed that all medical evidence of the presence of
the disease was absent.
While these reports are surely not submitted as evidence, they do lend
support and encouragement for the use of covert procedures in the treatment of
organic dysfunctions.
COVERT CONDITIONING
Behavioral Assessment
In addition to the usual behavioral assessment, a careful behavioral analy-
sis of the cancer behaviors necessitates a multidisciplinary and multimodal
approach (Carter & Soper, 1974). The psycho-oncologist works closely with
the medical team, which may include the primary physician, surgeon, oncolo-
gist, radiologist, and nutritionist. Consequently, behavioral intervention is di-
rectly related to and supportive of the patient's ongoing medical regimen. This
may include surgery, chemotherapy, immunotherapy, bone marrow transplant,
radiology, and genetic intervention. The goal of treatment is the same for the
entire team: to prevent, reduce, or eliminate the growth of tumor cells, and to
enhance the patient's quality of life and life span. Target behaviors in behav-
ioral intervention vary and are idiosyncratic to the patient across time. Exam-
ples include:
1. Decreasing anxiety preparatory to surgery.

2. Increasing or decreasing excitation or inhibition following surgery.
3. Decreasing the side effects of chemotherapy, such as nausea and vomit-
ing, and increasing the patient's acceptance of this treatment.
4. Increasing the intensity and/or duration of the stimulus ill immu-
notherapy and chemotherapy.
5. Increasing the patient's natural immunocompetence.
Special attention is made in each case in the behavioral analysis to com-
bine the principles of learning (Cautela, 1968; Herson & Bellack, 1976) with a
biological perspective (Waldenstrom, 1978).
THE USE OF COVERT CONDITIONING AND OTHER

BEHAVIORAL PROCEDURES IN PSYCHO-ONCOLOGY
The procedures that follow are designed to modify the antecedents or the
consequences of selected target behaviors described above. The major compo-
nents of the treatment model include relaxation training, thought stopping, and
one or more of the covert-conditioning procedures.
Thought Stopping
Thought stopping can be used as a self-control procedure to reciprocally
inhibit maladaptive thoughts or images relating to depressive or anxiety-pro-
voking stimuli regarding one's health. For example, "I'm going to die." In
addition, this procedure can be used as an operant to punish any image of
malignant mitosis and/or metastases. Since this procedure is described in detail
elsewhere (Wolpe, 1969; Cautela, 1969), it will not be reviewed here.
Relaxation
Modified Jacobsonian progressive relaxation (Wolpe, 1969) is used as a
self-control procedure (Cautela, 1969) to decrease general or specific anxiety-
provoking stimuli associated with cancer behaviors. Conceptually, anxiety re-
duction may also improve clarity of imagery (Richardson, 1969) and increase
one's own immunocompetence (Selye, 1955; Solomon & Amkraut, 1972:
Davidson & Schwartz, 1976). Relaxation may also be a necessary condition for
the enhancement of bioelectrical and biochemical processes at both a muscular
and cellular level (Wolpert, 1960; Basmajian, 1967, 1972). Several programs
exist that describe this procedure in detail (Bernstein & Borkovec, 1973; Cor-
bett & Corbett, 1976; Cautela & Groden, 1978; Benson, 1975, 1987).
Covert Procedures
There is increasing support for the assumption that "stimuli presented in
imagination via instruction have similar functional relationships to overt and
30 • BEHAVIORAL MEDICINE
covert behavior as do stimuli presented externally" (Cautela, 1986, p. 16).

These procedures have been labeled covert conditioning and are specifically
conceptualized within the proposed cancer treatment model in the following
way. Each procedure described includes a brief description of the procedure, its
learning theory basis, and examples of its application to psycho-oncology in
three specific areas. These are (1) antecedent behaviors that increase the proba-
bility of cancer; (2) intervention directed at the target behavior (the malignan-
cy); and (3) intervention directed at treatment-related consequences.
Covert Modeling
Covert modeling (Cautela, 1976) is a procedure in which the patient is
instructed to imagine observing a model performing various behaviors with
particular consequences. Covert modeling is used for learning new behaviors or
changing existing behaviors by imagining scenes of others interacting with the
environment (Cautela & Kearney, 1986). An example would be having the
patient imagine himself looking at a healthy part of his body. He sees and feels
his healthy cells flourishing and being supplied with red blood cells surround-
ing his tumor site. As these healthy cells multiply, the malignant cells decrease,
becoming weaker, fewer, and finally dying.
There is anecdotal evidence suggesting that neurological regulatory mech-
anisms exist that are responsible for influencing communication and learning
at a cellular level on the two body halves proportionately (Brown, 1984). These
mechanisms, which are called mirroring, seem to operate in a manner similar
to modeling.
The use of covert modeling in behavioral medicine and, more specifically,
psycho-oncology has been employed to modify some of the antecedent behav-
iors to cancer, for example, smoking (Nesse & Nelson, 1977). There are no
current studies using covert modeling to treat the target behavior of modifying
the cancer cells, but the procedure lends itself to this treatment in several ways.
First, the patient could view videotapes and/or photographs of natural killer
cells, T cells, and B cells increasing and destroying the malignant cells, and then
be taught to apply these images covertly.
Covert modeling can also be employed to treat some of the consequences
of cancer. In chemotherapy, it can be used to treat both the anticipation of
nausea and vomiting associated with chemotherapy and also prevent the condi-
tion from occurring. In addition, covert modeling could be employed to en-
hance health behaviors and compliance with medical cancer treatment.
Covert Positive Reinforcement

This procedure is used to increase the strength and/or frequency of a given
behavior (Cautela & Kearney, 1986). In this procedure, the patient is asked to
imagine the behavior to be increased and then asked to imagine that he is
receiving a reinforcing stimulus for engaging in the adaptive behavior (Cautela,
1970a). This procedure has been used to treat a multitude of both approach
and avoidance behaviors (Cautela & Kearney, 1986).
Relative to using covert conditioning for antecedent behaviors in the
field of psycho-oncology, several oncology researchers have shown that acute
and prolonged stress (Kiecolt-Glaser, 1988; Glaser, Rice, Speicher, Stout, &
Kiecolt-Glaser, 1986; Kielcolt-Glaser, Dura, Speicher, Trask, & Glaser, 1991)
modulate both endocrine and immunological activity. Covert positive rein-
forcement has been applied to anxiety-related anticipatory behaviors, such as test
anxiety (Kearney, 1984; Kostka & Glassi, 1974). Kiecolt-Glaser et al. (1984)
found that increased distress generated by commonplace stressful events, like
examinations, is reliably associated with poorer immune function. They also
found that distress-reducing interventions may enhance certain aspects of im-
mune function (Kiecolt-Glaser et aI., 1985).
There are no research studies reported using covert conditioning to modify
immunological or endocrinological function in the treatment of cancer. There
is some support for using covert events in a nonoperant framework in the field
of guided imagery (Naparstek, 1994). Further research is needed to determine
the differential efficacy of using covert-conditioning procedures versus other
visualization interventions.
In the covert-conditioning model, an example of how covert positive rein-
forcement would be used follows: The patient mayor may not be relaxed, since
relaxation is not a necessary requirement. The patient is asked to imagine the
behavior to be increased (increased lymphocytic activity, which may include an
increase in natural killer cells, T and B cells, etc.) and then to imagine that he is
receiving a reinforcing stimulus for engaging in the adaptive behavior. The
reinforcing stimulus is an idiosyncratic reinforcer that is in no way necessarily
related to the cancer. It could be a beautiful sunset.
The consequences that follow, or may be an integral part of the immediate
cancer treatment, may include pain, chemotherapy, radiation, medication, medi-
cal compliance, and lifestyle changes. The use of covert positive reinforcement
has been found to be more effective than other procedures (Cautela, 1977a;
Stevens, 1982) in reducing pain, nausea and vomiting (Burish, Carey, Krozely,
& Greco, 1987), and medical compliance (Cautela & Kearney, 1986).
Anecdotally, covert positive reinforcement has been successfully used spe-
cifically with two patients in private practice. The first patient was a 4-year-old
leukemic child who needed weekly spinal taps to monitor the status of her
disease. The procedure typically evoked fear, crying, and refusal to sit still in
the necessary position. Covert positive reinforcement was used to increase
medical compliance with the procedure. The child was asked to imagine that
the needle stick was a "pleasant tickling sensation" and that she felt totally
relaxed while the fluid was being extracted. The reinforcing stimulus that she
then imagined was that "Care-bears" were dancing, singing, and jumping for
joy inside her. The child was taught the image in the presence of her mother,
and they practiced twice daily. The result was that the mother reported a
significant decrease in the child's anticipatory anxiety verbalizations and a
significant increase in her relaxed behavior during the spinal tap. The oncology
staff was amazed at the unusually relaxed behavior of this child during such a
stressful procedure (L. O. Corbett & N. J. Corbett, personal communication,
1989). Covert positive reinforcement was also successfully used to decrease
nausea and vomiting both before, during, and after each chemotherapy treat-
ment in a 33-year-old patient with an inoperable cancer of the common bile
duct (L. O. Corbett & N. J. Corbett, personal communication, 1992).
Covert Extinction
In covert extinction (Cautela, 1971), the patient is instructed to imagine
that the reinforcing stimuli maintaining any maladaptive physiological behav-
ior do not occur, and subsequently, the behavior decreases or is eliminated. The
maladaptive anticipatory events experienced by an oncology patient including
anxiety, depression, grief, and bereavement are accomplished by negative scan-
ning, feelings of helplessness, and/or decreased levels of reinforcement. Several
investigators have reviewed the biochemical response to loss (Osterweiss, Solo-
mon, & Gren, 1984; Stroebe & Stroebe, 1987). In 1977, Bathrop found that
significant loss results in a depressed immunocompetence. Maunsell, Brisson,
and Deschenes (1992) found that numerous stressful life events, existing along
with a history of depression prior to breast cancer diagnosis, were strong
indicators of psychological distress and placed the individual at risk. Similarly,
Cooper, Cooper, and Faragher (1989) found that some major life events (death
of a husband or close friend) were significantly related to breast disease and its
severity.
Brasted and Callahan (1984) proposed a learning model for unresolved
grief: "This process centers around an extinction of conditioned emotional
responses learned in response to trauma of the loss and the acquisition of new
responses in place of old behaviors that are no longer prompted or rewarded by
the deceased" (p. 161). Callahan then cites the similar hypothesis of Averill &
Wisocki (1981) and proceeds to present a treatment using covert extinction of a
42-year-old woman with "unresolved grief" (Callahan, 1993. pp. 161-171).1
Target Behaviors
One of the first reported uses of a covert extinction model to reduce a
tumor was reported by Green (1977). A terminally ill cancer patient was placed
in a hypnotic trance and was instructed to visualize that the "blood supply to
the tumor was cut off, causing the tissue to cool and the tumor to starve"
(p. 111-112). Initially, the patient showed a very favorable response to this
treatment. An example of using covert extinction would be that the patient
imagines that the cancer cell is frantically running around with the mouth wide
open searching for protein and no nourishment is available. As its unsuccessful
search increases, it gets weaker and weaker and finally dies. Corbett (1993)
'Cautela (1993) notes that covert positive reinforcement and covert modeling are also used to
increase the patient's general level of reinfocement (Cautela, 1984).
reports a single case utilizing covert extinction to reduce excessive iron levels in
a patient with hemochromatosis. Theoretically, covert extinction could be used
to decrease any endocrinological or hormonal variables that may affect cell-
mediated immunity or immunological function.
Cautela (1986) provides a case example employing covert extinction in
modifying pain-related behaviors. This procedure, used in conjunction with
covert positive reinforcement and covert modeling, may help the psycho-on-
cologist reduce pain experienced by numerous cancer treatments. Theoretically,
a covert extinction program could be developed prior to the onset of chemo-
therapy and possibly reduce the probability of classically conditioned nausea
and vomiting (Bovbjerg et ai., 1992).
Covert Sensitization
This is analogous to a punishment paradigm and is used to decrease the
frequency of maladaptive approach behaviors. The term "sensitization" was
chosen because the purpose of the procedure is to build up an avoidance
response to the undesirable stimulus. In covert sensitization scenes, the target
behavior is immediately followed by an imagined aversive consequence (Cau-
tela & Kearney, 1986). Usually, the aversive component is introduced before the
imagined maladaptive behavior is completed to disrupt earlier links in the
behavioral chain. The client experiences aversion relief and begins to feel better
as soon as he rejects the object (Cautela, 1967).
In cancer treatment, the undesirable behaviors are those activities of the
neoplastic cells themselves. These activities consist primarily of mitosis and
tumor cell replication, along with metastases. More discrete maladaptive neo-
plastic cellular responses include a signal that initiates a burst of RNA-DNA
synthesis, resulting in the replication of malignant cells or any phase that
results in the completion of mitosis (Baserga, 1965). The goal of cancer treat-
ment as hypothesized by Skipper, Schabel, and Wilcox (1964) is to accomplish
selective killing of tumor cells.
Using an operant punishment paradigm, then, the purpose of covert sensi-
tization is to decrease the maladaptive approach behaviors (decrease the num-
ber of tumor cells and those activities that reinforce them) through the applica-
tion of an aversive stimulus presented in imagination. The procedure is labeled
"covert sensitization" because both the behavior to be modified (tumor cell
division) and the noxious stimulus (an immunological agent, such as lympho-
cytes) are presented in imagination. A noxious stimulus frequently employed in
covert sensitization, nausea and vomiting, is ill-advised in the treatment of
cancer patients, because this behavior itself is frequently a maladaptive re-
sponse to be decreased, particularly for those individuals receiving chemo-
therapy and radiation.
Antecedent Behaviors. Covert sensitization has been used primarily in

the treatment of maladaptive approach behaviors. Some of these maladaptive
antecedent behaviors have been found to increase the probability of cancer.
Covert sensitization has been applied to alcohol abuse (Elkins, 1980; Dougher,
Crossen, & Garland, 1986; Dougher, Ferraro, Diddams, & Hill, 1989; Dough-
er & Smith, 1993) and smoking (Cautela, 1970c; Emmelkamp & Walta,
1978).
More specifically, however, stimuli that act as antecedents to the produc-
tion of cancer cells include the continuing activity of a virus, stimuli such as
radiation or chemicals, physiological or psychological stress, or any biological
event that miscodes information and consequently results in the replication of
an abnormal cell (Huebner & Todaro, 1969; Temin, 1970). These antecedents
precipitate a certain (idiosyncratic) type of learning for cancer cells and this
behavior is reinforced (increased) by consequences, for example, protein suste-
nance. If the reinforcing consequences could be eliminated, the cancer cells
would die.
Target Behaviors. One of the first researchers to use a visualization mod-

el in the treatment of cancer was Simonton (Simonton, Simonton, & Creigh-
ton, 1978; Simonton, Simonton, & Sparks, 1980). Simonton, an oncologic
radiologist by profession, asked a patient:
To picture his treatment, radiation therapy, as consisting of millions of tiny
bullets of energy that would hit all the cells, both normal and cancerous, in
their path. Because the cancer cells were weaker and more confused than
the normal cells, they would not be able to repair the damage, ... and so
the normal cells would remain healthy while the cancer cells would die.
(Simonton et aI., 1978, p. 7)
Using a covert sensitization model, the patient is instructed that he has

influence over eliminating these consequences by imagining an extremely un-
pleasant event occurring as the cancer cell is about to receive protein or about
to divide. A typical example of what the patient may imagine is described:
You imagine that an ugly, weak and hungry cancer cell is searching for
protein. You hate this cell and you know that its ugliness will increase if you
allow it to be nourished. You want this cell to die and you immediately
notice a beautiful and magnificent army of white lymphocytes in the area.
Just as the cancer cell is about to engulf a stomachful of protein, you
quickly summon your army of lymphocytes which viciously attack the
cancer cell en masse. You watch the cancer cell struggling as it is gulped and
torn apart by thousands of lymphocytes. You laugh as you see the white
army devour the cancer cell and you breathe a sigh of pleasure as you follow
the protein to its rendezvous with your healthy cells. You feel relaxed and
healthy as the protein is assimilated by the healthy cells.
After the therapist presents the scene, the patient is asked to visualize the
same scene again by himself and signal by raising his finger when he has
achieve clear imagery and can actually see the lymphocytes killing the cancer
cell. A feeling of pleasure and relief (escape conditioning) is provided in the
scenes when he sees the cancer cell die and sees the healthy cell consume the
protein. This procedure can be enhanced through the use of audiocassette tape
recording for the purpose of practice. The patient is given a prescribed number
of trials to practice at home each day.
Consequence of Cancer and Treatment. These authors, given the oncol-

ogy patient's level of anxiety, depression, and pain, see few advantages in using
a covert sensitization model in the treatment of the consequences of cancer.
Covert sensitization, as in other punishment paradigms, increases the proba-
bility of lowering one's general level of reinforcement (Cautela, 1984), as well as
increasing the probability of generalizing the aversive stimulus to the treatment
environment.
Covert Classical Conditioning and Psychoneuroimmunology

Cautela and Kearney (1986) reviewed the development of covert condi-
tioning and expanded on seven major theoretical assumptions. Covert classical
conditioning is subsumed under the covert-conditioning learning assumption.
This assumption is that all categories of behavior respond similarly to the laws
of learning, for example, heart rate, galvanic skin response, or imagery may be
reinforced or punished (Ascher & Cautela, 1972, 1974; Cautela, Walsh, &
Wish, 1971).
Ader and colleagues (Adcr & Cohen, 1975, 1993; Ader, 1981; Ader,
Felton, & Cohen, 1991) and numerous other researchers have laid the founda-
tion for an emerging field, called psychoneuroimmunology. As early as 1975,
Ader and Cohen found that they could use classical conditioning to condition
immunosuppression. Recently, Bovbjerg et al. (1992) noted that women under-
going chemotherapy for breast cancer accidently experienced classically condi-
tioned nausea and vomiting. Similarly, in 1990, these authors (Bovbjerg et aI.,
1990) noted that immunosuppression was also inadvertently classically condi-
tioned. Buske-Kirschbaum, Kirschbaum, Stierle, Lehnert, and Hellhammer
(1992) conditioned an increase of natural killer cell activity in humans. In their
experiment, healthy subjects were exposed to a conditioning procedure in
which a neutral sherbet sweet (conditioned stimulus) was repeatedly paired
with a subcutaneous injection of 0.2 mg of epinephrine administration. An
increase of natural killer cell activity could be observed (unconditioned re-
sponse). On the conditioning test day, the conditioned group showed increased
natural killer cell activity after reexposure of the sherbet sweet combined with
saline injection. No increase was found in control groups that previously re-
ceived the sherbet sweet in combination with saline.
In covert classical conditioning, all pairings of the unconditioned stimulus
are performed in imagination (Elkins, 1980; Miller & Dougher, 1989). Dough-
er et al. (1989) classically conditioned aversion to alcohol during covert sensi-
tization. Kiecolt-Glaser et al. (1985) (see Kiecolt-Glaser & Glaser, 1992, for a
review) found relaxation training in 45 geriatric residents produced significant
increases (approximately 30%) in natural killer cell activity. Theoretically, a
covert classical conditioning model could be designed for at-risk and/or cancer
patients using relaxation (unconditioned stimulus) repeatedly paired with a
reinforcing image (conditioned stimulus) and thereby produce and increase in
natural killer cells (conditioned response).
Other Covert Conditioning Procedures

Because of space limitations, covert negative reinforcement, covert re-
sponse cost, and the self-control triad are not reviewed in this chapter. These
procedures, however, would be included in a total treatment plan.
SUMMARY AND CONCLUSIONS
A brief review of the literature is presented in this chapter to alert the

reader of the status of using imagery in the field of behavioral medicine. While
emphasis on visualization has increased significantly in recent years, there is a
dearth of existing research in the clinical application of the covert-conditioning
procedures to the field of behavioral medicine. A body of literature exists that
demonstrates the effectiveness of these procedures in the treatment of other
maladaptive approach and avoidance behaviors.
The objective of this chapter is twofold: (1) to discuss the use of covert
conditioning in the field of behavioral medicine as an effective adjunct in the
holistic treatment of individuals suffering from human maladies of physiologi-
cal origin; and (2) to discuss possible new strategies that might encourage
further research in the use of covert conditioning applied to behavioral medi-
cine and more specifically to psycho-oncology.
Several of the covert-conditioning procedures are defined and rationales
for their use given. Examples are given of how each would be applied in the
treatment of a cancer patient using three parameters: antecedent conditions,
target behaviors, and consequences of cancer.
Several clinical and research issues need to be clarified, refined, and pro-
moted in the holistic treatment of the oncology patient. With this goal in mind,
the inclusion of the covert-conditioning interventions (operant and classical)
should enhance the psycho-oncologist's ability to effectively treat the oncology
patient because of the sound learning-theory model on which they are based.
In designing a research model to test the efficacy of the covert procedures
in psycho-oncology, single-case designs would be advisable to meet both pa-
tient needs and the standards of scientific rigor. Use of this model would enable
the clinician to continue seeing his patient as an individual, rather than a
statistic, while allowing the patient to have the satisfaction of feeling like an
individual (Aldridge, 1992).
To facilitate further studies, Aldridge (1992) recommends a central re-
search agency for the consultation, coordination, and analysis of single-case
designs, along with methods of data acquisition, statistical analysis, and data
presentation suitable for clinicians to use in their daily practice.
In applying the single-subject design using the covert-conditioning proce-

dures, hypotheses should be developed and tested. If the outcome demonstrates
therapeutic efficacy, the procedures should then be included in randomized
clinical trials (see Rowland, 1994, comments on Goodare, 1994).
Both the clinician and the researcher need to remember that the goal in the
holistic treatment of the oncology patient is not necessarily singular. Aldridge
(1992), in reviewing the needs of individual patients in clinical research states,
"The goal of therapy is not always to cure: it can also be to comfort and
relieve" (p. 64). LeShan (1992) notes that in Levy's study (Levy, Herberman,
Lippman, & Angelo, 1987) the best predictors of survival in women with
recurring breast cancer was the joy they experienced in life. This is similar to
Cautela's (1984) emphasis on increasing daily the individual's general level of
reinforcement to enhance the sense of joy and well-being. Hopefully, progress
in the field of psycho-oncology can be generalized to other organic dysfunc-
tions in the field of behavioral medicine.
FUTURE CONSIDERATIONS
The basic assumption of a functional similarity between overt physiologi-

cal events and covert physiological events are fairly well established in the
behavioral literature. Serious limitations exist in identifying the parameters
involved in covert conditioning and neoplastic behaviors. Relatively little re-
search has been done to identify the mediating events between these biological
systems. Many poorly understood phenomena occur between covert processes
and their influence on cellular functioning.
Cautela's (1977a) review of the literature and speculation in terms of a
Pavlovian theoretical model of cancer serves as a major contribution in concep-
tualizing cancer behavior within a learning framework. There are still addition-
al components to be added to this model that explain how covert imaginal
events mediate neoplastic cellular responses and/or immunological resistance.
The work of Becker and his colleagues (Becker, 1963, 1972, 1990; Becker
& Selden, 1985; Becker, Bachman, & Friedman, 1962) may well add a major
critical component between mediational events and cellular behavior. They
show that cells and tissues possess electrochemical properties that are subject to
biological control by the external induction of electrical energy (low current
and voltage). The possible correspondence and interaction between biological,
bioelectrical, and biochemical imaginal covert events and the bioelectrical com-
munication model proposed by Becker and colleagues may represent one miss-
ing link between these two interacting biological subsystems. It remains to be
investigated. Such an integrative model has promise both for a better under-
standing between overt and covert stimulus events on regenerative cellular
behavior and possible action for covert imaginal events on one's immunological
systems (Gillman & Wright, 1966; Polgar & Kilbrick, 1970).
In addition to McGuigan's (1978) conceptualization of covert events func-
tioning on a neurophysiological level, there is a compelling need to integrate
conceptualize these proposed models at a cellular and molecular level. Behav-

ioral intervention is dependent on this integration. Todaro and Heubner (1972)
show that every cell contains in its DNA a segment coding for malignancy.
Similarly, Speigelman et al. (1970) shows that cancer viruses are able to enter the
cell and alter its genetic composition. Henrickson (1972) provides the molecular
theoretical model in which he relates both covert and overt neural communica-
tion (based upon RNA memory molecules) to their nucleotide genetic basis. It is
his theoretical formulation that may offer us the theoretical component to better
understand how covert events affect both viral and encoding cellular functioning.
An integration of the work of Cautela and Kearney (1986), McGuigan
(1978), Becker (1990), Hendrickson (1972), and Walleczek (1994), along with
their supporting empirical data, may provide us with a more comprehensive
behavioral model with which effective clinical intervention can be constructed.
Any practicing psycho-oncologist should be familiar with the ongoing
research and clinical applications from various theoretical models. For exam-
ple, the National Institute for the Clinical Application of Behavioral Medicine
(1993) presented "The Psychology of Health, Immunity, and Disease." Further
research focused on integrating and/or testing various intervention strategies
with the behavioral model proposed in this chapter would be most helpful to
the field of psycho-oncology.
In addition to the need for a more comprehensive theoretical model that
would adequately account for the relationship between covert processes and
neoplastic behavior, a number of empirical questions are in need of further
investigation:
1. How do covert imaginal aversive as well as reinforcing events influence

the behavior of neoplastic cells?
2. What are the electrochemical parameters of covert events on neoplastic
functioning?
3. Can covert (imaginal) events influence overt viral behavior at a cellular
level?
4. How do covert aversive and/or reinforcing events influence immu-
nological mechanisms?
5. What are the effective parameters in each of the covert conditioning
procedures related to the neoplastic cellular cycle?
6. Are these covert conditioning procedures more efficacious than existing
treatment modalities for specific neoplastic conditions?
7. Do the covert conditioning procedures enhance the effectiveness of ex-
isting medical treatment and the oncology patient's quality of life?
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4
The Nature of Walking

A Foundation for the Experimental Analysis
of Orientation and Mobility
Jeffrey Kupfer
INTRODUCTION
Moving through the environment efficiently and safely is an important skill in

the development and survival of organisms. Walking is one form of locomotor
movement or travel by which human beings access or avoid particular objects,
events, or areas in the environment. These locomotor movements are an impor-
tant part of both commonplace and complex activities such as vacuuming rugs,
mowing yards, carrying packages to and from the car to the house, marching in
parades, sneaking out of a dull meeting, rushing to morning classes, crossing
the street within the crosswalks, carrying glasses of water filled to the top,
preparing to steal second base, dancing to a waltz, or strolling casually before
taking in a movie. Common to each of these diverse activities is the behavior of
walking; that is, walking at different speeds, with different gaits and postures,
under different sets of circumstances, and controlled by different consequences
that are arranged by the environment in which we live. The variables that
control walking are broad-ranged, and research on these variables has been
conducted from a "microlevel of analysis" of coordinated motor skills involv-
ing various parts and portions of the body to a "molar-level of analysis" of the
entire organism walking within simple and complex environments. At both
Jeffrey Kupfer • Mediplex of Holyoke, 260 Easthampton Road, Holyoke, Massachusetts 01404.
45
levels of analysis, vision plays a crucial role in the acquisition and maintenance
of walking, and there is a substantial amount of research devoted to the analy-
sis of the effects of vision and visual loss on walking. This chapter will focus on
some of the methodological approaches to examining walking at both levels of
analysis and, in particular, the role of vision and the effect of visual loss on
walking will be described.
MOTOR SKillS, VISION, AND WALKING
The motor skills required for walking have been described in terms of
milestones in child development in which the presence or absence of particu-
lar reflexes during various stages of development appear to be critical for
upright motor functioning. For example, the asymmetric tonic neck reflex is
seen in newborns until 4 months. This reflex accounts for an infant's ability
to move his or her own head, but there is an inability for an infant at this age
to move his or her head and arms independently of each other. At age 4
months, symmetric tonic neck reflex emerges and the body shows segmenta-
tion and separation of responses of arms, legs, neck, and hind quarters. Ac-
cording to Hart (1980), the reflexes of the newborn must be disengaged from
reflex patterns in order for them to playa role as the key structure in building
erect posture. A normal walking gait demands not just normal neck reflex
activity but also the development of righting reactions, balance, protective
reactions, rotation, and normal muscle tone. Without these skills, a child is
unable to develop and refine skills in walking, climbing, and running. The
labyrinthine or vestibular righting reaction allows the head to remain in up-
right position when the pelvis is moved, whereas the neck-righting reaction
brings the lower parts of the body into line with the upright head. Optic-
righting reflexes are responsible for orientation of the head and that orienta-
tion is controlled by vision.
Another important motor skill that is critical to the development of walk-
ing is balance, the ability to maintain or assume any body position or posture
against the force of gravity. Chaney and Kephart (1968) suggest that posture is
the basic pattern from which all other movement patterns develop, and the
center of gravity in one's posture is the point from which direction, space
orientation, and movement must originate. According to the authors, only
when line, direction, and force of gravity are established can a child proceed to
the development of coordinates in space. The positions of the head and the
body are critical for the maintaining proper balance and posture. The head
must be properly aligned to the body with conformity to the supporting base.
The body, in proper alignment with the head, is designed to react to change and
restore disturbed equilibrium in order to maintain posture and balance. Pos-
ture, therefore, results from the interacting motions of the head, torso, and
limbs to maintain balance, orientation to gravity, and adjustment to accelera-
4 • THE NATURE OF WALKING 47
tion. In turn, all of these interacting motions are affected by the vestibular,
visual, tactual, and kinesthetic systems that aid in positioning and dynamic
stabilization of the body during walking.
The role of vision is critical to the learning and performance of most
motor skills, especially walking. Visual training is an ancillary part of many
motor education programs, because children are involved visually in the
training activities (Cratty, Ikida, Martin, Jennett, & Morris, 1970). Some re-
searchers have suggested that of the four sources of sensory information that
can serve to preserve postural stability (i.e., vision, vestibular stimulation,
proprioception, and touch), the visual system processes exact information
about space more efficiently than the other sensory modalities (Howard &
Templeton, 1966).
Researchers have examined the role of vision in relation to motor develop-
ment. In their observations of the development of vision in infants and young
children, Gesell, Ilg, and Bullis (1949) describe three functional parts of vision:
(1) fixation is that part of vision that seeks and holds an image; (2) focus
enables the viewer to discriminate and define an image; and (3) fusion unifies
and interprets the image on the cortical level. These observations have led to
the development of age norms and visual maturity levels for children from
4 weeks to 9 years of age on the basis of eye-hand coordination, postural
orientation, fixation, and retinal response.
Some researchers have described the relationship between walking behav-
ior and visual loss in reference to "environmental input." Miller (1967), for
example, suggests that loss of vision affects gait mechanically because of the
loss of sensory data necessary for timing of steps, impoverished balance, and
deficiency of protective reflexes. Out-toeing (walking with the toes oriented
outward) is a commonly observed gait pattern in visually impaired individuals
and may develop as a source of increased tactual input. A "shuffle gait" may
develop when the feet are used as feelers, particularly during indoor walking in
which "runners" or "guidestrips" are placed along hallways, or during out-
door walking in which the visually impaired individual is searching for shore-
lines. Additionally, out-toeing can also increase the base of one's support;
however, if out-toeing is excessive, walking speed may be impeded (Aust,
1980).
A wide-based gait is commonly observed in individuals with visual impair-
ments as a way to increase stability during walking. According to Aust (1980,
p. 68), both the wide-based gait and shuffle gait result in slow walking speed,
but this gait may be desirable for individuals with visual impairments who are
reluctant or fearful of stepping out because of insufficient orientation and
mobility techniques. Similarly, a shortened, guarded stride may be seen in an
individual with visual impairments who is fearful of walking into objects.
Typically, as one's speed increases, the tendency to veer decreases; whereas a
shortened stride, which tends to decrease walking speed, may serve to increase
veering (Aust, 1980).
MOVEMENT THROUGH THE ENVIRONMENT,

VISUAL LOSS, AND WALKING
An important component in the rehabilitation of persons with visual im-
pairments is the development of efficient and safe walking. The motor skills
described above are important for smooth and coordinated execution of walk-
ing; however, it is the entire body that must move successfully through simple
and complex environments. Therefore, from a mobility rehabilitation stand-
point, the level of analysis often shifts from one involving movement of limbs,
for example, to one involving the person moving safely and efficiently in a
living room, a kitchen, a front yard, and a residential street, as well as a
supermarket, a hotel lobby, a crowded sidewalk or mall, and an airport termi-
nal. This level of analysis is particularly important for the mobility rehabilita-
tion of persons with visual impairments because mobility instructors must
provide these individuals with a means to get around their environment.
Characteristics of walking can be described with respect to both efficient
and safe walking (Armstrong, 1972). Directional continuity, for example, de-
scribes the maintenance of straight-line walking for prespecified distances and
efficient walking is inferred from this measure (Brabyn & Strelow, 1977). Im-
peded walking describes decreases in forward movement and safe walking is
inferred by the absence of abrupt decreases in forward movement or walking
speed, such as when persons with visual impairments stumble or catch the tips
of their canes (Brabyn & Strelow, 1977). Accordingly, an adequate measure of
directional continuity must be sensitive to veering (i.e., the number or duration
of deviations from a fixed central point or the distance of lateral movement
(Armstrong, 1972; Brabyn & Strelow, 1977; Dodds, Carter, & Howarth,
1983; Howarth, Heyes, Dodds, & Carter, 1981), whereas an adequate measure
of impeded walking must be sensitive to changes in walking speed.
A common way in which mobility instructors train persons with visual
impairments is in the use of physical structures or landmarks as aids for orient-
ing walking within an environment (Allen, Griffith, & Shaw, 1977; Armstrong,
1972; B1asch & Hiatt, 1983; Braf, 1974; Elias, 1974; Herms, Elias, & Rob-
bins, 1974; Hill & Ponder, 1976; Templer, 1980, 1983; Templer & Zimring,
1981; Tooze, 1981; Wardell, 1980). One physical structure is referred to by
mobility instructors as a shoreline. A shoreline is a line or a contrast between
two surfaces, such as that between a sidewalk and grass strip. An individual
with visual impairments can use a shoreline for body alignment and mainte-
nance of straight-line walking. Individuals trained to use a prescriptive long
cane for walking can maintain straight-line walking over extended distances by
placing and keeping the cane tip at the junction where the sidewalk meets the
grass strip or by occasionally touching the shoreline with the cane tip using a
sweeping or dragging arc motion.
Over the years during which this type of mobility training has proceeded,
mobility specialists have reported their observations regarding the effectiveness
of shorelines in controlling walking. Mobility specialists, for example, report
that effectiveness of a shoreline as a mobility aid primarily depends on the

degree of variation in the shoreline. Continuous shorelines provide optimal
conditions for straight-line walking, discontinuous shorelines are less than
optimal (Blasch & Hiatt, 1983), and environments without shorelines (i.e.,
open space areas) often result in disoriented walking (Aiello & Steinfeld, 1979;
Allen et aI., 1977; Braf, 1974; Foulke, 1979; Hill & Ponder, 1976). Unfor-
tunately, most shorelines are constructed on the basis of architectural and
landscaping aesthetics rather than for functional use by persons with visual
impairments, and thus shorelines are often discontinuous and complex. Much
of the architectural and mobility research has examined the effects of variation
in walking surfaces and shorelines on locomotion in complex environments
(Braf, 1974; Elias, 1974; Herms et aI., 1974; Templer, 1980).
Several studies have examined walking with respect to directional continu-
ity and impeded walking. In one study, a 100-foot-long texture strip was added
to a community sidewalk to serve as a continuous shoreline (Templer, 1980).
The texture strip was a 120-inch-wide strip of thick, resilient paint, similar to
that used to surface outdoor tennis courts. Participants with visual impair-
ments were recruited to serve in the study. However, no information was pro-
vided regarding the degree of visual impairment or to the methods of partici-
pant recruitment. All participants were provided canes and instructed to walk
along the texture strip and to continue walking an additional 100 feet, with the
latter distance serving as a control condition to evaluate the effects of the
textured strip on mobility. The participants were then instructed to turn and
retrace their steps, repeating first the control condition and then the test seg-
ment of the course. Test sessions were recorded using time-lapse photography
to record elapsed walking time and to determine the number of walking devia-
tions by subjects. All participants followed the textured strip and maintained a
safe and direct course without encountering any obstacles (i.e., telephone
poles, newspaper stands, benches, etc.), which were located at various points in
the test area. Under the control condition, however, all but one participant
wandered from a projected direct course and had to change direction after
encountering obstacles. Although the author provides a summary of the results
from this study suggesting that the textured strip produced efficient and safe
walking, there are no quantifiable data provided for within-participant com-
parisons between test and control conditions.
Dodds et al. (1983) examined the reliability of three observers viewing a
videotape of a participant with visual impairments. In this study, three indepen-
dent observers were required to view the mobility performance by the partici-
pant and to examine straight-line walking by continuously tracking the partici-
pant's pavement position from video recordings. The information supplied by
observers was recorded on a number of electronic timers by means of a five-
channel keyboard, one channel being allotted to each pavement zone. As the
participant was walking in one zone, for example, the observer depressed the
key for that zone. When the participant moved into another zone, the observer
depressed a different key and held it down until the participant moved out of
that zone. These data were used to calculate the proportion of time spent by the
participant in each zone in relation to the total time taken to complete each
section of a route. Interobserver correlations for the two viewings suggested
observers can make consistent and replicable judgments about pavement posi-
tion of the participant. Unfortunately, the study provides no information re-
garding the degree of visual impairment by the participant, the means of partic-
ipant recruitment, the dimensions or characteristics of the pavement, testing
area or recording devices, or performance of the participant.
Some research in safe walking for individuals with visual impairments has
been directed toward examining the extent to which a surface material used for
a shoreline may become a potential hazard and disrupt walking. In one exten-
sive technical review, characteristics of various floor materials and textures
were described and evaluated on the basis of safety features such as walking
resistance, slip-resistance, and trip hazards (Templer, 1980, 1983). Each of
these characteristics describes how walking can be impeded by a particular
shoreline material. Impeded walking may result from irregularities or non-
uniformity in surface design, different heights within a pattern of surface mate-
rial or heights between materials, joint width or depth, and so on. Results from
research on characteristics of surface materials suggest that variations in surface
heights as small as III inch (12 mm) can impede forward motion in visually (or
physically) impaired persons (Architectural and Transportation Barriers Com-
pliance Board, 1984; Templer, 1980, 1983).
To summarize, in conceptualizing the characteristics of walking, there are
two levels of analysis that are most often considered: (1) coordination of move-
ments by parts or portions of the body, and (2) the entire organism moving
through the environment. At both levels of analysis, the visual system is critical
in the acquisition and maintenance of walking; however, other types of stimuli
exert control over walking such as auditory, tactile, and proprioceptive. The
role of these other stimuli in controlling walking become more predominant
with visual loss.
METHODOLOGICAL ISSUES IN THE ANALYSIS OF WALKING
There are at least two methodological issues that have hindered both
progress in an experimental analysis of walking (at both levels of analysis) and
the development of an effective technology. The first issue is the apparent
absence of standardized methods for measuring walking performances and the
lack of standardized experimental preparations used by researchers. Mobility
researchers and mobility trainers frequently agree on the complexity of walking
and identify this fact as a reason for the conspicuous absence of standardized,
objective measures of walking (foulke, 1970; Strelow, Brabyn, & Clark, 1976).
In response to these measurement difficulties, one researcher has proclaimed
that the measurement of mobility in a scientific sense was not viable and
instead has utilized subjective rating scales to evaluate mobility performances
(Kay, 1974, 1981). The impact of this lack of standardized measures of walking
on mobility rehabilitation and technology is reflected in the following passage
that appears in the national plan Report of the Panel on Visual Impairment and
Its Rehabilitation (1983):
Research is needed on the basic skills and senses related to mobility and
orientation. The contributions to mobility of the various attributes of vision
need to be identified. No accepted method exists for evaluating and grading
orientation and mobility performance, but there appears to be considerable
potential for developing standard testing procedures for quantitatively or
qualitatively grading these skills in both partially sighted and nonsighted
individuals. The development of such metbods would facilitate and encour-
age correlations of visual function with other senses and skills. (p. 7)
The passage suggests that the emergence of a standard experimental ap-

proach and standard measures would be beneficial to advancing an analysis of
walking at both levels described in the previous section.
The second methodological issue that seems to have hindered the emer-
gence of an effective analysis of walking, as well as hindered the development of
standard measures of walking, is related to conceptualizations about behavior
in general. It is important to point out that these two issues are not mutually
exclusive. The manner in which research questions about walking are raised
and the specific experimental approach utilized by researchers are influenced,
to a large degree, by the manner in which behavior is conceptualized. For
example, some of the research on motor skills involved in walking has been
criticized because many of the important environmental variables that contrib-
ute to the acquisition of motor skills involved in walking are not controlled
directly. Hart (1980) suggests that researchers have based studies on the as-
sumption that movement is the basis for cognitive learning. The research find-
ings relative to motor activities increasing cognitive functioning are of three
primary types: (1) correlative studies in which comparisons are made between
mental, academic, perceptual, and motor scores; (2) experimental studies in
which programs of perceptual motor education are evaluated by the extent to
which they change other attributes; and (3) studies of the development of
perceptual-motor capacities in infants. Hart (1980) has criticized the findings
from some of this research on the basis of:
confusing methodological approaches and assumptions, too short training
periods, lack of controls of the independent variables, small numbers of
subjects, undifferentiated samples, inadequate statistical techniques, inade-
quate reporting and over-interpretation and over-generalization of findings
... However faulty the research findings, the theories are being used across
the country as the basis for various training curricula. (p. 15)
Much of the research literature in orientation and mobility describes con-

ceptualizations of walking by individuals with visual impairments primarily
in terms of cognitions or schema formed (or not formed), and in terms of
information processing. One theory, for example, describes various cognitive
features that are required in order for any sensory aid to enhance mobility
performance:
Any sensory aid to mobility must allow the formation of a spatial percept,
otherwise the skills described could not be demonstrated with the speed
and grace of a sighted person. This must be a fundamental supposition. To
execute a mobility task, the input information to the spatial senses must
stimulate a percept related to the task and the sensory inputs must be in the
form that such a percept can be formed. This becomes a prerequisite to
mobility for blind persons and is not merely the outcome of the design of a
specific device. It was only necessary to have a means for observing behav-
ior from which a general conclusion could be deduced. Any device which is
to be used for aiding mobility should meet this basic requirement. The
actual form of the sensory input and the initial response to it are not
important, provided that the percept formed is quickly learned and can be
used in conjunction with other percepts-or spatial inputs from other
senses. (Kay, 1974, pp. 33-35)
Other mobility researchers have proposed similar theories to account for

efficient and safe walking by individuals with visual impairments (e.g., Foulke,
1970; Kay, 1974; Mettler, 1987). Apparently, none of these theories seem to be
comprehensive enough to explain the total phenomenon of orientation and
mobility (Welsh & Blasch, 1980), and one researcher has suggested that the
absence of a general theory of mobility has hindered the refinement of training
methods and the design of instruments intended to assist mobility (Foulke,
1970).
It is argued here that there is not so much a need for a general theory of
mobility as there is a need to integrate selected forms of experimental methods
and measures of walking into an existing comprehensive theoretical framework
of human behavior. For example, conceptualizing walking as "operant behav-
ior" has several advantages in terms of methodology, theory, and practice. The
following section will describe some of these advantages.
OPERANT BEHAVIOR AND WALKING
In order to evaluate the effectiveness of orientation and mobility rehabilita-

tion or to determine the effectiveness of any sensory aid or environmental
design to enhance walking in individuals with visual impairments, it is neces-
sary to specify the relevant features of walking in precise terms. The methods
used in the analysis of operant behavior in which a specific behavior is recorded
automatically in a controlled environment, relatively free of problems of ob-
server bias can be applied to the analysis of walking. The advantages of the
direct measurement of walking, like operant behavior, depend on the reliability
of the recording system, the adequacy of the sample duration of
behavior, and the interaction between the recording system and the behavior
being sampled (Lindsley, 1964; Skinner, 1938).
One good example of the advantages of adopting this methodological

strategy involves a series of demonstrations that were conducted to examine the
utility of various computer-analyzed measures of mobility (Brabyn & Strelow,
1977). One of these demonstrations examined walking performances of six
participants walking straight toward a designated target under three different
conditions: (1) sighted walking; (2) walking with degraded vision, in which the
experimental room was darkened, a light was mounted at a height of 1.6 m on
a pole, and a face mask of diffusing glass was worn by participants to reduced
light perception to a blur extending over 30 to 40° of the visual field; and
(3) auditory walking, in which the light described immediately above was
replaced by a metronome (set to 1.5 Hz) mounted at the same height. The
participants performed each of these three tasks ten times and the order of
conditions were different for each participant. Deviations in speed and path
trajectory by participants increased under the degraded vision and auditory
control, and average walking speeds by participants decreased under these
same two conditions.
When standard measures of walking speeds are used in mobility research,
researchers can describe performances by participants with greater accuracy, as
well as draw inferences with greater precision. For example, reduction of aver-
age walking speeds (the total path length traversed per unit time) is a measure
of impeded walking; however, some reports suggest that solely interpreting
changes in average speed as a means to evaluate impeded mobility may be
misleading (Brabyn & Strelow, 1977; Dodds et ai., 1983). A slower speed of
walking, for example, may indicate impeded mobility, but competent walking
is likely to be characterized by moderate speed and not necessarily the maxi-
mum of which an individual with visual imapirments is capable. With respect
to the effects of various textures used in continuous shorelines, changes in
walking speed can be a useful measure of impeded walking if control proce-
dures are conducted under the most optimal shoreline conditions (Brabyn &
Strelow, 1977) and under the least optimal shoreline conditions (Templer,
1980). The average walking speed generated under these two control condi-
tions can be compared to that under various textured surface conditions.
Although walking has not received extensive investigation in operant be-
havior research laboratories, it is possible to describe walking in the language
common to operant theorists and researchers. For example, in describing how
forms of walking can be affected by environmental consequences, Skinner
(1953) suggests that:
if the differential contingencies change, the topography of behavior changes
with them. Even the very common responses which enable us to walk
upright continue to be modified by the environment. When we walk on the
deck of a ship at sea, a special set of contingencies prevails in maintaining
our orientation in the gravitational field. The new differential reinforce-
ment sets up "sea legs." At the end of the voyage the old contingencies
work a reverse change. (p. 96)
A major implication of conceptualizing walking as operant behavior is
that an analysis of walking necessarily expands the range of controlling vari-
abies examined. In this analysis, the effects of the consequences of walking are
examined as well as the effects of antecedent stimuli on walking.
The implications of conceptualizing walking as operant behavior are im-
portant at both of the levels of analysis described previously. For example,
within the context of motor skills involved in walking, reflexes employing the
striped muscles are involved directly in maintaining posture. Some of these
well-defined responses are effective enough to be acquired as part of the genetic
equipment of the organism. The role of the environment in controlling these
various motor skills involved in normal walking has received far less discussion
by researchers. Walking, as operant behavior, is concerned with that part of the
environment in which conditions for effective action are more unstable and
where genetic endowment is less probable (Skinner, 1953). Some experimenters
have noted that walking movements produce stimulus changes in an infant's
environment (i.e., tactile, visual, auditory, kinesthetic) that directly reinforce
walking and have suggested that instrumental learning, as well as reflex activity,
is critical to the development of walking (Zelazo, Zelazo, & Kolb, 1972). Thus,
from an operant behavior perspective of walking, an expanded form of analysis
at this level should examine the consequences of walking (i.e., the consequences
of each movement or step, posture, or gait, as well as stimulus conditions under
which particular consequences control these behaviors).
An operant behavior perspective would also examine those environmental
consequences that are imposed on the individual who is walking and examine
the manner in which vision contributes to successful walking under such condi-
tions. In most circumstances, an individual develops effective walking and
adjusts to the spatial world because visual stimulation from various objects set
the occasion on which certain responses lead to particular consequences, such
as physical contact with those objects. The visual field can be the occasion for
walking, as well as effective manipulatory action related to other operant be-
havior. Under these circumstances, the contingencies responsible for walking
are generated by the relations between visual and tactual stimulation charac-
teristic of physical objects (Skinner, 1953). The contingencies responsible for
walking, however, change considerably when visual stimulation from physical
objects is no longer possible. Under these circumstances the nature of stimulus
control is primarily under auditory and tactual stimulation, as well as under
proprioceptive stimulation (Peel, 1974; Welsh & Blasch, 1980). Orientation
and mobility specialists primarily devote their skills and services to a popula-
tion with visual impairments in an effort to establish effective stimulus control
over walking. However, the opportunities for establishing stimulus control are
severely limited because nearly all environments in which people walk are
designed to favor individuals with vision or individuals without significant
visual impairment.
The implications of conceptualizing walking as operant behavior have
been directed toward three important areas: (1) methodology and standardized
measures of walking; (2) integration of research from two levels of analysis;
and (3) rehabilitation and technology in the field of orientation and mobility.
Rather than invoking a new theory of walking, the previous review describes
the expansion of an operant behavior perspective and methodology to the
analysis of walking. One of the highest forms of integration in science occurs
when researchers recognize similarities in the relevant variables between ex-
periments in one field and other experiments in an apparently remote area of
research (Sidman, 1960). For example, detection research (which is typically
the domain of the psychophysical laboratory) has merged with stimulus con-
trol and behavior acquisition research (which is the domain of the experimen-
tal analysis of behavior), and the result of this integration is a sophisticated
analysis and technology for the detection of small-tumor simulations in a
lifelike model of a human breast (Bloom, Criswell, Pennypacker, Catania, &
Adams, 1982; Madden et aI., 1978; Pennypacker, 1986; Pennypacker et aI.,
1982).
There are at least two compelling reasons for conducting experiments that
examine the effects of different ground surfaces affecting walking in persons
with visual restrictions. First, many mobility researchers and rehabilitation
specialists have identified the need for and the potential of modifying ground
surfaces to aid persons with visual impairments in efficient and safe walking,
particularly in complex environmental settings. According to the Report of the
Panel on Visual Impairment and Its Rehabilitation (1983):
Enhanced "human engineering" studies are needed to aid partially sighted,
legally blind, and nonsighted persons. Appropriate coding for guidance
purposes, for example, through the use of wall colors and/or textured
surfaces, floor color and textures, and special lighting, can enhance visual
and nonvisual cues to aid function and mobility; all of these should be
investigated. One possibility is to use special floor-tile textures to guide
individuals to specific locations ... The development of appropriate simu-
lated environments would be valuable in studies to aid the rehabilitation of
the visually impaired patient. (pp. 7-H)
Thus, it is reasonable to direct an experimental analysis toward an area of
research that appears to be in great demand and that may have important and
immediate applications for the field of orientation and mobility.
The second reason for examining the effects of ground surface modifica-
tions on walking is that, relative to other areas of research in mobility, this
particular area of research appears to be the most advanced in terms of stan-
dardi'.ed measures of walking and standardized experimental techniques. In-
deed, if integrating the results from an experimental analysis of walking into a
general analysis and theory of operant behavior is a critical step in the directing
orientation and mobility toward a natural science of walking then the most
reasonable starting point for this analysis would be to examine what might be
considered the existing "state-of-the-art," because many of the advantages
gained from such an integration would become more evident in an area of
research that is on the threshold of becoming an experimental analysis.
Although previous studies have examined either straight-line walking or
decreases in walking speed as a function of shoreline characteristics, Kupfer
(1993; Kupfer and Malagodi, 1996) examined both measures of straight-line

walking and walking speed as a function of walking surfaces. A simultaneous
comparison is critical because these measures do not necessarily covary. For
example, a change in walking surface designed to improve straight-line walking
may create a hazard and result in a decrease in walking speed.
The general layout of the experimental equipment and the pathway is
shown in Figure 4.1. Detection panel& were constructed by securing pressure-
sensitive flexible relay switches to a smooth ground surface and placing acrylic
sheets over these switches. The relay switches were connected by electrical
wireto transformers that activated running time meters. These detection panels
were placed next to one another to form three adjacent straight pathways (6 m
x 0.5 m) and were wired together, forming a series of panels to measure the
total time spent on any of the three pathways: (1) the central series detected
1.5 METERS
~ START SWITCH PADS
4
PLACEMENT OF
90 0 SHORELINE
3
I
I
2 I
I
I
I POWER SOURCE
I
TIMER
a
RESPONSE
START SWITCH PADS RUNNING

TIME
METERS
Figure 4.1 Path layout and placement of detection panels, time meters, response counters, and
electromechanical equipment.
pressure exerted by participants walking on the central series under the various
surface conditions tested; (2) the right series detected pressure exerted by par-
ticipants veering to the right of the central series; and (3) the left series detected
pressure exerted by participants veering to the left of the central series. One of
the dependent measures-the duration of the time spent by participants on
each of the panel series-was recorded directly by elapsed-time meters con-
nected to each series of panels. This measure was used to assess straight-line
walking.
Two sets of switch pads located at both ends of the pathway were con-
nected by electrical wire to a response counter. These switch pads were oper-
ated by pressure exerted by participants stepping off any of the three series of
panels after walking the entire 6-m-long pathway. The response counters,
therefore, recorded each complete path traversal (i.e., one counter activation
per 6 m walked) and were used to calculate the average speed of each I-m panel
length walked by participants. Walking speed was defined as the number of
I-m panel lengths traversed for the total duration of the trial.
In one experiment, Kupfer (1993; Kupfer and Malagodi, 1996) compared
these measures of walking in participants with visual restrictions that were
generated under both a continuous shoreline condition and under a no-shore-
line condition with those generated under two different heights of a textured
surface material (i.e., I-mm and 2-mm raised rubber studs that were approx-
imately 26 mm and 20 mm in diameter, respectively). When a continuous
shoreline is placed on an open, smooth surface area, the stimuli that comprise
that shoreline can exert control over the walking of an individual with visual
impairments and produce a straight line of walking. In the absence of specific
"guiding" stimuli, such as in open areas, the accuracy of straight-line walking
deteriorates, resulting in veering and inefficient walking. A continuous shore-
line and an open area are two extreme conditions representing the most opti-
mal and the least optimal conditions for unsighted walking, respectively. These
two conditions served as control conditions in the first experiment. Both I-mm
and 2-mm textured surfaces and the 90° shoreline produced few deviations
from straight-line walking, whereas a smooth surface produced greater devia-
tions from straight-line walking. The 90° shoreline and the I-mm textured
surface conditions did not produce decreases in walking speed, whereas the
smooth surface produced decreases in walking speed. Under the 2-mm textured
surface condition, decreases in walking speed by participants were a function of
the cane method employed.
In a follow-up experiment, Kupfer (1993) applied the methodological
procedures developed in the previous experiment described above to compare
two emergent cane motions used by the participants with visual restrictions.
In this experiment, participants were instructed to either: (1) hold the cane
in front of the midsection of their body and to move the cane forward
while walking forward (cane trail), or (2) drag the cane in an arc motion in
front of their body while walking forward (touch-drag). For all participants,
textures surfaces under all experimental conditions produced straight-line walk-
ing, and walking speeds were lowest under the 2-mm texture (touch-drag)
conditions.
The results from both experiments suggest: (1) I-mm and 2-mm textured
surfaces placed in open areas can be used as a structure by persons whose
vision was temporarily occluded for maintenance of straight-line walking; (2)
physical dimensions of textured surfaces may impede walking and conse-
quently, decrease walking speed, depending on the cane method employed; and
(3) experiments designed to examine the effects of textured surfaces on walking
should employ measures of walking speed and straight-line walking. Both of
these measures are important characteristics of efficient and safe walking, re-
spectively. Experimental designs that measure simultaneously these two charac-
teristics of walking will produce more accurate depictions of orientation and
mobility than either measure recorded and assessed apart from the other. These
two measures and the methodology described by Kupfer (1993; Kupfer and
Malagodi, 1996) and those described in other experiments (Brabyn & Strelow,
1977; Strelow et aI., 1976) may be used to address further experimental ques-
tions on the effects of other environmental events on walking.
Some important questions regarding safe walking and disruptive effects of
obstacles on walking can be examined using these types of experimental proce-
dures and measures. Many of the questions regarding the effects of obstacles on
orientation and mobility in persons with visual impairments can be arranged
experimentally, such as (1) how significant is the disruption in the speed of
walking; (2) how much distance separates the individual from the obstacles
before a "safe" adjustment is made; (3) whether a relationship exists between
variables (walking speed and distance between individual and object) manipu-
lated in questions 1 and 2 above; (4) once an obstacle is circumvented, how is
straight-line walking reestablished; and (5) how do textured stimuli aid or
hinder the visually impaired person under these circumstances. An experimen-
tal pathway, such as the one described in Kupfer (1993; Kupfer and Malagodi,
1996), can be designed to contain various types of obstacles, and their effects
on straight-line walking and walking speed can be measured directly. The
effects of various cane techniques used to detect and avoid obstacles can be
evaluated as well. Answers to these and other related questions may lead to
clarifying the vague and overused term "safe walking," by referring to two
different behavior outcomes. One outcome may be classified as disrupted walk-
ing, which is controlled by variables that decrease both walking speed and
straight-line walking. The conditions under which the term "disrupted" is used
may be a function of the contiguity between the changes in these two charac-
teristics of walking and the magnitude of these changes. A second outcome,
impeded walking, may refer to variables that decrease walking speed without
affecting straight-line walking, such as the change in walking speed that may
occur during the transition of walking on a hard surface to walking on sand.
The clarification of terms used to describe different characteristics of walking is
an important outcome in an operant behavior perspective of walking, and the
impact of this view on the verbal behavior of researchers and practitioners in
the field of orientation and mobility will be discussed at greater length in the
last two sections of this chapter.
In Kupfer (1993; Kupfer and Malagodi, 1996), subjects wore ear plugs in
order to attenuate extraneous sounds that may contribute to orientation or
produce results that may confound the tactile control exerted by the various
surfaces with those under auditory control; however, the experimental appara-
tus and procedure described in these experiments can be useful to examine the
effects of auditory stimuli on walking as well. For example, some teaching
methods that are designed to establish and maintain straight-line walking (such
as "squaring off") and proper cane movement techniques can provide auditory
stimuli (activated by photobeam) as a consequence for veering or for cane
motions that cross beyond specific boundaries. Auditory feedback, used in
conjunction with indoor mobility training, has been shown to decrease the
amount of time required by individuals with visual impairments to demon-
strate proper orientation and mobility skills (Peel, 1974).
Another important experimental question is raised: To what degree do the
results from experiments with participants whose vision was temporarily oc-
cluded generalize to individuals with varying degrees of and experiences with
visual impairment? Nothing in the experimental methodology described by
Kupfer (1993; Kupfer and Malagodi, 1996) or those described by Brabyn and
Strelow (1977) and Strelow et al. (1976) would suggest that these meth-
odologies would be inadequate to answer these questions. Other experimental
questions regarding other rehabilitation facets of walking can now be ad-
dressed, including the effects of prosthetic devices and physical therapy on
walking speed and accuracy.
Another advantage of the experimental methods described in this chapter
is that researchers who primarily study variables such as gait and posture and
the other motor skills involved in walking can also examine how these skills are
affected when walking speed and straight-line walking change as a function of
environmental conditions. The distribution of body weight changes as one
walks up or down hill and this has an effect on gait and posture. It is for this
reason that experienced backpackers who hike on steep, narrow trails often
redistribute the weight in their backpacks in order to achieve optimal walking
speeds, to minimized back or leg injuries, and to prevent falling. As Howard
and Templeton (1966) suggest, spatial behavior is not only conditioned by
ways in which the body is constructed and moves, but also by the nature of the
physical world in which the body moves. Other natural characteristics of
ground surfaces and terrains that affect walking can be arranged experimen-
tally. The effects of inclines and declines in the surface on walking speed and
straight-line walking can be examined in a manner in which the slope of either
of the two variables can be manipulated systematically. Miller (1967) suggests
that as speed increases, the tendency to veer decreases; whereas a shortened
stride, which tends to decrease walking speed, may serve to increase veering.
These relationships can be examined by arranging environmental conditions in
the manner described above or by arranging environmental consequences, such
as pOSItive reinforcement, for walking specific distances either within some

specified period of time or within a specified boundary. Such consequences for
specific types of walking are seldom arranged in orientation and mobility
experiments in general. Studies that produce reliable data on reflexes, gait,
posture, and so on are important; supplementing these data with information
in regards to the environmental conditions under which these data are gener-
ated would result in a body of literature that has greater generality and would
provide orientation and mobility specialists with a better data base to predict
the types of walking individuals with visual impairments may emit under vari-
ous environmental conditions.
CONSEQUENCES OF WALKING
There are other issues that arise from conceptualizing walking from an
operant behavior perspective. Up to this point, all discussion of antecedent
stimuli (i.e., shorelines, smooth surfaces, and textured surfaces) and walking
has been restricted to an analysis of these stimuli on two different characteris-
tics of walking. Other types of environmental events that have received far less
experimental inquiry are the consequences of walking. From an operant condi-
tioning perspective, an analysis of consequent events on walking is critical to all
discussions regarding discriminative control of antecedent stimuli; statements
regarding the manner in which these antecedent stimuli control behavior are
incomplete in the absence of a thorough analysis of the consequent events that
occur in their presence. Catania (1984) suggests that in dealing with discrimin-
able stimuli and discriminable properties of the environment, complex relation-
al features of the environment could serve as discriminative stimuli and in all
cases in which stimuli are involved, it is important to treat these stimuli in
terms of their relations to responses and consequences. "Discriminative con-
trol," says Catania, "is based upon the three-term contingency: stimulus-
response-consequence. None of these terms is significant in isolation" (1984,
p. 157).
The adaptive significance of walking speed and straight-line walking for
an individual's survival can only be examined with the aid of proper functional
definitions relating walking movements to real environmental changes. Specific
consequences for walking can be arranged, such as providing monetary incen-
tives for maintaining an average walking speed, or for straight-line walking, or
walking specific distances. Events such as loading and unloading a moving van,
a walk-a-thon, or a demonstration march illustrate how contingencies of rein-
forcement can be arranged explicitly based on walking. The arrangement and
direct manipulation of specific consequences for walking in an experimental
analysis would enhance the generality of these response classes as well as
broaden the range of variables available to experimental manipulation that
ultimately are responsible for producing safe and efficient walking (c.f., John-
ston & Pennypacker, 1980).
INSTRUCTION, VERBAL BEHAVIOR, AND WALKING
In any experimental analysis of walking, the role of verbal instruction in

exerting control over the dependent variable of interest must be treated in its
own right. Subtle forms of instructional stimuli have been shown to influence
nonverbal responding, even to the point of preventing experimental contingen-
cies from having their full influence (Catania, Matthews, & Shimoff, 1982). A
brief review of the literature on instructional control of behavior illustrates the
enormous complexity involved in instructional control and the paucity of sys-
tematic research on instructional design. In one review on instructional prac-
tices, recommendations are suggested to experimenters to provide a complete
report of the experimental instructions and to "restrict instructions to intro-
ductory, orienting statements designed to engender initial responding ... [so
that] response dimensions that are particularly critical to the investigation are
left uninstructed and thus dependent on interaction with experimental contin-
gencies" (Pilgrim & Johnston, 1988, p. 62).
Limiting instructions, however, cannot override significant influences of
preexperimental histories of participants. For example, in the experiments by
Kupfer (1993; Kupfer and Malagodi, 1996), the instructions delivered to par-
ticipants avoided describing specific cane methods and the process of partici-
pant selection was sensitive to excluding individuals with formal orientation
and mobility training; however, the participants' preexperimental histories were
uncontrolled. It is unlikely that all three participants in this experiment had
never witnessed an individual with visual impairments using a cane. Indeed, all
three participants emitted cane motions that corresponded with one of the
most commonly used cane methods-the touch-drag method. Additionally,
there were no provisions in this particular experiment to guarantee that partici-
pants did not discuss experimental experiences with each other. These factors
suggest that the role of verbal behavior and the influence of the verbal commu-
nity (described in the following section) must be included in a thorough analy-
sis of walking. This fact should be apparent to mobility specialists who have
encountered the common difficulty of teaching long cane meth-ods in mobility
training and the degree to which verbal instruction by the instructor interacts
(in many cases competes) with the tactile and proprioceptive stimuli generated
by cane motions and cane contacts with the environment (Peel, 1974).
In light of the fact that an analysis of the three-term contingency is absent
in the orientation and mobility literature, any discussion of walking as operant
behavior strictly on the basis of these experiments is speculative. However, the
wealth of experimental and theoretical literature on operant behavior and the
epistemology of radical behaviorism (d., Malagodi, 1986; Pennypacker, 1986;
Skinner, 1945, 1953, 1969, 1974) has sufficient scope and generality to extend
to some aspects of walking (Baer, Wolf, & Risley, 1968). Thus, the remainder of
this chapter will focus on the implications and issues that arise from viewing
walking as operant behavior.
CONTINGENCIES OF REINFORCEMENT AND WALKING
Experiments that compare the effects of two or more types of antecedent

stimuli on walking may have some immediate and important implications for
practitioners and researchers interested in delivering state-of-the-art services to
individuals with visual impairments. (However, see Johnston, 1988, for a dis-
cussion on limitations of comparison studies.) Still more general questions need
to be addressed: What is the nature of walking? How is walking acquired? How
do antecedent stimuli (in any form) come to exert control over walking?
As one begins to consider the range of potential experimental questions
regarding walking that can and should be asked, the limits on the generality of
the results from orientation and mobility experiments become clearer. The
putative stimulus control over walking demonstrated in Kupfer (1993; Kupfer
and Malagodi, 1996) or those described by Brabyn and Strelow (1977),
Strelow et al. (1976), and Templer (1980) is only a very small part of the
picture. It is apparent from these experiments that under a specific stimulus
condition, participants emit a relatively specific pattern of walking; however,
the questions of why participants walk as they do under that condition remain
unanswered. The fact that a person walks over to a telephone and picks up the
receiver when the telephone rings implies the existence of stimulus control by
the ringing phone over walking and picking up the receiver, but the analysis
falls short when no reference is made to the set of circumstances responsible for
the development of that stimulus control. Thus, these questions are important,
not simply as questions that address the variables that influence walking in
individuals with visual impairments but the more basic issues regarding walk-
ing and the contingencies of reinforcement that are responsible for its acquisi-
tion and maintenance. These contingencies of reinforcement may be examined
at a microlevel of analysis (i.e., the consequences of each step, discriminative
control of visual, auditory, tactile, or proprioceptive stimuli, and so on), as well
as at a molar level of analysis (i.e., social, economic, and cultural variables).
Although the contingencies of reinforcement responsible for walking are
not explicitly described or examined in orientation and mobility studies, the
measurement systems and response class definitions described earlier in this
chapter provide the basis to begin such an analysis (Brabyn & Strelow, 1977;
Kupfer, 1993; Kupfer and Malagodi, 1996; Strelow et aI., 1976). For example,
contingencies can be arranged to differentially reinforce walking at specific
speeds. Similarly, the sensitivity of walking to subtle changes in reinforcement
contingencies or reinforcement schedules can be examined to clarify the sim-
ilarities and differences between walking and other operant behaviors. These
types of experimental questions, as well as others, will have important implica-
tions for a scientific analysis of walking, and can provide a basis for the inclu-
sion of walking into the domain of a general science of behavior.
An important issue that arises from an operant behavior perspective of
walking concerns the language of walking and the manner in which specific
terms are used to describe specific behavioral and environmental events. It is
argued here that an analysis of the verbal behavior of the researchers and
practitioners in the field of orientation and mobility is as critical to understand-
ing walking as the direct analysis of the walking individual. The analysis may
begin with drawing a distinction between reinforcing either of the characteris-
tics of walking (walking speed and straight-line walking) directly or indirectly
(Catania, 1984). One may ask: Does the contingency of reinforcement specify
that the individual must walk a certain way? Often times, questions of this sort
lead to asking questions about the possible relationships that exist between the
verbal community and the individual. The verbal community begins to take on
a significant role in establishing control over walking as early as infancy, such
as when parents arrange the conditions for those rudimentary but all-impor-
tant first steps of walking and all of the contingencies of reinforcement that
follow an infant's early successes. Subtle contingencies of reinforcement for an
operant response (carrying a glass of water without spilling) may exert control
indirectly over walking speed as when a person decreases walking speed to
avoid spilling. More direct, explicit rules and instructions for walking adminis-
tered by members of the verbal community can bring individuals into contact
with reinforcement contingencies, such as "stay on this sidewalk and you will
find the Registrar's Office straight ahead." Depending on distance factors be-
tween the individual and the destination point, the verbal community may
further influence walking speed with implicit advice: "The office closes in 5
minutes." The specifications of reinforcement contingencies for walking that
are established by the verbal community (implicit or explicit) must be consid-
ered in a thorough analysis of "operant walking." Furthermore, some of these
questions can be addressed experimentally using the measurement systems
described previously in this chapter.
The role of the verbal community in shaping verbal behavior related to
walking of sighted and nonsighted persons requires further elaboration, partic-
ularly with respect to private events. In the case of sighted (unimpaired) per-
sons, the verbal community arranges conditions to differentially reinforce ver-
bal responses with respect to walking behavior (i.e., "walking straight"), often
based on simple stimulus dimension such as walking parallel to a straight
object. Additionally, verbal responses that describe walking in reference to
some object ("walking-to-the-left-of") can be differentially reinforced by the
verbal community on the basis of the relational features between properties of
environmental events (Catania, 1984). In both of the situations above, the
verbal community achieves success in establishing self-descriptive verbal behav-
ior by individuals about walking because the objects in the environment and
the relations between objects and walking by an individual are public (visually)
for both the sighted individual and the verbal community. However, the situa-
tion changes when an individual becomes visually impaired. The verbal com"
munity does not maintain the degree of control in establishing verbal behavior
as it did in the situation above and the degree of control that is established
depends not only on the extent of the visual impairment (degree of visual
stimulation) but also the degree to which other public stimuli are conspicious
to both the individual and the verbal community. It may be argued that although
orientation and mobility specialists teach effective walking skills (mobility),
the role of the researcher is not just to study the effects of antecedent stimuli on
walking, but also to examine ways in which antecedent stimuli can be arranged
so that the verbal community has more conspicuous stimuli (i.e., tactile) to use
to establish more effective contingencies over verbal behavior (or orientation
behavior).
Skinner (1945) describes a similar situation in which the verbal commu-
nity can generate verbal behavior in response to private stimuli:
Consider, for example, a blind man who learns the names of a trayful of
objects from a teacher who identifies the objects by sight. The reinforce-
ments are supplied or withheld according to the contingency between the
blind man's responses and the teacher's visual stimuli, but the responses are
controlled wholly by tactual stimuli. A satisfactory verbal system results
from the fact that the visual and tactual stimuli remain closely connected.
(p.374)
This process of arranging contingencies for verbal behavior has important

implications for practitioners and researchers in the field of orientation and
mobility. There is a limitation on accessibility to events that are not so "closely
connected," and hence a limitation on the accuracy of the verbal behavior of
the individual with visual impairments (all individuals for that matter) with
respect to describing private sensations (tactile, proprioceptive, interoceptive)
and describing relations between the individual's position while moving in
space. Pick (1980) points out a distinction between two types of tactile percep-
tion. One type of perception, tactual, is considered a more passive process in
which stimulation is imposed on a person's skin and the person reports he feels
something touching him. The other type, haptic, refers to a more active process
in which a person actively touches something else and the person reports he is
feeling something. Whether a person is reporting about an event in the environ-
ment or reporting about his or her own behavior with respect to the environ-
mental event, the limitations of the accuracy of the report are inescapable.
An analysis of the role of the verbal community, in addition to the verbal
responses by the individual with visual impairments, provides a more complete
account for the way in which a response such as, "I am walking straight," is
emitted in open areas, as well as emitted next to walls, 90° shorelines, and so
on. A persons' verbal responses to gross deviations from walking a straight line
may be a function of the verbal community basing instructional control and
reinforcement on the conspicuous manifestations, but the individual presum-
ably acquires the response in connection with a wealth of additional pro-
prioceptive stimuli (Skinner, 1945, p. 375). The term "orientation" implies the
person "knows" the environment, not only in the sense that safe and effective
walking is emitted but also that the person can talk about his or her own
behavior. The main problem that researchers and practitioners of orientation
and mobility must face is the same problem behaviorists have had to face: What
is particularly clear and familiar to the potential knower (individual with visual
impairments) may be strange and distant to the verbal community (researchers
and practitioners in orientation and mobility) responsible for his or her know-
ing (Skinner, 1969).
The analysis of the three-term contingency with respect to walking may
expand the range of behavioral phenomena addressed by a science of behavior.
The benefits of this expansion can be favorable for those individuals in the field
of orientation and mobility as well, because this analysis may begin to clarify
many of the complex issues that have hindered the development of an effective
methodology for examining walking and of a conceptual framework for inter-
preting experimental results. One of these issues concerns the role of "subjec-
tive experience" of persons with visual impairments. For example, Mettler
(1987) suggests:
In understanding how an individual learns and practices a skill, we must
consider individual, subjective elements of personal skill, personal judg-
ment, and personal knowledge-all of which are contributed by the indi-
vidual in the performance. Not only are these not formulable in formally
objective terms, as is common in the language of behaviorism, they have yet
to be adequately formulated through any analysis. One can describe and
measure in physical terms the processes involved in human action and so
detail what happens in the observable world as the behavior occurs, but of
necessity this description leaves out the role of the subjective mental life of
the self-directed agent. It is a fallacy to infer from the fact that you can
describe human behavior in naturalistic terms, that therefore human action
is adequately described. (p. 476)
It is true that "human action is not adequately described" in the absence of an

analysis of the role of the verbal community. An operant behavior perspective
may provide a more thorough-going analysis of walking that is inclusive of
private events as well as public events, without abandoning the practice of
describing events in objective, or "naturalistic" terms (Skinner, 1969, 1971,
1974, 1978).
In summary, the science of behavior has made significant strides in the
analysis of operant behavior and in understanding human behavior in general.
Additionally, the conceptual analysis of verbal behavior and private events has
had a significant impact in promoting a scientific understanding of individual
behavior, cultural processes, and human affairs (Skinner, 1945, 1953, 1971,
1974). In contrast, the field of orientation and mobility has been slow in the
development of effective scientific understanding of walking. Adopting similar
methodologies to those used in the analysis of operant behavior may change
the rate at which new effective technologies emerge, but it is argued here that
the scientific study of walking will develop only if effective verbal behavior by
researchers and practitioners emerges as well. Iwata (1991) suggests that often
times many theoretical questions about the nature of operant behavior can only
be answered through technological arrangement of the environment, and that
the answers do not necessarily produce new theoretical concepts but simply
extend operant theory. In the introduction to this chapter, it was suggested that
a new theory in orientation and mobility was not necessary, but rather walking
and verbal behavior about walking can be treated in a satisfactory manner
within existing operant behavior theory. Some of the many advantages of
bringing an analysis of walking into the domain of operant behavior theory
have been presented throughout this chapter, and those advantages not men-
tioned may only be discovered during the course of research and rehabilitation.
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5
Treatment of Substance Abuse

in Older Adults
Daniel L. Segal, Vincent B. Van Hasselt,
Michel Hersen, and Christopher King
Substance abuse is one of the most prevalent health care problems in the United
States, accounting for a staggering toll on society and the afflicted individual's
physical and emotional well-being (Schilit & Gomberg, 1991). For older adults,
in particular, abuse of alcohol and other drugs is a significant and burgeoning
problem (Brody, 1982; Parette, Hourcade, & Parette, 1990; Ruben, 1992;
Zimberg, 1987). Indeed, epidemiological research conducted over the past
several years reveals that alcohol and substance abuse rank third among lead-
ing psychiatric problems in Americans 55 years and older, accounting for
approximately 10 to 12% of those who receive services from mental health
professionals (see Ticehurst, 1990; Zimberg, 1974). Several estimates of prob-
lem drinking or alcoholism in older adults have yielded prevalence rates in the
general community of between 2 and 10% (d. Fredriksen, 1992; Gomberg,
1982; Shuckit, 1977), and these most likely are underestimates. Prevalence
estimates are even higher in certain settings, such as medical wards and nursing
homes (Horton & Fogelman, 1991). Nevertheless, these data suggest that there
are between 1 and 3 million older heavy alcohol users in the United States who
Daniel L. Segal • Department of Psychology, University of Colorado at Colorado Springs, Colo-

rado Springs, Colorado 80933-7150. Vincent B. Van Hasselt and Michel Hersen • Center
for Psychological Studies, Nova Southeastern University, Fort Lauderdale, Florida 33314.
Christopher King • Department of Clinical Neuropsychology, Bryn Mawr Rehabilitation Hospi-
tal, Malvern, Pennsylvania 19355.
69
suffer deleterious medical, emotional, and legal consequences. Further, these

sequelae have an untoward impact at the societal level (e.g., high economic
losses, increased health care costs, diminished work productivity) as well (Mo-
rey & Martin, 1989; Parette et a!., 1990). Unfortunately, only 15% of alco-
holics in this age group appear to receive some form of mental health treatment
(King, Altpeter, & Spada, 1986; National Council on Alcoholism, 1981).
In contrast to alcohol abuse, use of illicit drugs, such as cocaine, hallu-
cinogens and marijuana, among the elderly is relatively uncommon (Kofoed,
1985; Schilit & Gomberg, 1991), with the exception that some heroin users
survive into old age (Horton & Fogelman, 1991; Schilit & Gomberg, 1991).
However, illicit drug use is expected to increase substantially as younger co-
horts of drug users age (Kofoed, 1985). Also, the majority of current older drug
abusers began their addictions early in life and continued their patterns
throughout their middle years. By contrast, abuse of prescription and over-the-
counter (OTC) medications is already widespread among older adults (Kofoed,
1985). In fact, the elderly consume over 25% of all prescribed medication,
while constituting only 11 % of the general population (Brown, 1982; Schilit &
Gomberg, 1991). The most frequently prescribed medications for older adults
include sedatives, minor tranquilizers, and cardiovascular agents, while widely
used OTC medications are analgesics, antacids, and laxatives (Schilit & Gom-
berg, 1991).
Despite epidemiological data indicating a serious alcohol and drug abuse
problem in older adults, it is commonly believed that these figures are under-
estimates and that substance abuse often remains underdiagnosed and under-
reported (Dupree, 1989; Kofoed, 1985). Several reasons have been offered for
these contentions, including (1) lack of consensus concerning the definition of
substance abuse (Brown, 1982; King, Van Hasselt, Segal, & Hersen, 1994),
(2) inadequate case-finding strategies for isolated, disenfranchised, and "hid-
den" elderly alcoholics who may covertly abuse alcohol and drugs (see Dupree,
1989; Zimberg, 1978), and (3) reluctance of older adults to seek psychiatric
services in general (Lazarus, Sadavoy, & Langsley, 1991). Moreover, as the
proportion of older Americans continues to rise due to advances in the fields of
medicine and nutrition (resulting in longer life expectancies), it is anticipated
that there will be a parallel increase in the number of older alcohol and drug
abusers. Indeed, the heavier drinking rates of younger (Bukstein, Brent, &
Kaminer, 1989) and middle-aged alcoholics is expected to result in a greater
rate of drinking in older adults as individuals in this younger cohort age and
continue their drinking patterns (Alexander & Duff, 1988).
Despite the extent and magnitude of substance abuse in older adults, only
a modicum of clinical and investigative attention has been directed to this
problem. Several factors appear to have impeded efforts in this area. First, for
many years there was a widely held belief that substance abuse was not a
serious difficulty for the elderly (Brody, 1982; King et a!., 1986). This is largely
attributable to the fact that substance abuse in the elderly has not been distin-
guished from substance abuse problems in the general population; thus, it has
5 • SUBSTANCE ABUSE IN OLDER ADULTS 71
not been recognized as a unique disorder warranting investigation. These per-

spectives have been challenged only recently, as the scope and characteristics of
the problem in older adults have been more clearly articulated.
Second, the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV; American Psychiatric Association, 1994) criteria for
substance abuse and dependence have limited relevance or applicability to
older alcohol and drug abusers given their unique clinical presentation (see
discussion by King et ai., 1994). The need for more elder-specific diagnostic
criteria is considerable, in that many health care professionals (as well as abus-
ers themselves) fail to recognize signs and symptoms of abuse or dependence,
thus precluding appropriate referral and determination of the most appropriate
form(s) of intervention (Ruben, 1992). Some misdiagnoses occur because alco-
hol abuse by older adults can produce symptoms that are indistinguishable
from organic brain syndrome or dementia (Brody, 1982). Similarly, some signs
of alcohol abuse (i.e., falls, disorientation) are erroneously attributed to old age
and perceived to be "normal" in the aged population. Besides dementia, symp-
toms of older substance abusers often mimic and are viewed as signs of other
psychiatric disorders, such as depression and anxiety (Katz, Curlik, & Nemetz,
1988). Consequently, treatment is often applied to the affective component of
the disturbance, while the substance use disorder is ignored.
Third, primary motivating factors propelling younger alcoholics into treat-
ment appear to be absent or less pressing for older alcoholics (King et ai.,
1986; Pattee, 1982). For example, fear of employment loss due to abusive
drinking is salient in younger alcoholics; however, only 20% of males and
8.5% of females over age 65 are still working (King et ai., 1986). In addition,
younger alcoholics frequently have been apprehended by the authorities and
are subsequently monitored by the legal or criminal justice system. By contrast,
older adults have less criminal involvement than any other age group (Shichor
& Kobrin, 1978). Illustrative are data showing that the overall proportion of
elderly drivers is low. And because such individuals are less likely to operate
motor vehicles, they are arrested for drunk driving less often, further limiting
their identification as potential treatment candidates. Along these lines, judges
and law enforcement officials often show leniency toward elderly persons, thus
diminishing the likelihood of penalization in many cases where sentencing (and
referral) clearly is warranted (Shichor & Kobrin, 1978). Another reason for
lack of treatment involvement in substance-abusing older adults is that physi-
cians frequently neglect to consider and assess substance abuse in their elderly
patients (see Strang, Bradley, & Stockwell, 1989). Indeed, many still maintain
the false premise that younger substance abusers simply die or outgrow their
addictions (Kofoed, 1985; Strang et ai., 1989).
Confrontation by family members is also a significant motivator for
younger substance abusers to seek treatment. However, many older substance
abusers live alone and are estranged from family and friends (Dupree, 1989;
Pattee, 1982). Even when family support is available, many relatives deny or
minimize the problem due to their own shame and embarrassment about this
type of problem in a family member, as well as their misconceptions of its

gravity (Kofoed, 1985). Zimberg (1987) notes that the "delayed perception of
this subpopulation of alcoholics" is a function of denial by family members and
health care professionals, including their tendency to "dismiss the problem by
rationalizing that elderly persons have nothing left except their bottle, so why
take that away" (p. 58). Such "collusion" perpetuates the denial and stigmatiz-
ation that already characterize the disorder.
Pragmatic concerns (e.g., lack of transportation or financial resources,
physical disabilities) further hinder prospective older clients from seeking assis-
tance (Ruyle, 1988). Indeed, many impoverished and underinsured older adults
are unable to allocate spending for mental health services when other basic
needs are concurrently unmet. A final barrier to research and treatment, espe-
cially in the elderly who were early-onset drinkers, is the discouragement and
hopelessness many experience as a result of a lifetime of unsuccessful attempts
at sobriety. The prospect of yet another treatment attempt may make the older
substance abuser view this option with even greater bleakness. As such, a large
number of older chronic alcoholics simply see little reason to seek mental
health services.
Given the growing recognition of this serious problem, the past few years
have witnessed an acceleration of clinical and investigative endeavors directed
toward the assessment and treatment of substance abuse in older adults. Re-
ports of work in this area, however, have been disseminated in disparate pub-
lication outlets and have not been categorized and reviewed in order to point to
directions that the field should pursue. Most of this work has consisted of case
reports and uncontrolled group treatment outcome studies, mostly without
adequate follow-up. Few single-case experimental designs or controlled out-
come studies have been conducted to date. The purpose of this chapter, there-
fore, is to critically review extant treatment approaches with older substance
abusers. Following a discussion of general treatment issues pertaining to sub-
stance-abusing older adults, we will review behavioral, family, and group inter-
ventions that have been carried out with this population. Then, current issues
and gaps in this area will be identified, and suggestions for directions that
future research might take will be offered.
GENERAL TREATMENT ISSUES
Elder-Specific Treatment versus Mainstreaming

In an influential report over a decade ago, Janik and Dunham (1983)
argued that because of the apparent lack of differences between younger and
older substance abusers, interventions specifically targeting the latter were
unwarranted. A convergence of findings from more recent studies, however, has
challenged this notion and points to the need for specialized interventions for
older adults (see Schonfeld & Morosko, 1988). Kofoed, Tolson, Atkinson,
Toth, and Turner (1987), for example, posit that previous researchers have
evaluated only the degree to which older alcoholics benefit from traditional
treatment approaches relative to younger patients. Therefore, the question of
whether elder-specific treatment approaches are more effective than "main-
streaming" (i.e., integration of older adults with younger clients in therapeutic
contexts) has not been adequately addressed. Particularly illustrative are data
from Kofoed et al. (1987) showing that elderly drinkers treated in a same-age
peer group demonstrated less attrition, were more likely to complete interven-
tion programs, and had better outcome than those in a mixed-age group.
Previous research in this area already had shown that older alcoholics in peer
groups remained in treatment longer and had higher attendance rates than
younger problem drinkers (Atkinson, Turner, Kofoed, & Tolson, 1985), al-
though mixed-age groups were not employed in these earlier studies. Kofoed et
al. (1987) argue that older adults respond differently than younger clients to
traditional treatment, and therefore require therapists who are specifically
trained in elder-specific counseling approaches.
It is noteworthy that strategies emphasizing supportive sociotherapeutic
interventions are more efficacious with older adults than the vigorously con-
frontative methods typically applied to younger clients (Zimberg, 1978). The
limited utility of confrontation with the former group has been viewed as
resulting from a hesitancy on the part of older adults to enter a type of treat-
ment that implicitly labels them as "alcoholic" (Canter & Koretzky, 1989) and
leads to further stigmatization by the family and community. Similarly, King et
al. (1986) caution against use of active confrontation with older alcoholics, due
to their (1) frequent discomfort with involvement in mental health services in
general, and (2) their need for more time to openly discuss sensitive issues with
a therapist. This important treatment consideration further supports the need
for elder-specific approaches. Additionally, Horton and Fogelman (1991) note
that "negative attitudes toward the elderly are common in nonaging-focused
treatment settings and can be expected in alcoholism treatment settings as
well" (p. 304). Certainly, such biases against the elderly would be moderated in
settings specifically designed to meet the unique needs of this population. In a
recent review of work in this area, Atkinson, Tolson, and Turner (1990) con-
cluded that "given proper arrangements for treatment, most importantly an
elder-specific outpatient program, older alcoholics can be engaged successfully
in treatment irrespective of onset age" (p. 578). Clearly, further empirical
investigation of this issue is warranted.
Motivation for Change

Attempts to modify use patterns in a client who fails to acknowledge the
existence of alcohol or drug related problems, or who is insufficiently moti-
vated for change, are likely to be unsuccessful. Consequently, an evaluation of
the patient's motivation to modify his or her substance abuse behavior must be
carried out prior to implementation of remedial efforts. DiClemente and Pro-
chaska (1982) conceptualize such change as a stage-related process. In this
model, change is directly linked to motivation. Therefore, substance abusers

who fail to recognize their own problematic patterns and dysfunctional behav-
iors have little motivation for change. In such instances, interventions that
primarily raise consciousness (e.g., psychoeducation, bibliotherapy) can help
clients to consider their actions more objectively. Once such difficulties are
acknowledged, clients may be directed to more structured therapeutic activities
in which behavioral consequences of drinking and viable options are discussed.
By this point, motivation has increased to the point that change is possible. In
this "action" stage, instigation of self-efficacy is fostered through increasing
coping skills, personal recognition, and self-reinforcement for goal-directed
accomplishments. Finally, a level of "behavior maintenance" is attained that
involves continued action to generalize newly acquired skills and treatment
gains across daily activities.
DiClemente and Hughes (1990) applied these concepts clinically to outpa-
tient alcoholism treatment in an adult sample and found differences between
stage of change profile groups on measures of alcohol consumption, self-effi-
cacy, and temptation to drink. Regrettably, while the "stages of change" model
has been validated with adult alcoholics in outpatient treatment (DiClemente
& Hughes, 1990), its relevance to older alcohol and substance abusers has yet
to be ascertained. Thus, further research is needed to assess the potential utility
of this approach for the study of substance abuse assessment and treatment in
older adults.
Relapse Prevention
Relapse prevention refers to a combination of strategies employed to de-
crease the probability that currently sober individuals will resume active drink-
ing or drug use. Anecdotal evidence suggests that relapse is to be expected and
is part of the transition to a more stable sobriety. Thus, frequent regressions in
both goal-directed behavior and underlying motivation are considered a nor-
mal part of the rehabilitation process. Schonfeld, Rohrer, Dupree, and Thomas
(1989) report empirical evidence demonstrating that relapse is indeed quite
common, often occurring within the first 90 days subsequent to termination of
treatment.
Strang et al. (1989) note that cognitive-behavioral techniques have been
successfully employed in relapse prevention. Identification of high-risk situa-
tions and behavioral rehearsal of relevant coping strategies are crucial. Strang
et al. (1989) document the importance of inoculating drinkers against relapse
and providing assertion training for dealing with high-risk situations or en-
counters (e.g., refusing a drink offered at cocktail party). Other high-risk situa-
tions or threats to sobriety include marital conflict, loneliness, negative physi-
cal states, and social isolation. Similarly, an investigation of antecedents to
relapse in a sample of 30 adult alcoholics suggested that negative emotional
states (i.e., anger, loneliness, sadness) were the most powerful predictors of
relapse (Schonfeld et aI., 1989). Such data point out the need to enhance coping
skills in substance abusers in order for them to better manage their negative
feelings (without turning to substance use).
Despite the recent interest in relapse prevention, little research has been
conducted to assess applicability of specific approaches to older substance
users. Utility of strategies employed for such purposes with younger popula-
tions has yet to be examined with older substance-abusing adults.
Psychiatric Comorbidity
The issue of comorbidity or dual diagnosis has received increased attention
in recent years (see Bukstein et aI., 1989; Evans & Sullivan, 1990; Schilit &
Gomberg, 1991). Speer, Sullivan, and Schonfeld (1991) have recently called
attention to the dual diagnosis problem specifically among older adults. In
addition to examining factors directly associated with substance abuse, comor-
bid psychiatric symptomatology (i.e., unipolar depression, bipolar disorder,
schizophrenia, anxiety disorders, and personality disorders) must also be ad-
dressed in order to promote motivation for recovery and decrease the likeli-
hood of relapse due to a focus on only one dimension of the problem. Canter
and Koretzky (1989) reported that many older alcoholics appear to use alcohol
as a form of "self-medication" to cope with bouts of depression and anxiety.
Indeed, depression is the most common psychiatric disorder in older adults
over 65, with an incidence of 10% in this age group (Schilit & Gomberg,
1991). Along these lines, Hyer, Carson, Nixon, Tamkin, and Saucer (1987)
found that depression covaried significantly with alcoholism in the general
population, and that health concerns of elderly patients frequently masked
depressive episodes. Whether depression is a cause or effect of abusive drinking
has yet to be unequivocally ascertained. However, as mentioned earlier, reduc-
tion of depressive symptomatology alone may, in fact, enable the older adult to
continue his or her maladaptive substance use.
It should be underscored at this point that the suicide rate of older Amer-
ican males is the highest of any age by sex group. Such self-destructive actions
have been linked to the accumulation of adverse circumstances (e.g., declining
health, retirement, death of spouse, depleted financial resources) associated
with aging (Templer & Cappelletty, 1986). In their review of suicide in the
elderly, Templer and Cappelletty (1986) note that those who abuse alcohol
are particularly at risk. Other risk factors for suicide in the elderly include
being unmarried or widowed, involuntarily retired, and physically impaired.
Thus, loss of social reinforcement, self-efficacy, and personal esteem fre-
quently precipitates depressive symptoms and subsequent suicide attempts in
older men (Templer & Cappelletty, 1986). Hyer et a!. (1987) concur that
alcohol abuse and physical deterioration exacerbate existing affective disor-
ders and may precipitate suicidal gestures in elderly persons. Given the seri-
ousness of the dual diagnosis problem among older adults, the expected in-
crease in this population, and the lack of preparation and preparedness on the
part of the current mental health system to adequately deal with this type of
patient (see Speer et aI., 1991), future research and knowledge in this area are
clearly warranted.
Cognitive and Physical Impairment

While a positive social environment is generally considered requisite to
treatment compliance and therapeutic change, other factors, such as level of
physical and cognitive functioning, must be assessed in the elderly prior to
implementing interventions. The physical state of most alcoholics, for example,
is quite poor, given their typically unhealthy lifestyles (Schilit & Gomberg,
1991). Indeed, the physical and medical complications of prolonged alcohol
abuse (in conjunction with the already compromised physical state of many
older adults due to the natural effects of aging) appear to be staggering. As a
result, Schilit and Gomberg (1991) have underscored the need for "physical
rehabilitation," including nutritional, exercise, and recreational programs as
important aspects of intervention for most older adult alcoholics. Treatment
planning for older adults is especially affected, as detoxification is often slower
and in some cases sometimes cannot be implemented due to other physical
concerns.
The adverse effects of alcohol abuse on cognitive functioning also have
been well-documented (see review by Tarter & Edwards, 1985), although few
studies have specifically examined cognitive capacities in older alcoholics. Still,
older alcoholics have displayed deficits on several cognitive functions (short-
term memory, visual-spatial relationships) relative to matched nonalcoholics
(Hartford & Samorajski, 1984). Further, Tarter and Edwards (1985) note that
while some alcoholic cognitive deficits are reversible, especially during the
initial postdetoxification period, complete recovery is rare. The clinical ram-
ifications of such long-lasting neuropsychological impairment have been ad-
dressed in alcohol rehabilitation that involves the (re)training of coping and
interpersonal skills. For example, Canter and Koretzky (1989) demonstrated
that cognitively unimpaired elderly alcoholics benefited most from a tradition-
al multimodal program, while patients exhibiting cognitive dysfunction re-
quired specialized procedures such as greater individual counseling and an
emphasis on stress-reduction techniques. Additionally, Tarter and Edwards
(1985) concluded that cognitive capacity is predictive of treatment success or
failure. In summary, comprehensive assessment of physical and cognitive fac-
tors is necessary to enable treatment providers to tailor their interventions to
the level of cognitive and physical functioning in older clients.
TREATMENT
Investigations of treatment strategies for substance-abusing older adults

have ranged from purely descriptive case studies to comparative outcome stud-
ies. For purposes of review, we have grouped these studies within each of three
treatment orientations: (1) behavior therapy, (2) family therapy, and (3) group
therapy.
Behavior Therapy
Cognitive-behavioral approaches have been applied with success in
younger substance abusers for several years now (see reviews by Bukstein &
Van Hasselt, 1993; Ingram & Salzberg, 1988; Oei & Jackson, 1984). For older
substance abusers, the importance of a social component to treatment was
recognized as early as 1964 when Droller described the treatment of seven
older alcoholics (age range 62-82 years old) that involved detoxification fol-
lowed by socialization with peers and placement in a communal setting to
avoid isolation (Droller, 1964). Rosin and Glatt (1971) documented the charac-
teristics and causes of drinking in 103 older alcoholics and suggested that
attendance at a day treatment program in conjunction with home visits by staff,
friends, and family would provide "social protection" to such clients. Similarly,
Zimberg (1978) reported that "social interventions" (i.e., a combination of
group socialization, social and family casework) with antidepressant medica-
tion were effective in eliminating alcohol abuse in older adults, regardless of age
of drinking onset. While these early case studies demonstrated the potential
efficacy of socially oriented interventions, empirical support with larger num-
bers of subjects was lacking.
In another early case study by Horton and Howe (1982), "response cost"
procedures were implemented with a 68-year-old male nursing home resident
diagnosed as a chronic alcoholic with organic brain syndrome. In this case,
access to reinforcing social activities was contingent on alcohol use as deter-
mined by daily breathalizer analyses exceeding 0.10. Although the resident's
drinking behavior decreased dramatically once contingencies were established,
he was re-referred for treatment 6 months later after a relapse. However, an
examination of clinical records revealed that the patient remained abstinent
when the treatment plan was followed stringently; relaxed record keeping and
lax enforcement of the response-cost contingencies on the part of the nursing
home staff led to resumption of drinking in this client.
More recently, Fredriksen (1992) developed an innovative alcohol reha-
bilitation program specifically for isolated and impoverished older women.
This approach (1) helped clients form social support networks by providing
community outreach, as well as educational and recreational alternatives in a
supportive peer group environment, and (2) offered formal alcohol treatment,
which occurred subsequent to participation in social and support activities.
The social programming component served to attract and engage this previ-
ously hard-to-reach population. Further, increasing social support may have
been a useful ameliorative strategy in its own right, particularly for older
female alcoholics who typically have minimal social support available (Fred-
riksen, 1992). Unfortunately, an empirical evaluation of this model was not
conducted.
One of the first outcome studies with follow-up data was conducted by
Wiens, Menustik, Miller, and Schmitz (1982), who examined the effectiveness
of a multimodal alcoholism program (chemical aversion and medical care) for
older alcohol abusers. Aversion therapy consisted of "associating the sight,
smell, taste and thought of alcohol with an unpleasant reaction" (p. 464).
During a 2-week inpatient stay, patients received five aversive conditioning
trials. After discharge, outpatient "booster" trials were initiated to enhance
durability of therapeutic gains. Of the 78 patients treated over 2 years, 65 %
(N = 51) evidenced continuous sobriety throughout the 12-month follow-up
period.
Dupree, Broskowski, and Schonfeld (1984) emphasize the need for broad-
based, programmatic, behavioral interventions that include a functional analy-
sis of addictive behavior, self-management training, social reinforcement, and
education. These elements were employed in their Gerontology Alcohol Project
(GAP), a comprehensive 12-month day program designed to treat late-onset
alcoholism in the elderly. Using an A-B-C paradigm for clarifying anteced-
ents, behaviors, and consequences associated with abusive drinking, patients
were first taught to identify such factors as they specifically related to them.
Next, self-management skills (e.g., drink refusal, tension reduction) were re-
hearsed for "high-risk" situations identified as particularly conducive to drink-
ing, such as negative mood states or attending a party with easy alcohol avail-
ability. Finally, alcohol education, covering medical and psychological aspects
of alcohol abuse, and problem-solving skills training (problem identification,
generation of solutions, decision-making) were provided.
Results indicated that 24 of 48 late-onset elderly alcoholics completed the
program. Of these graduates, 21 participated in 1-, 3-, 6-, and 12-month
follow-up assessments. Seventeen subjects were abstinent at discharge, while 14
maintained sobriety at the 12-month probe. In addition, graduates showed
improved community adjustment, as reflected by increased social support and
a greater number of friends.
Similarly, in a study of older male veterans (range 65-70 years old) treated
in a 28-day inpatient alcohol treatment program at the Veterans Administra-
tion Medical Center in Jackson, Mississippi, Carstensen, Rychtarik, and Prue
(1985) documented the positive impact of a multiple-component behavioral
treatment strategy consisting of problem-solving therapy, self-management
training, alcoholism education, and medical care. Additionally, vocational re-
habilitation and marital therapy were available when warranted. Program
graduates were contacted 2 to 4 years after discharge to evaluate therapeutic
maintenance. Of the 25 graduates located, 16 agreed to participate. Half of
these patients (n = 8) maintained total abstinence, while an additional 12%
(n = 2) significantly reduced their drinking. Thirty-eight percent (n = 6) re-
ported current abusive drinking. Results of this promising study attest to the
durability of comprehensive behavioral treatment in older adult alcoholics.
However, the small sample size and absence of a control condition preclude the
drawing of any definitive conclusions.
Commentary
Overall, results of programs employing behavioral interventions have been
encouraging for reduction of alcohol abuse in the elderly. While the compara-
tive efficacy of such approaches has yet to be determined, multidimensional
interventions appear to have the greatest potential, since they also target con-
current difficulties (e.g., poor self-management skills, physical and cognitive
deficits) characterizing many older alcoholics. Further, these programs are in-
novative in that they train requisite interpersonal skills in addition to modifying
problematic drinking patterns. Acquisition of relevant interpersonal skills are
especially important for older alcoholics, many of whom lack viable social
support networks (Fredriksen, 1992; Pattee, 1982).
Several of the studies reviewed (e.g., Wiens et aI., 1982; Dupree et aI.,
1984; Carstensen et aI., 1985) are particularly impressive, in that they involve
adequate follow-up evaluations (at least 6 months) and a specific focus on older
adults. Unfortunately, none of these investigations included a control condition
and sample sizes were small. Indeed, combining the number of older alcoholic
patients for whom follow-up data are available reveals a grand total of 115 (as
36 subjects dropped out or refused assessment at follow-up). However, despite
the limitations we have underscored, the behavioral investigations carried out
with elderly substance abusers provide a strong initial base for development of
larger-scale, controlled research in the future.
Family Therapy Interventions

Amodeo (1990) discussed the advantages of incorporating the family sys-
tem in the treatment of a substance abusing older adult: (1) more comprehen-
sive assessment; (2) further reinforcement of therapeutic strategies; and (3)
enhanced maintenance and generalization of treatment effects. Nonetheless,
family involvement is often impeded since the social environment of many
elderly patients is limited. When significant others are available, however, they
should be engaged in therapy in order to provide the therapist with additional
historical information, as well as an understanding of family issues and prob-
lems that relate to the client's substance use pattern. For example, problem
drinking in other family members may be revealed. Other systemic issues, such
as inadvertent collusion, or "enabling," must also be assessed. Without atten-
tion to family and environmental circumstances that may be factors in initia-
tion or maintenance of substance use behavior, efforts focused solely on the
alcohol or drug abuse itself will have minimal impact or short-lived effects
(Amodeo, 1990).
The emphasis on family processes and environmental factors contributing
to the substance abuse problem helps clients recognize the importance of these
areas, which otherwise may be neglected. Relatedly, identification of potential
prosocial activities (e.g., hobbies, recreational events) can be optimally in-
cluded in treatment so that family members can reinforce these positive behav-
iors and strengthen numerous competing responses to abusive drinking. As

familial relationships improve, the client may utilize such social support as a
buffer and source of resilience against other stressors, so that relapse is more
likely to be averted. Finally, Amodeo (1990) recommends that, in addition to
direct involvement in conjoint therapy, significant others should assist by ac-
companying the identified patient to self-help meetings or attending support
groups (e.g., Al Anon) for families of addicted persons. While the need for
family therapy appears great, currently there are no extant data as to the effects
of this therapeutic modality on the amelioration of substance abuse in older
adults.
Group Interventions
The value of group treatment for older substance abusers has been high-
lighted by several researchers and clinicians (Amodeo, 1990; Dunlop, Skorney,
& Hamilton, 1982; Ruyle, 1988). Group interventions are particularly useful
to help the patient identify with same-aged peers who also struggle with sub-
stance use problems. Without peer contact or pressure, older alcoholics are
more likely to minimize the severity of their difficulties; consequently, they are
less likely to seek treatment (Amodeo, 1990). Further, establishment of a cohe-
sive group fosters feelings of belonging and increases participation in persons
who otherwise may be socially isolated and unmotivated to change.
Group work with older adults appears to differ in many ways from such
therapy with younger clients (Dunlop et aI., 1982). Ruyle (1988) identified
several fundamental tenets for group interventions with older adult alcoholics.
These include: (1) recognition that socializing, problem solving, and advice
giving may be of value to isolated members coping with reality-based stressors
associated with aging; (2) the value of "life review" or reminiscence to increase
bonding among group members and provide the opportunity to view the past
in a more positive light; (3) abstinence as a treatment goal, but without the
dictum that group members "recognize and admit their alcoholism;" (4) the
importance of an active, directive, and self-disclosing group leader who helps
reduce anxiety brought on by the group experience and models appropriate,
albeit difficult, self-disclosure for many older members; and (5) the encourag-
ing of members to socialize outside of the group to reduce isolation and pro-
mote a readily available sober support network.
Despite a wealth of anecdotal evidence, however, we were unable to find
any studies that empirically evaluated the group treatment for older adult
substance abusers. As such, its value relies solely on clinical lore and cannot be
confirmed at present. Research in this area obviously is warranted in the future.
SUMMARY AND FUTURE DIRECTIONS
Recent statistics document the significant and burgeoning problem of sub-

stance abuse among older adults, resulting in deleterious consequences to af-
flicted individuals and society in general. Moreover, it is anticipated that the

number of older alcohol and drug abusers will increase as the proportion of
older Americans continues to rise and as younger cohorts of heavier substance
abusers age. We reviewed reasons for the relative paucity of clinical and investi-
gative attention directed to this problem despite its seriousness and anticipated
worsening. It is hoped that this chapter can raise awareness about the scope of
the problem and the pressing need for concentrated investigative efforts in the
identification, assessment, diagnosis, treatment, and prevention of substance
abuse in older adults. Additionally, we provided an overview of general treat-
ment issues pertaining to substance-abusing older adults, including discussion
of elder-specific treatment versus mainstreaming, motivation for change, re-
lapse prevention, psychiatric comorbidity, and cognitive and physical impair-
ment.
Due to the magnitude of the problem, and the only-recently expanded
attention from clinical researchers, several suggestions for future directions are
offered. Foremost, the need for better identification or case-finding strategies to
reach and serve older adult substance abusers is emphasized, given the numer-
ous obstacles to treatment participation faced by many older substance abusers
as well as the large number of "hidden" older alcohol abusers. We are com-
pelled to conclude that most elderly substance abusers do not identify the
problem themselves and enter directly into a form of substance abuse treat-
ment. Similarly, many aged substance abusers are not adequately identified by
physicians, family members, and law enforcement and criminal justice officials.
Indeed, very few investigative efforts to date have been directed to identification
of older substance abusers. Dupree (1989) compared the relative effectiveness
of three case-finding strategies relative to older adult alcoholics: Community
Agency Referral Network (CARN; networking with local service providers for
elderly and giving training to identify elderly alcohol abusers), Public Aware-
ness Campaign (PAC; employing mass media such as pamphlets, billboards,
television, and newspaper announcements to educate general public), and
Community-Based Outreach (CBO; screening and follow-up of patients at local
health clinics). His findings suggest that the CARN generated the highest num-
ber of appropriate referrals while operating at the lowest cost.
The value of detection and identification of older adult substance abusers
is great, given the relatively positive data for the effectiveness of treatment once
the older client engages in treatment. Existing case-finding strategies must be
implemented on a larger scale than is currently practiced, and new ones devel-
oped and evaluated.
Once the prospective client is identified, there must be increased emphasis
on outreach to combat the many obstacles to treatment participation faced by
many older substance abusers. The need for home-based intervention is under-
scored, given the fact that many older substance abusers are not propelled into
treatment through the usual avenues. Supportive individual counseling in the
home of the substance-abusing older adult may be welcomed by many who are
isolated or lack positive human connections. The goal of this type of contact is
to establish a positive relationship with the client and increase motivation to
attend more traditional programs. Presence of a caring professional may also be

welcomed by many older substance abusers who typically are isolated. With-
out the support of a "liaison" therapist, the prospect of joining an alcohol
therapy group or Alcoholics Anonymous may be too threatening to many older
substance abusers due to long-standing avoidance and denial.
In addition to the shortcomings in existing case-finding strategies, ade-
quate diagnosis and assessment become the next barriers to the treatment
phase for substance abuse. As King et al. (1994) point out, elder-specific assess-
ment measures have not yet been developed and validated, although some
existing instruments have been adapted for use in older populations. Further
complicating diagnosis and assessment in older adults is that classical signs of
alcohol abuse/ dependence in this group are often not evident, or when present,
are misperceived as signs of old age, dementia, or other psychiatric conditions
(Katz et aI., 1988). In any case, improved diagnosis and assessment of sub-
stance abuse will undoubtedly enhance the selection of treatment strategies, in
that suitability for treatment and motivation of clients can be assessed. Further-
more, clients can be "matched" with particular treatment programs and thera-
pists to meet their unique needs. Improved assessment will also facilitate the
evaluation of treatment success, as changes over time can be ascertained with
greater validity. [The interested reader should see King et al. (1994) for a
thorough review of assessment deficits specific to this population.]
Our chapter also reviewed the behavioral, group, and family interventions
that have been carried out to remediate inappropriate drinking in older adults.
The early clinical observations (Droller, 1964; Rosin & Glatt, 1971; Zimberg,
1978) suggested that "social" interventions were effective in eliminating alco-
hol abuse in older adults. However, Brody (1982) cogently warned that,
Surely it is time to stop writing reviews and quoting vintage Zimberg,
Rosin, and Glatt. These assertions need repetition and proof, a matter of
critical importance since the need for treatment will grow at least in propor-
tion to the rate of growth of the elderly population. (p. 125)
Indeed, these early contentions have been somewhat clarified by recent

investigative efforts employing specialized behavioral procedures in group de-
signs. Results of such behavioral programs appear promising as to reduction of
abusive drinking by older adults. Multidimensional interventions that target
concurrent difficulties (e.g., poor self-management skills, physical and cogni-
tive deficits) have yielded positive results, and these programs seem especially
well-suited for older alcoholics, many of whom lack appropriate social skills
and support networks.
Despite some positives, however, considerable gaps and shortcomings ex-
ist in the current research base for the cognitive-behavioral treatment of the
aged alcohol abuser. For example, few studies include adequate follow-up eval-
uations of at least 6 months. Indeed, with alcoholics a I-year follow-up will
provide an even more conservative estimate of success. Particularly absent in
this literature are any studies that compare the relative efficacy of such behav-
ioral programs with matched control conditions. Another problem is the over-
reliance on self-reports (usually number of drinks consumed) as the primary
outcome measure. Due to the nature of the substance abuse problem, concomi-
tant denial, and numerous advantages in underreporting, self-report measures
certainly are limited. Despite these gaps, however, the behavioral investigations
carried out with older alcohol abusers provide the basis for improved research
in the future. Clearly, expansion of this promising research avenue is warranted.
As to family and group interventions, little empirical support is available de-
spite a wealth of clinical lore for both treatment strategies. Future research
should be carried out in this area, with special attention directed to including
more effective outcome measures, providing appropriate control conditions,
and following up clients for a minimum of 1 year.
Regardless of the therapeutic approach initially implemented, an interper-
sonally oriented aftercare program is suggested to augment social support and
aid generalization of treatment effects (see Canter & Koretzky, 1989). The
increased chance of social isolation and the concomitant negative emotional
states faced by older adults place them at a particularly heightened risk for
relapse without adequate social support. Increased cooperation among social
and health agencies, community centers, day treatments, and residential settings
is necessary to provide increased opportunities for older adults to participate in
social programs. Besides improved coordination of services, the need for in-
creased alcohol education and support is underscored. Such services are partic-
ularly important for those abusers who live in retirement communities, as
drinking rates in these living environments are substantially higher than for the
rest of the older adult population (see Alexander & Duff, 1988) and represent a
population that current outreach rarely affects. Education is also necessary for
physicians, paraprofessionals, and mental health workers who have contact
with older clients in order to improve their awareness of the clinical manifesta-
tions of the disorders, which frequently tend to be overlooked or misinterpreted.
While the present chapter has focused primarily on the growing literature
about alcohol abuse in the elderly, it is evident that information about abuse of
other drugs such as cocaine, hallucinogens, PCP, and marijuana is significantly
lacking for this population. Knowledge as to the course and effects of these
drugs in the elderly is sparse. Further, we are unable to find any studies docu-
menting treatment approaches with older drug abusers. Clearly, future research
is needed in this area, especially given the predicted rise in the prevalence of
such problems as younger abusers of these substances age.
We have witnessed an increase in the number and quality of investigative
efforts for the treatment of alcohol abuse in older adults over the last decade.
We therefore have concluded that certain interventions (i.e., behavioral, multi-
component programs) have value in the amelioration of this problem. Also in
light of current knowledge, an elder-specific approach to meet the unique needs
of this population is recommended. However, we also underscore that contin-
ued progress and refinement of intervention strategies are imperative if we are
to successfully reduce the suffering of a large number of elders.
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6
Behavior Analysis
and HIV Prevention
A Call to Action
Grace Baron
Very specific behaviors and environments perpetuate the spread of human

immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome
(AIDS) epidemic. Thus, writes the National Commission on AIDS (1993), it is
logical that behavioral and social science expertise should be fully utilized in
our national and global response to the epidemic, particularly in prevention
efforts. However, in sharp contrast to the energetic involvement by behavioral
scientists in other health areas such as smoking, safety, and exercise, there has
been relatively little activity in HIV prevention by those of us with expertise in
behavior change. What are the barriers keeping us so inactive? What can we
contribute? How can we accelerate our involvement? This chapter addresses
these questions and invites readers to apply the logic and practice of behavioral
analysis to the expanding local and global tragedy of AIDS.
At the 1994 Tenth Annual International AIDS Conference, Jonathan M.
Mann, the first director of the World Health Organization's AIDS program,
portrayed the global AIDS prevention effort as a failure. Furthermore, he
warned that
The gap between the expanding pandemic and the global response is grow-
ing, rapidly and dangerously.... Pilot projects are not being sustained, the
lessons learned from the past global experience are being ignored, commu-
Grace [3,lron • Department of Psychology, Wheaton College, Norton, Massachusetts 02766.
87
nity and political commitment to AIDS is plateauing or even declining.

(Radin, 1994)
At the same conference, grim reports of the exponential spread of the

disease into less developed countries (with 4 million people reported, and 17
million estimated as infected worldwide) triggered comparisons with the his-
torical Black Death scourge, which killed 25% of Europeans. Though we knew
early in the first AIDS decade that HIV can be kept from spreading by making
specific behavioral changes, the alarm call was not given loudly or widely
enough. Transmission through contact with infected blood has spread the dis-
ease from its earliest epicenters of localized and often marginalized popula-
tions, such as communities of gay men, Haitian immigrants, some African
groups, and intravenous drug users, via what is predicted to be a massive
"second wave" of heterosexual transmission. As AIDS spreads to every conti-
nent, it threatens hard-won economic progress in developing countries, further
debilitates communities already victimized by poverty and war, and strains all
available medical and social resources.
In the United States alone, most recent data from the Centers for Disease
Control (1994) tell us that:
• Approximately 1 million people are infected with HIV, representing
approximately 1 in 250 Americans.
• Over 300,000 Americans are diagnosed with AIDS.
• The largest reported increase in new AIDS cases is attributed to hetero-
sexual contact among young people.
• AIDS is now the leading cause of death among all Americans 25 to 44
years of age, surpassing homicide, suicide, heart disease, and cancer.
The HIV prevention activities of our nation's Public Health Service, a
division of the US Department of Health and Human Services, include collab-
oration and assistance with state and local health and education agencies,
national and local minority organizations, community-based organizations,
academia, business and labor, and religious organizations. Implicit in our na-
tional response to HIV is a belief that scientists are relentlessly seeking both a
cure and prevention strategies to slow the pace of HIV infection, and that there
is a rapid explosion of interest among scientists from many different disciplines
(Ostrow & Kessler, 1993).
SCIENTIFIC ACTIVITY IN AIDS/HIV
Psych lit and Medline

Despite a popular belief that all of our nation's resources have been
brought to bear on the AIDS problem and even a comforting assurance that
science is doing its part, the data tell another story on science's involvement
overall, and in prevention activities in particular. One would assume, for in-
6 • BEHAVIOR ANALYSIS AND HIV PREVENTION 89
stance, that given reports of the exponential spread of the HIV virus that
research activity might also rise at a fast pace. Surprisingly, the annual totals of
published research reports in medicine and psychology (as reported in Medline
and Psych Lit, two major electronic abstract and search services) displayed in
Figure 6.1 confirm a more moderate scientific activity level. And despite a
prevailing wisdom that scientific energies must aim specifically at prevention,
this same attentuated growth in research activity appears in scientific reports
on HIV prevention (see Figure 6.2). Furthermore, and perhaps most alarming,
the relative rate of scientific publications on HIV prevention, rather than treat-
ment, remains stable at about 18 to 20% (see Figure 6.3).
Scientific Activity Reported in Behavioral Publications

A review of eight selected behavioral journals (Behavior Analysis and
Social Action, Behavioral Assessment, Behavior Modification, Behavior Thera-
py, Behavior Research and Therapy, Journal of Applied Behavior Analysis,
Journal of Behavioral Therapy and Experimental Psychiatry, and Journal of
Consulting and Clinical Psychology) during the years 1982-1993 shows a very
recent, yet still low level of involvement to date by behavior analysts and
therapists in AIDS research and therapy (see Figure 6.4). From a total of 22
citations, eight focus on postinfection therapy or on topics other than preven-
tion. Fourteen research reports published in these behavioral journals discuss
10000,------------------------------------------------------,
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Figure 6.1. Annual number of citations on the topic of acquired immunodeficiency syndrome
(descriptors also include AIDS, HIV, AIDS/HIV) in PsychLit and Medline (1982-1993),
1500,-----------------------------------------------------------------------
--+--- Medhne -o-Psychlit
.
c
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Year
Figure 6.2. Annual number of citations on the topic of acquired immunodeficiency syndrome
(descriptors also include AIDS, HIV, AlDS/HIV) in PsychLit and Medline (1982-1993) that
include a focus on prevention.
~,-------------------------------------------------------------------
20
c
.. 15
~
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Year
Figure 6.3. Annual percentage of citations of acquired immunodeficiency syndrome (descriptors

also include AIDS, HIV, AIDS/HIV) in PsychLit and Medline (1982-1993) that include a focus on
prevention.
10,--------------------------------------------------------.
7.5
---+-AIDS -o-AIDS prevention
'0 5
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Figure 6.4. Annual number of citations in eight selected behavioral journals on the topic of ac-
quired immunodeficiency syndrome (descriptors also include AIDS, HIV, AIDS/HIV) and AIDSI
HIV prevention.
HIV prevention goals and strategies and are summarized in Table 6.1. Four
experimental reports, five correlational/survey studies, and five reviews or com-
mentary of research and theory provide a small but encouraging body of work
to welcome and guide new researchers and practitioners.
Of course, a number of behavioral scientists address HIV prevention in
behavioral publications other than those listed in this chapter (for example,
Alvord & Cheney, 1991, 1992; Bayes, 1990; Salina, Crawford, & Jason, 1991;
Winett, Moore & Anderson, 1991), at national behavioral conferences (for
example, Wulfert, 1994) and in a variety of other media (for example, Fuqua et
aI., 1993; Wulfert, 1994) and nonbehavioral journals (for example, Bandura,
1990; Kaemingk & Bootzin, 1990). Though one might even argue that such
publication in media and settings other than refereed journals might enhance
the transfer of our technology to persons and places where it is needed, this
chapter invites the development and transfer of a technology of HIV prevention
within our own profession.
Behavioral analysis has always thought of itself as a progressive movement,
born in the 1960s and nurtured by three decades of scientific and professional
success. We now have an admirable set of theoretical constructs, a sizable
experimental literature, and a socially valid and significant technology of be-
havior change currently being applied to a number of aspects of the human
condition. What is preventing us from further individual and collective action
in HIV prevention?
Table 6.1. Publications Related to HIV-AIDS Prevention in Leading Behavioral Journals 1989-1993 <.0
N
Study Subjects Methods Major findings
Antoni et aI. (1990) Gay men Review of influence of behavioral fac- Significant benefits of behavioral interven-
tors on immune functioning and tions (e.g., time-limited aerobic exercise
HIV disease progression program, relaxation training) on psycho-
logical and immunological function among
asymptomatic early-stage seropositive as
well as seronegative gay men
Coates (1990) Varied Review of effectiveness of sexual behav- Significant high-risk behavior change in se-
ior change interventions lected populations
Many at-risk populations have received
little research attention
Advocates and outlines a comprehensive
community-based approach to behavior
change
Desjarlais et aI. Drug users Review of drug use hard-data studies Some evidence that safer injection practices
(1990) in which dependent variables include are contributing to reduction in spread of
(1) HIV seroprevalence, and (2) vali- HIV
dated self-report Little evidence that threat of AIDS decreases
first drug use
Support for the validity of self-report data
DeVries et aI. 4 RNs in a hospital emergen- Experiment with multiple baseline Glove-wearing increased on the average ell
..,.,
(1991) cy room across subjects from 40.5% (baseline) to 73.0% (inter- :c
Intervention-performance feedback vention) and across risk settings ~
on wearing rubber gloves o
Finney (1991) Commentary on DeVries et aI. (1991) Suggests that glove-wearing may be too lim-
~
,.....
research report on increasing nurses' ited a target behavior to decrease risk ~
..,.,
glove-wearing significantly c
Encourages social validity measures and 15z
larger samples over longer periods of time ..,.,
Honnen & Kleinke Bar patrons in gay bars Experiment (ABAB design) Signs increased taking of condoms by 47% a-
(1990) Intervention = signs prompting taking
of free condoms co
...,
::J:
Kalichman et al. 106 African-American women Pre- and posttest experiment with Participants who viewed tapes presented by
(1993) recruited from low-income follow-up African-American women showed more ~
housing projects Intervention = 20-min videotapes on behavior change
0::0:1
HIV prevention including: (1) stan- Supports use of culturally sensitive AIDS
z>
dard message; (2) matched presenter prevention messages >
and viewer on sex ethnicity; (3) cul- !:(
turally relevent context '"v;
>
Z
Kalichman et al. 272 women in mass-transit Survey of AIDS knowledge perceptions 22% reported high-risk behavior
0
(1992) waiting areas and risk behavior High-risk nonminority women reported ::J:
greater perceived susceptibility than high- <:
risk minority women "'C
::0:1
...,
Minority women had more barriers to risk <
reduction (e.g., lower estimate of personal
...,
Z
-I
risk, less accurate AIDS knowledge, a
competing array of life problems) 0Z
Kelly et al. (1989a) 104 gay men, recruited and Experiment with waiting list control Reduced high-risk sexual practices
surveyed in gay bars Intervention = 12 min weekly group Increased skills for refusing sexual coer-
self-management strategies, assertion cions, AIDS risk knowledge, safer-sex
training, and relationship skills practices
Changes maintained at 8-month follow-up
Kelly et al. (1989b) 107 university students and Test construction and psychometric The measure (the AIDS Risk Behavior Test)
84 gay men evaluation of an objective measure is a sound measure of AIDS knowledge
of practical knowledge concerning
AIDS risk behavior
Kelly et al. (1990) 526 men who patronized gay Survey of sexual behavior in previous 37% reported high-risk sexual behavior
bars 3 months and psychological mea- Precaution-taking behavior related to per-
sures ceived peer norms, inner locus of control
score, risk behavior knowledge, age, and I.C
IN
(continued)
I,c)
Table 6.1. (Continued) oil>
Study Subjects Methods Major findings
accuracy of personal risk-estimation

Precaution-taking behavior was not related
to race or personal serostatus knowledge
Kelly et al. (1991) 68 gay men Correlational research 16-month Resumption of high-risk sexual practices is
follow-up after AIDS prevention ses- related to younger age, sexual behavior
sions history, greater number of partners, rein-
forcement values of past practices, intox-
ication preceding sex, lower depression
scores, belief in external causation, and
homosexual outness
Kelly & Murphy NA Review of trends in risk reduction and Though behavior changes in homosexual
(1992) AIDS/HIV risk reduction interven- and drug-user populations are confirmed,
tion outcome studies it remains less clear how these changes
were produced
HIV is becoming more prevelent among
heterosexual non-drug users in American
cities
There is a pressing need for systematic in-
tervention outcome research in (1) pre-
vention of and (2) emotional coping with cc
m
HIV/AIDS J:
~
St. Lawrence (1993) 195 African-American adoles- Survey of knowledge, attitudes, locus Teens retain many misconceptions about o
:11:1
cents recruited from clinics, of control, perceived risk, beliefs, HIV >
r-
teen centers, waiting rooms and sexual behavior Results suggest (1) prevention programs are
~
most timely before onset of sexual behav- m
ior, and (2) separate prevention programs o
for girls and boys B
z
m
BARRIERS TO BEHAVIORAL SCIENCE:

WHERE ANGELS FEAR TO TREAD
The diminishing involvement of the behavioral and social sciences in HIV

prevention stems, in some part, from metavariables such as slow or inaccessible
federal support, which dampen interest and punish initiative. Such federal
funding, for example, may be directed disproportionately at medical research,
or curtailed by level funding, or ideological or political restrictions on research
or prevention efforts. The National Commission on AIDS (1993) report, "Be-
havioral and Social Sciences and the HIV / AIDS Epidemic," documents this
chilling cultural and political climate that has kept prevention efforts inade-
quate, underfunded, and unpublicized.
At the level of our own personal and professional repertoires, we may be
deterred by an unfamiliarity or hesitance to tackle sensitive topics such as
sexual behavior (Anderson, 1991). We may lack the opportunity or not have
the perceived need or even the personal or professional skills to collaborate
with nonscientist HIV practitioners. Thomas Coates (1988), a behavioral sci-
entist who has been active in HIV prevention efforts since the early 1980s,
reminds us that sometimes faulty reasoning, specifically, a wish for a medical
magic bullet, diminishes and deters our prevention efforts. It seems that even
behavioral scientists might continue to think of prevention as a stopgap, rather
than the key, to ending the AIDS epidemic.
A number of serious methodological constraints in HIV prevention re-
search form one final, daunting barrier to involvement by behavioral scientists.
These include a perceived paucity of theoretical models, the difficult ethical
questions of balancing risks and benefits gained from research, the absence of
many standardized assessment tools, recruitment and sampling difficulties, the
impracticability of traditional control group or longitudinal methodologies,
and the difficulty of replication of existing findings over time and across age,
ethnic, and AIDS risk groups. Catania, Gibson, Chitwood, and Coates' (1990a)
substantial review of methodological problems in AIDS behavioral research
concludes that we also need to do research on how to do research in AIDS
prevention. It is little wonder that without such research we might feel thwarted
by an unusual trilemma of pressures for scientific rigor, urgency in dissemina-
tion, and the absence of a set of methods for articulating and assessing behavior
change in large population studies and in sensitive topics such as sexual behav-
IOr.
HOW CAN WE ACCELERATE OUR INVOLVEMENT?
Taken together, these barriers appear to exact a high response cost to the
behavioral researcher interested in HIV prevention, and may help explain our
caution and relative low rate of responding to date. The remainder of this
chapter invites the reader to sample strategies for increasing our thinking about
and doing HIV prevention research in the behavior analytical tradition. It

assumes that, once involved, we will approach the complex behavioral problem
of HIV prevention just as we might any other problem in social or clinical
behavior change, and bring to this vital area a number of theoretical frame-
works, detailed assessment protocols, and intervention and evaluation strategies.
But it asks us first to target a change in our own behavior, that of increasing our
own personal involvement, as researchers, or even clinicians or teachers, in the
effort to apply behavior analysis to this pressing social problem. The remainder
of this chapter outlines some strategies that may facilitate such involvement by
beginning researchers interested in HIV prevention. The following three sets of
behavioral changes in our own repertoires as scientists can be targeted simul-
taneously.
Becoming Familiar with HIV Prevention Research to Date

Outside the field of applied behavior analysis, a number of models based
in cognitive, motivational, social, and communication theories are available to
the researcher interested in HIV prevention. Leviton (1989) provides a highly
readable summary of this range of theoretical approaches to the problem.
Among the most popular are social-cognitive models of preventative health
behaviors, such as Becker's (1974) health belief model and Ajzen and Fish-
bein's (1980) theory of reasoned action, which assume that people's rational
decision-making capacities and consequent health-related behaviors are medi-
ated by variables such as perceived susceptibility or intentions and attitudes
shaped by social norms.
Although these theories give us terms and concepts with which to describe
the various hypothesized internal correlates of risky behavior, and may help us
to predict intention to engage in risky behavior or even actual risky behavior,
they do not provide scientific data on how to prevent the risky behavior. The
literature provides a number of larger frameworks for integrating such hypo-
thesized internal states with environmental contexts that facilitate or hinder
HIV-risky behavior. For example, Bandura (1990), Catania, Kegeles, and Coates
(1990b), and Fisher and Fisher (1992) seek to connect any number of inner-
focused cognitive variables to actual skills or strategies that individuals possess
or can learn in order to prevent high-risk behavior. Kaemingk and Bootzin
(1990) recommend a simultaneous focus on behavior change at both the indi-
vidual and community level. Two long-time HIV behavioral research teams, led
by Thomas Coates and Jeffrey Kelly, conduct and support intervention research
that combines individual or group cognitive-behavioral skills training with
community-based strategies for influencing mass-population level behavior
change (see Coates, 1988, 1990; Coates & Sanstad, 1992; Kelly & St. Law-
rence, 1988; Kelly & Murphy, 1992, for summaries of these prolific research
programs). Such community-wide behavior change models expand the vari-
ables relevant to HIV prevention into areas such as (1) providing accurate
information in key locations by key people about specific behaviors to reduce
risk; (2) modeled and salient standards and behaviors; and (3) natural supports
for decreasing risk behaviors.
Regardless of breadth or specificity of theoretical orientation, what do we
know about the published interventions that have worked? To answer this
question, the beginning researcher would do well to read Fisher and Fisher's
(1992) comprehensive analysis of critical features of available intervention
studies, which are conveniently summarized by target populations, including
homosexual/bisexual men, intravenous drug users, sexually transmitted disease
clinic patients, adolescents, university students, and the general public. This
meta-analysis identifies a number of intervention characteristics that favor risk
reduction behavior change, including that the interventions are conceptually
based, group specific, and combine information, motivation, and behavioral
skills. Even in these seemingly effective studies, however, Fisher and Fisher also
report serious methodological limitations that make the attribution of observed
effects to a specific intervention (outcome) or to a specific component of an
intervention (process), virtually impossible in most cases.
Practice Applying Behavioral Analysis to HIV Prevention

Behavior analysts have argued the utility of applying the operant approach
to HIV-related target behaviors such as engaging or abstaining from sex, using
or not using condoms, using or not using clean needles for drug injection
(Bayes, 1990; Alvord & Cheney, 1992; Mattiani, 1990). Studies listed in Table
6.1 include examples of the use of experimental-control group and single-case
interventions to change HIV-risky behavior change in a number of behavioral
environments. Analysis of conditions antecedent and consequent to HIV-risky
behavior will need to be population- or environment-specific. For example,
Wulfert and Biglan's (1994) social context model for analysis of adolescents'
risky behavior suggests a finer analysis of variables such as (1) behavior corre-
lated with HIV-risky behavior such as cigarette smoking, alcohol use, and
academic failure; (2) social context correlates such as friendship networks,
parental monitoring; and (3) male sexual coercion, which seems to contribute
to young girls' HIV-risky sexual behavior. It may be possible, once a number of
behavior analysts are doing HIV prevention research in a variety of environ-
ments, to create a generic behavior analytic schema or behavior analysis tool.
Tools specific to a particular class of target behaviors have been helpful in other
behavior change areas, for example, in dealing with challenging behavior in
persons with autism and other disabilities (Groden, Stevenson, & Groden,
1993) and might help to accelerate our own thinking and research.
But we do not yet have a organizing, let alone comprehensive, behavioral
analytical framework to welcome and guide our exploratory efforts in HIV
prevention. Such a framework will, no doubt, emerge once a critical mass of
behavior analytical researchers become involved. For the time being, I offer the
following three guidelines to the beginning researcher. They are not meant to
be exhaustive; rather, they may provide a frame within which behavioral scien-
tists can begin to think about HIV prevention and to plan future empirical
investigations.
1. Comprehensive behavior analysis targeted at HIV prevention must in-
clude the analysis of contingencies of reinforcement (antecedents, target behav-
ior, and consequences) in specific and relevant environments.
As we enter the environments of selected target groups, we can be hopeful
that our analytical tools will point us in the direction of possible manipulable
variables in observable behavioral dimensions. Much of HIV prevention re-
search to date focuses on identifying cognitive antecedents that predict risky
behavior. Behavior analysts' contribution to HIV prevention can be our experi-
ence and willingness to identify postcedent and antecedent variables that both
predict and influence HIV risky behavior (Wulfert & Biglan, 1994).
In one study (Honnen & Kleinke, 1990), well-placed prompts (signs in a
gay bar advertising free condoms) increased the number of condoms taken by
47%. Similarly, Salina and her co-researchers (1991) reported on the signifi-
cant impact of a package of behavioral rehearsal and media messages on ado-
lescents and their families' abilities to talk together about the topics of sex and
HIV transmission. DeVries, Burnette, and Redmon (1991) made a significant
change in nurses' glove-wearing in a hospital emergency room by combining
premeasurement instructions (on risky situations) with performance feedback.
Existing studies on HIV prevention, such as Coates' (1990) community-based
San Francisco model or Kelly, St. Lawrence, Hood, and Brasfield's (1989a)
group skill-building procedures with gay men, sometime show successful out-
comes; but often they cannot specify which components of a multielement
treatment package were critical to the process or exactly what the functional
relations are between these components and the resultant behavior change.
Such successful programs can provide the behavior analytical researcher with a
rich source of possible antecedent-behavior-consequence relations for future
research.
2. Target behavior relevant to HIV prevention can be overt behavior,
covert behavior (including thoughts, feelings, images), and physiological move-
ments (such as heart rate or immune system changes).
Change efforts should always target overt and measurable responses in
either individuals or groups that can help them prevent or avoid HIV contact,
such as the use of condoms or a specific communication skill that triggers
a partner's compliance with using a condom. Covert behaviors such as
self-statements, expectancies, and fears recur regularly in research on HIV pre-
vention. However, they are assumed to operate only as predictors or distant
antecedents of HIV-risky behavior. No study to date has reported the active
manipulation of such private events to change HIV-risky behavior. If we are not
to exclude these significant portions of the human behavior repertoire from our
HIV prevention efforts, we need a behavioral model that provides us with some
way to conceptualize and manipulate covert psychological and physiological

antecedents, concomitants, or consequences of HIV-risky behavior.
Covert conditioning (Cautela, 1973) provides such a theoretical model
and a number of procedures that give people systematic imagery-based rehears-
al of beneficial antecedent-behavior-consequence scenarios with the goal of
actually changing overt or covert behavior. Analogous to the overt operant
procedures that reduce or increase response frequency (i.e., punishment, extinc-
tion, response cost, positive reinforcement, negative reinforcement), these pro-
cedures ask the client to imagine a particular target behavior (e.g., being about
to light up a cigarette and smoke it) and then to imagine a particular conse-
quence (e.g., being violently ill and vomiting). This is an example of covert
sensitization, also called covert punishment, which has been used to decelerate
maladaptive approach behaviors such as overeating, alcohol or drug use, or
problematic sexual behavior such as exhibitionism. Other covert conditioning
procedures, such as covert reinforcement, can be used to change maladaptive
avoidance behaviors, such as fears, or to address deficiencies in areas such as
social skills. For example, a client who needs to learn to become more assertive
may be asked to imagine doing an assertive behavior (e.g., speaking up when a
partner suggests unsafe sex) and then immediately to follow that with imagin-
ing a pleasant scene. Cautela and Kearney's Covert Conditioning Handbook
(1988) and Covert Conditioning Casebook (1992) present numerous examples
of the uses of covert conditioning in clinical practice.
One variant of the covert-conditioning techniques, called consequence
training (Cautela & Baron, 1993), has particular relevance to HIV prevention.
It is often assumed that HIV-risky behavior is made more difficult to modify
because, like many maladaptive approach behaviors, its immediate conse-
quences are pleasurable and its aversive consequences are delayed or uncertain.
In consequence training, a person practices in imagery connecting distant or
delayed consequences with a target behavior. Combining such imagery-based
practice of such antecedent-behavior-consequence scenarios as part of an HIV
prevention package might well increase the self-control of persons in HIV-risky
situations.
There is even another way that including covert behavior targets and imag-
ery-based rehearsal strategies might expand the value and validity of our behav-
ioral research in HIV prevention. The long (10-15 years), often asymptomatic
phase of HIV progression provides behaviorists an opportunity for prevention,
or at least attenuation, of the impact of HIV infection on an individual's covert
psychological and covert physiological behavior. Though the exact functional
relations among behavior, immune function, and HIV progression are still
unknown, Antoni and his colleagues (1990) show significant benefits of time-
limited aerobic exercise and relaxation training on immunologic (e.g., T-cell
count), endocrine (e.g., plasma cortisol level), and neuropeptide (e.g., beta-
endorphin levels) parameters among asymptomatic early-stage seropositive as
well as seronegative men. These behavioral interventions also show positive
impact on self-reported psychological variables such coping styles, mood, and

optimism. Such research encouraged Bayes (1990) to propose that behaviorists
might do well to also target the much broader goal of decreasing immunologic
vulnerability, that is, conditioning the immune system to make HIV infection
less likely.
3. Our search for manipulable environmental variables should be ex-
tended to include larger dimensions, or metavariables, which affect the specific
variables that influence HIV-risky behavior.
Each environment-population cluster (e.g., adolescents in college, gay

men in gay community settings, young adult heterosexual partners in the dat-
ing bar scene, heterosexual African truck drivers who visit prostitutes) requires
its own analysis of what is often a multi tiered social context. So far, the concep-
tual models we have for such contextual analysis seem to have emerged, for the
most part, from years of collaborative dialogue by members of research teams.
It seems that a rigorous, yet socially valid, multi tiered research project may
demand a range of interests and skills that few individual behavior scientists or
isolated research groups can provide. Such collaboration may not only increase
the conceptual validity and effectiveness of our research, it may simultaneously
and naturally provide the social support and natural reinforcement for an
individual's initial efforts in this complex research area.
Though the functionality of our approach should make us natural allies
with activists and community health promoters, our personal, social, and pro-
fessional differences with regard to AIDS activists and program providers can
easily distance us from them and from the socially valid contexts we need for
our research. We must forge and nurture what Wachter (1991) calls "fragile
alliances" between traditional behavioral researchers and AIDS program devel-
opers and implementers and then develop them into constructive, functional
collaborations. Such teamwork is critical to increase the social validity of our
work and also because it may be dangerous and inefficient to develop programs
independently from those active in an environment (Kelly & St. Lawrence,
1988; Finney, 1991; Winett et aI., 1991). More broadly speaking, the enormity
of the AIDS pandemic demands a productive merging of the science of behavior
with the science of prevention (Coie et aI., 1993).
Expand Your Knowledge about HIV I AIDS

Establish a steady stream of information and a facilitative social or profes-
sional environment to teach you and keep you involved with AIDS/HIV pre-
vention issues. Alternatives include:
1. Read Randy Shilts's (1988) book, And the Band Played On. This is a
richly detailed comprehensive investigative report by the only reporter assigned
full-time, by the San Francisco Chronicle, to cover AIDS. As only a story can,
this book introduces you to the contingencies that shaped the earliest responses
of scientists, media, the gay community, and other health enterprises to the
AIDS epidemic.
2. Read the National Commission on AIDS (1993). This report, prepared
as a final document by the commission at the time it was disbanded (9/3/93),
prescribes a comprehensive research agenda as well as funding constraints
and possibilities in HIV prevention. Order this publication, and others (mostly
free or low cost), from the Centers for Disease Control (CDC) National
AIDS Clearinghouse, PO Box 6003, Rockville, MD 30849-6003. Telephone
1-800-458-5231.
3. Sign onto an AIDS-related bulletin board and start a dialogue with
others active in HIV prevention. The CDC National Aids Clearinghouse pub-
lishes a guide to AIDS-related electronic bulletin boards and Internet resources.
4. Bring HIV prevention data and research discussions into your work
setting. For example, behavioral scientists who teach in colleges and univer-
sities can infuse their courses in introductory psychology, research methods, or
applied behavioral analysis with a focus on HIV prevention research. Olander
(1991) introduces his students to the uses of the Standard Celeration Chart by
having them chart data on the spread of AIDS. The research summarized in
Table 1 in this chapter can serve as an introduction to a theoretical review or as
a basis for future experimental projects in HIV prevention.
5. Establish ties with a local AIDS organization. Let them know you want
to help with their HIV prevention programs. Befriend an AIDS activist.
6. Contact the Cambridge Center for the Behavioral Sciences, 675 Massa-
chusetts Avenue, Cambridge, Massachusetts 02139, telephone 617-491-9020.
The center is currently seeking funding for conferences and other avenues to
trigger collaborative thinking and research between behavioral scientists and
AIDS activists throughout the world. Call and add your name to the list of
behavioral scientists interested in these future collaborative projects.
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7
Improving Eating Habits
A Stimulus-Control Approach
to Lifestyle Change
William M. Beneke and Jerry G. Vander Tuig
Health and well-being are fundamental to improving the human condition, and
eating habits are an important component of wellness. Relationships between
diet and health are well established (Jeffery, 1988; frazao, 1994; National
Research Council, National Academy of Sciences, 1989). Vitamin and mineral
deficiencies and the diseases that they cause are rare in the United States today.
Most nutrition-related health problems now result from dietary excess, and
that will be the primary focus of this chapter. Currently, five of the ten leading
causes of death in the United States (coronary heart disease, certain types of
cancers, strokes, non-insulin-dependent diabetes mellitus, and atherosclerosis)
are associated with diet. Together these nutrition-related health problems ac-
count for nearly two thirds of the deaths that occur in the United States.
There are several risk factors contributing to the development of these
chronic diseases. Some risk factors, such as age, gender, or genetic background,
cannot be controlled by the individual. However, many arise from lifestyles or
behaviors that can be controlled. These include smoking, drug or alcohol
abuse, inactivity, inadequate health care, and a poor diet.
Often a person will make changes in lifestyle or behavior only after devel-
opment of a chronic health problem. For instance, a person may stop smoking
William M. Beneke • Department of Social and Behavioral Sciences, Lincoln University, Jeffer-
son City, Missouri 6S 102-0029. Jerry C. Vander Tuig • Cooperative Research, Lincoln Uni-
versity, Jefferson City, Missouri 6S102-0029.
105
after developing coronary heart disease or lung cancer. He or she may decide to
change eating behavior after becoming overweight or hypertensive or after
developing coronary heart disease or non-insulin-dependent diabetes. Clinical
nutritionists have specific dietary prescriptions to reverse or reduce the deleteri-
ous impact of these conditions and to improve health. Thus, there are low-fat
diets to reduce blood lipid and cholesterol levels, low-calorie diets for weight
loss, and low-salt or low-sodium diets for hypertensive individuals.
Recent emphasis has been placed on the role of nutrition in preventive
health care. The Surgeon General's Report on Nutrition and Health (US De-
partment of Health and Human Services, 1988) made the following conclu-
sions: (1) excesses and imbalances in dietary intake can increase the risk of
chronic diseases; (2) dietary changes can improve the health of Americans; (3)
the primary dietary priority is reduced consumption of fat, especially saturated
fat; and (4) similar dietary recommendations apply to prevention of essentially
all diet-related chronic diseases. This report established a sound basis for di-
etary recommendations for chronic disease prevention.
Food choices and eating behaviors will ultimately affect that person's diet
and therefore health and well-being. Therefore, the US Department of Agricul-
ture and the Department of Health and Human Services (1990) have issued
seven dietary guidelines for Americans. They suggest that people should eat a
variety of foods; maintain healthy weight; choose a diet low in fat, saturated
fat, and cholesterol; choose a diet with plenty of vegetables, fruits, and grain
products; use sugars only in moderation; use salt and sodium only in modera-
tion; and consume alcoholic beverages in moderation or not at all. These
guidelines are designed to prevent or delay development of nutrition-related
chronic health problems.
Despite an increased awareness of the relationship between nutrition and
health, obesity continues to be the most common nutrition-related disorder in
the United States. Recent statistics indicate that 23 % of Americans are over-
weight and the incidence has increased in the past two decades. This has
occurred even though surveys indicate that Americans are eating fewer calories
than they did 20 years ago. This suggests that levels of physical activity may be
decreasing or that people are underestimating and underreporting their energy
intake (Tippett & Goldman, 1994).
Obesity is associated with health problems such as coronary heart disease,
hypertension, non-insulin-dependent diabetes mellitus, and certain forms of
cancer. Reducing the incidence of obesity will make a significant contribution
to reducing the total cost of health care in the United States. Because obesity
results from excess energy intake relative to expenditure, solving the obesity
problem will require changes in lifestyle. These changes will require a reduction
of energy intake, an increase in physical activity, or a combination of both.
Weight reduction programs that incorporate increased physical activity are
more successful than those that rely on reduced intake alone (Foreyt, 1987).
Dietary surveys indicate that Americans are making some changes in their
diets. People are eating foods that contain less fat and more carbohydrate. For
7 • IMPROVING EATING HABITS 107
instance, consumption of low-fat or skim milk has increased considerably,

while consumption of whole milk and eggs has decreased in the last 15 years.
At the same time, Americans ate more grain products such as pastas, cereals,
and grain mixtures. Although this is a step in the right direction, consumption
of more fruits and vegetables has not occurred. Clearly, people are becoming
more concerned with reducing their intake of fat, sugar, and salt, and the food
industry is making an increased effort to meet the public demand for healthier
food products (Tippett & Goldman, 1994).
Since the early 1900s the life expectancy of people living in the United
States has increased considerably. It is expected that in the next 40 years, the
number of people older than 65 will increase to 25% of the population. The
increased number of elderly brings an increase in the incidence of nutrition-
related health problems such as heart disease, hypertension, and diabetes. Es-
tablishing healthy eating habits early in life may be effective in preventing or
delaying these problems. This will also reduce the health care costs associated
with these diseases.
Given sufficient initial motivation, most individuals can follow dietary
guidelines in the short run, but will fail to do so over a longer period. Most
commercial weight loss programs, based primarily on restricting caloric intake,
produce initial weight losses that are adequate (1-2 pounds per week) and
sometimes even quite dramatic. The majority of individuals in these programs
regain much of the lost weight within 2 years; gradual returns toward pretreat-
ment weight are evident after 1 year. (Goodrick & Foreyt, 1991). Individuals
are unable to maintain their adherence to the dietary guidelines that produced
the initial losses.
One reason for the lack of long-term adherence is the failure to address the
personal, social, and environmental changes needed to support and maintain
altered eating habits. Technologies and knowledge of behavior analysis can be
readily adapted to address this problem and promote long-term enhancement
of desirable eating habits and therefore improved nutrition. Providers of sound
nutrition information clearly know what should be done. The problem they do
not adequately address is how to get people to adopt dietary prescriptions,
especially on a permanent basis.
GOAL SETTING
A necessary first step in altering food intake is the establishment of goals

for nutritional changes, along with specific approaches for achieving them. The
nature of these goals will playa major role in determining the ultimate success.
Evaluation of any program attempting to alter nutritional habits should first
look at the fundamental program goals. After all, there is little benefit in
attempting to assess the long-term effectiveness of a program if its basic goals
are flawed. At least three characteristics should be considered in the initial
evaluation of goals.
Goals Should Enhance Overall Nutritional Status

When establishing goals to change food intake behavior, attention should
be paid to improving the complete nutritional status of the individual. Unfor-
tunately, quackery and fad diets exist that are not based on sound nutritional
guidelines. These types of diets often limit food selections, require expensive
supplements, and promise rapid results but make no attempts to permanently
change eating habits.
There are many good sources of nutrition information to use when setting
goals to change food intake behavior. The recommended dietary allowances
(RDAs) provide a set of guidelines for meeting needs for individual nutrients
(Food and Nutrition Board, National Academy of Sciences, 1989). The RDAs
are based on average needs of a population of healthy people and are estab-
lished for specific age and gender categories. They are meant to provide guide-
lines to protect people from receiving too little or too much of a given nutrient
over a time. It is important to realize that the RDAs are not daily requirements,
but represent values that can be compared with nutrient intakes averaged over a
period of a week or more. The further an individual's average daily intake
deviates from the RDA for any given nutrient, the more likely that the individu-
al will develop a nutritional deficiency.
Dietary Guidelines for Americans (US Department of Agriculture, Depart-
ment of Health and Human Services, 1990) also provide sound nutritional
information for anyone attempting to change eating habits. If one incorporates
these guidelines into goals for changing eating behavior, it is likely that he or
she will meet most of the nutritional requirements.
A more recent set of guidelines provided by the US Department of Agricul-
ture is the Food Guide Pyramid-A Guide to Daily Food Choices. It divides
foods into six groups and suggests the number of daily servings one should eat
from each group. The emphasis again is on variety and moderation. By choosing
foods from all of the groups, including plenty of fruits, vegetables, and grain
products, and limiting intake of foods high in fat, sugar, or salt, one can build the
foundation for a balanced diet. If one follows these guidelines, he or she will also
avoid excess intake of calories and nutrients that contribute to development of
obesity, hypertension, atherosclerosis, and coronary heart disease.
Goals Should Address Any Specific Presenting Problem

People may decide to make changes in eating habits solely to improve
nutritional status. This is a worthwhile goal, but it is more likely that changes
in diet and eating behaviors are considered only after development of a nutri-
tion-related health problem. Consequently, goals should be tailored to an indi-
vidual's particular condition. For example, people with elevated blood lipid
levels are advised to limit their intake of dietary fats and cholesterol or those
with hypertension may need to reduce their intake of salt or sodium.
Several chronic health problems are associated with development of ob-

esity. Even a moderate amount of weight loss will usually improve these condi-
tions. For instance, hypertension and non-insulin-dependent diabetes are asso-
ciated with excess weight gain. Reduced blood pressure and improved glucose
tolerance are observed after weight loss. Losing even a moderate amount of
weight may lead to improved health and wellness (Bray, 1987). It is important
that people attempting to lose weight set reasonable and attainable goals. It is
unrealistic (and usually unhealthy) to expect a weight loss of more than 2 or 3
pounds per week.
To the extent that a program stands up to this initial scrutiny, it becomes
worthwhile to examine goals from a more behavioral perspective that ad-
dresses the likelihood of achieving long-term changes in eating. The focus shifts
from what the goals are nutritionally to how they will be translated into
behaviors associated with eating. Eating 1200 to 1400 calories per day might
be a desirable goal for an adult woman attempting to lose weight at a 1 to 3
pounds per week rate. However, the focus is now on what and how much to eat
of different foods to achieve that goal.
Program Flexibility Enables Individualizing for long-Term Success

Programs likely to have long-term benefit will be flexible enough to be
individualized (Brownell & Wadden, 1991). To achieve permanent lifestyle
changes in eating habits, it is necessary to consider the individual's eating
patterns and food preferences. An individual who dislikes seafood will be
unlikely to follow an eating plan in which fish appears as a frequent main dish;
forbidding Italian food is unlikely to succeed with an individual whose food
preferences include pasta. Eating plans that require elaborate meal preparation
are difficult to follow for parents who work full-time while raising small chil-
dren.
Proscribed Foods May Set Up Conditions for Failure

Except for individuals with specific food allergies, an eating plan should
have few or no forbidden foods. Learning to eat problematic foods (e.g., ice
cream in a low-calorie or low-fat dietary program) in controlled moderation is
more likely to result in permanently altered eating habits than excluding those
foods altogether. Individuals who attempt to eliminate problem foods from
their diet are likely to ultimately succumb to temptation and violate this pro-
scription. After all, problematic foods are usually those that are highly palat-
able, preferred, and eaten frequently by the individual. Violation of the pro-
scription is likely to elicit feelings of guilt and cognitions of failure. These, in
turn, make further uncontrolled eating more likely, exacerbating the feelings of
guilt and failure (Sternberg, 1985).
ASSESSMENT
Assessment of current eating habits and nutritional status is an important

next step. This assessment should take into account current eating habits and
food preferences to develop a personalized treatment program. The assessment
should include not only a record of foods and quantities consumed, but also the
situation in which eating occurred and the social and emotional consequences
of eating.
Eating problems vary with individuals. Non-food-related consequences
may lead to specific poor (unplanned, unhealthy) eating habits. Those habits
are likely to have come under stimulus control of the environment in which
they occur [see Thomas (1991) for a thorough review of stimulus control].
Family dinners commonly serve as an important occasion for social interaction.
The presence of abundant, high-calorie foods at family dinners both cues and
enables consumption of large quantities during an extended meal. Positive
social interactions may serve to reinforce the overeating that occurs and the
behavior of getting together for and preparing such meals. While this is com-
mon, it may not be a major focus of overeating for everyone. Others may have
difficulty with mid afternoon snacking. An individual may consume sufficient
foods at midafternoon snacks to create a positive caloric imbalance and weight
gain. This unplanned snacking may occur in response to boredom (absence of
available reinforcers for competing activities). Alternatively, it may be cued by
specific events such as children arriving home from school. Yet another individ-
ual may be confronted with a problem-eating situation associated with vending
machines in the workplace or donuts available during coffee breaks. The point
is that these eating problems are not universal. Individual problems should be
identified and dealt with. It makes no sense to provide costly educational and
treatment programs that focus on changing habits that an individual does not
need to change. Careful assessment allows treatment to be more sharply fo-
cused on each client's eating problems.
Ongoing assessment of eating habits and patterns and nutritional status
enables determination of improvement as treatment progresses. Initial assess-
ment not only pinpoints specific eating problems, but also establishes a bench-
mark from which to measure improvement. Ongoing assessment enablers eval-
uation of treatment effectiveness and helps to identify subtle improvements
before they would otherwise become noticeable to the client. If the program
includes reinforcement of these desirable changes, ongoing assessment of eating
habits is a necessary feature. Ongoing assessment also promotes gradual, sus-
tained progress that is more likely to result in permanent lifestyle changes.
STIMULUS-RESPONSE CHAINS
Eating is more than a fork-to-mouth proposition. Treatment programs

developed in our laboratory (e.g., Paulsen, Lutz, McReynolds & Kohrs, 1976;
Beneke & Timson, 1987) have conceptualized eating as a stimulus-response

chain: a sequence of stimuli and responses that ultimately produce the rein-
forcer maintaining the chain. Each stimulus in the chain serves two functions:
(1) a conditioned reinforcer that maintains the response that produced it, and
(2) a discriminative stimulus that sets the occasion for (cues) the response that
follows (Baum, 1994).
For example, viewing a beverage commercial on television might serve as a
discriminative stimulus for approaching the refrigerator, a behavior maintained
by the sight of the refrigerator door. The sight of the refrigerator door also
serves as a cue for the next behavior in the chain, opening the door. Opening
the door is reinforced by a view of the refrigerator contents, which also cues the
next behavior, reaching for a beverage. Ultimately, the last response in the
chain, drinking, is reinforced by the beverage itself.
We have developed a behavioral-nutritional weight-loss program that
views eating in the framework of a larger chain. How an individual develops a
meal plan, shops for the needed groceries, stores them, and then prepares and
serves the foods has a major influence on what is eaten. Specific choices (ac-
tions) at each point in the chain can promote healthy, planned eating or lead to
less healthy, unplanned eating. Purchasing two bags of potato chips because the
store offers a "buy one, get one free" bargain, for example, virtually insures
that household members will increase their consumption of potato chips. The
extra bag of chips in the cupboard will function as a cue for eating potato chips
until it is empty. The bargain was not such a good deal after all. Its effects were
to both enable and cue unplanned eating. The high fat content of potato chips
makes this undesirable for individuals attempting to lose or control weight or
limit fat intake. Choosing alternative actions such as buying only the amount of
potato chips needed or planning to substitute fresh vegetables for potato chips
before shopping would lead to more healthy, planned food intake.
Since stimuli early in the chain are weaker conditioned reinforcers than
those in closer proximity to the primary reinforcer, behavior changes made
early in the chain will be easier to implement and maintain (Reynolds, 1975).
In the beverage example, substituting another behavior (e.g., muting the com-
mercial) for approaching the refrigerator is much easier than substituting an-
other behavior for opening the beverage container at a later point in the chain.
AN EATING CHAIN
We have developed a specific stimulus-response chain as the conceptual

framework for our applied research. It represents an idealized picture of what
the main food preparer in a household ought to be engaging in to maximize
planned, controlled eating. Since our research has focused on weight control,
the nutritional goals are to eat a balanced but calorically restricted diet. Actual
caloric goals are set to allow a weight loss of 1 to 3 pounds per week, but not to
fall below 1000 Cal/day. The lower limit insures that individuals can design a
balanced diet and will have sufficient opportunity to practice new eating behav-
iors. Planning is the first link in our eating chain.
Good Eating Begins with Planning

For the most part, we eat what we buy. Overpurchasing leads to overeat-
ing. Thus, a desirable eating chain begins with planning what to eat and
converting that plan to a list of ingredients needed to prepare it. This yields
menus for the week or two for which foods will be purchased and the ingre-
dients needed. The list of ingredients, adjusted for those ingredients already on
hand, can then be organized into a shopping list. The shopping list becomes the
cue to guide food purchasing, the next link in the chain.
Considerable nutritional guidance, whether from nutrition professionals
or from printed sources may greatly facilitate development of a sound meal
plan. Meal plans should address the dietary guidelines for Americans (U.S.
Department of Agriculture, Department of Health and Human Services, 1990)
described earlier, along with any specific dietary requirements that might be
prescribed for existing nutrition-related chronic health problems. Although
considerable initial effort is needed, menu cycles can be repeated periodically,
reducing the total planning efforts required on a longer basis.
Controlling Food Purchasing Reduces Consumption and Waste

The ultimate goal of good food buying is to use the carefully prepared
shopping list as the cue that controls what is purchased. In a sense, this means
ignoring the other cues provided by the manufacturers of prepared foods and
by the grocery store or supermarket itself. Both the grocery stores and manu-
facturers have profit-based goals and motivations. Since profits vary with sales
volume, they attempt to maximize sales. The food industry carefully designs
product packaging, advertisements, and even how products are displayed in the
store to maximize purchasing. Without a carefully prepared and arranged
shopping list, food purchasing comes under the stimulus control of these fac-
tors. As a result, the consumer is likely to overbuy and therefore overeat, and
will do so in unplanned, uncontrolled ways. What is needed is a systematic plan
for transferring control of purchasing from cues provided by the food industry
to items written on a shopping list. However, simply telling individuals to shop
with a list is insufficient to accomplish this. Special knowledgeltraining is
needed to make this effective (Beneke & Davis, 1985; Beneke, Davis, & Vander
Tuig, 1988).
Food Storage Strategies Can Head Off Unplanned Eating

Unplanned eating is often cued by the visibility of food items. A clear glass
cookie jar placed on the kitchen counter is quickly emptied. Snack foods stored
at eye level in the cupboard become tempting cues for individuals who open the
cupboard door in search of something else. Food storage strategies that reduce
the visibility and availability of problem foods can reduce the salience of these
cues for uncontrolled (unplanned) eating. Lining that cookie jar with foil,
placing problematic snack foods in less visible and accessible corners of the
cupboard, or a more radical act of removing the refrigerator light bulb can
reduce unplanned eating by making foods cues less visible and problem foods
less accessible.
Some techniques that minimize food cues leading to uncontrolled eating
can also preserve nutrient content of fresh foods. As a general rule of thumb,
foods without added preservatives retain nutrient values to a greater extent
when stored in cool, dry, and dark conditions. Storage strategies that keep food
products out of sight such as in the cupboard, refrigerator, or freezer also serve
to reduce the nutrient losses from food. Increased nutrient losses also occur
with longer food storage times. This is another reason for avoiding unplanned
food purchases by planning menus and limiting food purchases to only those
foods needed and that can be used within a given period.
Food Preparation Plays a Major Role in Controlling Eating

and in the Nutritional Quality of Foods
Food preparation can be a focus of unplanned eating because it exposes
the preparer to a variety of food cues. Some ingredients are themselves edible
and tempting. They are visible and readily available for unplanned snacking
during preparation. But not all cues are visual. Cooking odors add important
eating cues that can diffuse over a wide area of the home. Tasting is often an
important part of cooking, and it can easily get out of control. Taste and odor
cues are often present under conditions of hunger, when self-control is more
difficult. To make matters worse, these food cues may actually function as
conditioned stimuli to increase hunger because of their past pairing with eating
(Detke, Brandon, Weingarten, Rodin, & Wagner, 1989; Weingarten, Hendler,
& Rodin, 1988).
Behavioral coping strategies available for dealing with food preparation
problems focus on minimizing the availability of edible ingredients, reducing
the salience of cooking odors, and establishing behaviorally complex strategies
to make tasting inconvenient or difficult. Edible ingredients (such as cheese or
chocolate chips) should be removed from storage only when the recipe calls for
adding them, and quantities not used returned to storage immediately. This
limits the time they are available and visible on the kitchen counter as cues for
unplanned snacking. Cooking odors can be reduced by using an exhaust fan
and by cooking with lids on pots and pans. The latter also has the benefits of
making tasting more difficult and may contribute to reducing the loss of water
soluble vitamins during cooking.
Good cooks taste food as they prepare it; but for some, excessive tasting
can add considerable calories. Increasing the complexity of the act of tasting
eliminates much excess in this behavior. The addition of lids to pots already
makes tasting a two-handed task (one hand holds the lid, the other holds the
spoon). A two-spoon tasting strategy adds further complexity. Commonly used
in commercial cooking for sanitary reasons, this strategy consists of dipping
one spoon in the pot and transferring its contents to a second spoon that the
cook tastes from. One of our clients reported holding a toothpick in her mouth
during cooking (its removal requiring yet another step in tasting). Our experi-
ence has been that these complex behavior strategies revealed far more "nib-
bling" during food preparation than our clients believed they were engaging in.
Beyond these strategies, some food preparation can be shifted to times
when hunger is reduced. Not all food preparation must occur immediately
before a meal when hunger levels are generally higher. Shifting baking, for
example, to occur after a meal makes those food cues available under condi-
tions of reduced hunger. Many other dishes can be prepared ahead and refriger-
ated until cooking at mealtime. Preparing foods under conditions of low hun-
ger makes engaging in self-control strategies more likely to succeed.
Food preparation also has a major impact on the fat content of a diet. Fats
added at cooking are a major contributor to the total fat content of meals. Fried
foods have increased fat content and calories because of added fats and because
fried foods sit in their own fat during cooking. Sauces, salad dressings, gravy,
mayonnaise, and butter and margarine all have significant fat content and can
greatly increase the fat and caloric content of foods they are added to.
Alternative food preparation strategies are self-evident: broiling instead of
frying meats, carefully measuring limited amounts of added fats or learning to
cook with spices as substitutes for the flavor enhancement of fats. Since these
changes are likely to affect "family favorites" and long-standing food prefer-
ences, they will be difficult to implement on the permanent basis needed.
Gradual changes can alter food preferences slowly and are more likely to
become part of a new eating lifestyle. Our research group has developed a
cookbook specifically to facilitate this gradual transition (Schiff, Paulsen, &
Moore, 1986). Rather than providing numerous low-calorie recipes, we fo-
cused on recommending spices and other flavor-enhancing techniques to re-
place fats, breading, and other calorie-adding food preparation methods. These
changes can be made gradually to the recipes for "family favorites" to promote
long-term changes in food preparation.
Handling and preparation of food can influence its nutrient content as well
as flavor and calories. Cooking foods in water reduces the content of water-
soluble vitamins (B and C). Foods high in these vitamins should be cooked in a
minimum amount of water. Where possible the water (now containing vitamins
Band C) should be used in making soups or gravies. Vitamin C is also de-
graded when exposed to oxygen, so fresh fruits and vegetables high in vitamin
C should be peeled or sliced only shortly before serving or cooking.
Fat-soluble vitamins (A, D, E, and K) are insoluble in water. Vitamin A is
sensitive to light and air. It is best to keep vitamin-A-rich foods such as dark
green or yellow vegetables in a dark place.
How Food Is Served Influences What and How Much We Take

and Therefore Eat
Food service is a system for presenting food cues to individuals eating a
meal or snack. The nature of these cues will influence the quantities and variety
of foods consumed. Place a 5-pound roast beef on the dinner table. Individuals
eating at that table, seeing the ample quantity present, will react by taking more
than if only 2 pounds of the 5 were served. Leave the same 2-pound roast on its
platter on the kitchen counter so that individuals must get up from the table to
serve themselves, and they will eat even less. Research conducted by Schacter
and colleagues clearly indicates that when food is readily accessible and highly
visible, more is consumed. And this is especially so for overweight individuals
(Rodin, 1976; Schacter & Rodin, 1974).
Changes in the way a family serves foods are easy to implement and
(perhaps because it is not difficult) easy to maintain in the long run. If the
habitual manner of serving family dinners includes serving dishes on the dinner
table and frequently passing serving dishes around the table to facilitate taking
more, food service changes can have dramatic effects on food consumption.
Such changes include: (1) serving from the kitchen, (2) requiring each family
member to serve him- or herself, (3) placing foods in non-see-through contain-
ers, and (4) placing only the quantities of foods planned for a meal in the
serving containers. Of course, it is easy to generalize these principles to snack
foods. Limited quantities, served in non-see-through containers, not placed
where they are reachable when doing other things (such as watching television)
or frequently encountered in a home's traffic pattern greatly reduce unplanned
snacking.
It's Never Too late: Changes in Behavior during the Eating of a Meal
or Snack Can Still Produce Desirable Nutritional Effects
Although changes made earlier in the eating chain are likely to have the
greatest effects, changes at this link of the chain can have important conse-
quences. Part of the reason is that many changes made earlier in the chain are
specific to the individual's home. Changes in actual eating habits, on the other
hand can generalize to eating in a wider range of environments. During the
eating of a meal, stimuli affecting consumption include the foods on one's plate
and in nearby serving dishes. Of course, internal hunger cues are also impor-
tant. Behavioral coping strategies involve manipulating those cues to directly
influence eating.
Weight-control programs developed in our laboratory have included "per-
sonal dishes" -a 9-inch dinner plate with a wide border and a six ounce clear
bowl provided by the program and a beverage glass supplied by the participant.
The key rules for using the personal dishes include: (1) everything that is eaten
(at least at home) must be eaten from the personal dishes, (2) all food to be
eaten at a meal (or snack) must be served to the dishes before actual eating
begins, and (3) no second helpings. Additional rules cover exceptional circum-
stances. Using the dishes in this manner controls unplanned snacking that now
requires stopping to get out (perhaps even wash) the personal dishes (Buchin &
Beneke, 1987).
Portion control is an equally important function of the personal dishes.
Serving all foods before eating allows choices to be made that would not
otherwise be possible. For example, if an individual wanted a small serving of
cake, it becomes possible to enable that in a planned way by putting smaller
portions of meat and vegetables on the plate. Visual inspection of all foods to
be eaten in a meal (or snack) also assists in controlling portion sizes. The visual
effect of all foods on the dishes creates the impression that adequate amounts of
food are present. This may reduce or eliminate binge eating that has been
shown to occur with extreme dietary restriction (Polivy & Herman, 1985).
After consuming the planned foods for a meal or snack, remaining in the
presence of food cues can lead to additional unplanned eating (obviously
breaking the personal-dish rules). Separating the individual from the food cues
as soon as the individual is "finished" reduces or eliminates that tendency.
Either the individual should leave the situation or the food cues should be
removed. Where neither is practical, removing the individual's dishes and eat-
ing utensils helps to block further (unplanned) eating.
Other self-management strategies are designed to enhance the relative
importance of internal cues on the control of eating. Many individuals need to
slow their rates of eating for sensations of fullness to become cues to stop
eating. The delay between ingestion of food and the sensation of fullness simply
allows too much time for additional ingestion when eating is rapid. Putting
silverware down and hands on lap between bites is an easily learned behavior
chain that dramatically slows eating rates. If the extra time is used in polite
conversation, the technique begins to feel natural for the learner. Leaving small
amounts of foods on the plate helps reduce the effectiveness of the "clean plate"
as the signal to stop eating.
Postmeal Cleanup Can Become a Problematic Eating Situation

for Some Individuals
After a meal, food cues are still present and function as powerful stimuli
for unplanned eating by individuals doing postmeal cleanup. The folk adage,
"Too much to throwaway; not enough to keep," is a rationalization for un-
planned eating after a meal. To the extent that this is problematic for an
individual, the best coping strategy is to reduce the time these cues are present
in a tempting, edible form. Doing cleanup immediately after a meal and quick-
ly altering the physical appearance of foods to be discarded to look like gar-
bage rather than edible morsels should minimize unplanned eating during
cleanup. Alternatively, the cleanup task can be delegated to a family member
who does not find this situation tempting.
Generalizing the Eating Chain Framework to Other Eating

Environments Is a Straightforward Task
It is not difficult to think of a sequence of stimuli and responses that lead
up to eating in other situations. A restaurant eating chain might consist of
planning (where to go eat), going to the restaurant, ordering, serving (if from a
buffet or family-style restaurant), eating, and (perhaps) postmeal conversation.
Then consider what choices (actions) could occur at each link that lead to
planned and unplanned eating and what kinds of cues would make each more
likely. At the planning stage, for example, choosing the local luncheon smor-
gasbord might be more likely to lead to uncontrolled eating than selecting a
restaurant specializing in appealing salads. It might be the case that newspaper
advertisements of luncheon specials cue the selection. Selecting restaurants
offering healthy specials increases the likelihood of controlled, healthy eating.
Finally, devise a self-management intervention that presents cues for the action
leading to controlled eating and/or eliminating the cues for actions that lead to
uncontrolled eating. If an intervention is not helping, there are two likely
reasons. Either the intervention does not occur early enough in the stimulus
response chain, or it is not clever enough to produce the action leading to
controlled eating (McReynolds, Green, & Fisher, 1983; Rachlin & Green,
1972).
CHANGING NUTRITIONAL HABITS FOR THE LONG-TERM
Using behavioral chains and stimulus control principles to alter eating

behaviors has considerable promise for long-term change. Important behavior
changes occur well before opportunities for uncontrolled eating. Skinner
(1953) called these actions that alter the likelihood of uncontrolled eating
controlled responses and considered them essential elements of self-control.
Subsequently, Rachlin and Green (1972) argued that controlling responses
were choices between small-immediate reinforcers and larger-delayed ones. If
controlling responses occurred far enough before availability of the small-im-
mediate reinforcers (opportunities for uncontrolled eating), the larger-delayed
reinforcers associated with improved nutritional habits would have greater
strength. The greater strength of the larger-delayed reinforcers would maintain
the controlling responses, and this is especially so when the delay to the larger
reinforcer varies (Chelonis, King, Logue, & Tobin, 1994). Some of these con-
trolling responses, such as rearranging cupboards, also have relatively perma-
nent stimulus effects. For these reasons, stimulus-control approaches are likely
to have long-term effects on improving nutritional habits.
McReynolds, Lutz, Paulsen, and Kohrs (1976) provided the first experi-
mental demonstration of the superiority of a stimulus-control approach to
weight loss over the potpourri of behavioral techniques pioneered by others
(e.g., Stuart, 1967; Harris, 1969; Wollersheim, 1970). Both stimulus-control
and a multiple-technique treatment produced equivalent weight losses at the

end of a 16-week treatment. The stimulus-control treatment resulted in superi-
or weight maintenance at 3 and 6 months posttreatment. A subsequent follow-
up study showed that by 18 months posttreatment, the stimulus-control sub-
jects were maintaining 80% of their treatment losses compared to maintenance
of 66% of treatment losses in the multiple-technique approach. The stimulus-
control approach also produced more consistent follow-up results across sub-
jects (Beneke, Paulsen, McReynolds, Lutz, & Kohrs, 1978).
Favorable follow-up results are not limited to carefully controlled research
studies. A stratified random sample of the first 1040 clients in Eating Slim (a
stimulus control approach operated as a state extension program in Missouri)
were contacted by telephone to determine their weight and use of program
techniques. At the time of telephone contact, 118 subjects sampled who had
completed treatment had been out of treatment for 9 to 29 months. Those who
had been out of treatment 9 months reported significant additional weight loss;
on average, treatment losses were maintained by subjects contacted at 13, 17,
21, and 29 months posttreatment. Subjects reporting follow-up weights at or
below their weight at the end of treatment were significantly more likely to have
reported continuing to use stimulus-controilchaining techniques during the
follow-up period (Paulsen, Beneke, Wrinkle, Davis, & Bender, 1981). These
studies and others conducted in our laboratory indicate the promise of stimu-
lus-control and chaining-based programs.
Some additional steps can be taken to further enhance nutritional changes
for the long term. One key element is maintaining long-term motivation sup-
porting changes in eating habits. To the extent that individuals are motivated to
alter nutritional habits because of chronic health problems, their motivation
may be reduced to the extent that the health problems are ameliorated. Taking
additional steps to maintain motivation is important. New motivation and
incentives must be created to support behaviors that were earlier maintained by
negative reinforcement (escape from the physical and psychological discom-
forts of chronic health problems). See Chapter 2, this volume, for a discussion
of the problems of maintenance of avoidance behavior.
Programming for social support by arranging for praise and compliments
directed toward new eating behaviors is one key ingredient. Increased partici-
pation in physical activities enabled by improved health is another. To the
extent that physical activities are enjoyable, they will help maintain altered
eating habits. Many activities, such as recreational softball or volleyball, can
have important social consequences that can maintain and encourage a more
healthy lifestyle. Most physical activities have health benefits of their own that
complement and support the benefits of altered nutrition.
For weight loss, simple, permanent, long-term commitments are helpful
for preventing relapse. Permanently altering larger clothing or donating it to
charity eliminates a "convenient path of retreat." Planning for holiday eating
can prevent problems. Continued self-monitoring of eating habits and body
weight are helpful for early identification of undesired changes. Garrow and
Gardiner (1981) reported the use of a nylon waist cord that was permanently
attached to patients. Regaining small amounts of weight made the cord tight
enough to serve as a proximal cue for returning to the use of weight-control
techniques. Garrow and Gardiner (1981) reported that the waist cord tech-
nique produced significantly better posttreatment maintenance than a no fol-
low-up treatment control. The waist cord approach required no effort by the
patient, yet reliably indicated the need for renewed efforts using program tech-
niques. Perhaps designer waist cords could become a healthy fashion trend.
A set of cognitive-behavioral techniques to promote long-term mainte-
nance of changed nutritional habits comes from research on addictive behav-
iors. These techniques focus on preventing relapse by preparing for the cogni-
tive consequences of relapse. How an individual interprets a small slip can
greatly affect long-term efficacy of a program. Programs that avoid long lists of
proscribed foods minimize negative cognitive consequence of "slips." It is im-
portant that an uncontrolled eating episode not be interpreted as failure or an
indication of the hopelessness of attempting dietary management. To further
reduce relapse, at least two key elements should be included: (1) information
about the actual nutritional consequences of a slip (i.e., that the enormous
portion of pie translates into less than 1/2 pound of weight gain), and (2)
development of a sensible plan to be followed if a slip occurs. This improves the
chances that an episode of uncontrolled eating will cue for renewed attention to
altering eating habits rather than a cue for giving up and abandoning self-
control approaches to dietary management.
SUMMARY AND RECOMMENDATIONS

Approaches to changes in eating habits based on behavioral principles of
chaining and stimulus control offer much promise. These principles, creatively
applied, have been shown to be effective in altering eating habits and improving
nutrition. The idealized eating chain developed in our work is designed for the
main food preparer in a household. Most of the environmental and behavioral
changes will ultimately affect all family members. This can have important
consequences for the prevention of obesity and other nutrition-related diseases
by establishing desirable eating habits in children early in life. The value of this
eating chain for altering nutritional habits is now recognized by the American
Dietetic Association (Terry, 1994).
Although long-term effectiveness of chaining/stimulus-control approaches
for dietary management is superior to alternative treatments, much additional
work is needed. More basic research expanding our knowledge of how biolog-
ical, genetic, and environmental factors interact to determine eating patterns
will enable development of superior programs for changing nutritional habits.
More applied research is needed to develop programming for improved long-
term maintenance of desirable eating habits. Much of the behavioral research
on changing eating habits has focused on weight control, and weight change
has been the primary outcome studied. Weight-control research should be

expanded to include other health- and nutrition-related measures, and more
behavioral research targeting other nutritional goals would provide the re-
search base needed for generalizing beyond weight loss.
A final area in need of additional work is finding more cost-effective ways
of delivering behavioral programs. Modularizing programs and presenting in-
dividual clients with only those modules relevant to changing their specific
eating problems is one possibility that has not been explored. It has the theoret-
ical benefit of eliminating unnecessary teaching and learning, but it requires the
development of inexpensive, reliable means for assessing specific behavioral
problems associated with eating. Clever systems for delivering individualized
modules in groups settings would also be required for efficient program deliv-
ery. Although some relevant research has already been published, work on
developing more cost-effective delivery systems is still in its infancy (Taylor,
Agras, Losch, Plante, & Burnett, 1991).
Acknowledgment. Preparation of this chapter was partially supported by

USDA/CSRS grant No. MO-X-OH91-519.
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8
Memory Rehabilitation
Techniques with
Brain-Injured Individuals
Brady J. Phelps and Carl D. Cheney
Cognitive rehabilitation is the label often used when referring to a variety of

techniques that focus on the amelioration and retraining of thinking and mem-
ory behaviors following traumatic brain injury (Wood, 1990). The most fre-
quent complaint following brain injury, and to which the bulk of the cognitive
rehabilitation literature is addressed, is that of memory disturbance (McGlynn,
1990). The need for effective remedial programs is immense, since estimates
run as high as 2 million Americans likely to experience traumatic brain injury
each year, with the costs of rehabilitation estimated in billions of dollars annu-
ally (Department of Health and Human Services, 1989; National Head Injury
Foundation, 1992).
Based on the obvious enormity of the problem, one would expect cognitive
rehabilitation therapy to encompass state-of-the-art procedures in order to
maximize the return of the brain injured to independence if not productive
lives. Such is not the case. There is no single, coherent picture of what the best
cognitive rehabilitation is or how it should be done (Wesolowski & Zencius,
1994). Some authors have gone so far as to argue that a technology of cognitive
Brady J. Phelps • Department of Psychology, South Dakota State University, Brookings, South
Dakota 57007-0997. Carl D. Cheney • Department of Psychology, Utah State University,
Logan, Utah 84322-2810.
123
rehabilitation does not exist, given the diversity of concepts and approaches
assumed under that title (Wood & Fussey, 1990).
This chapter is a review of the state of theory and application in cognitive
rehabilitation. We argue that there is a serious need to increase emphasis on the
proven procedures of behavior analysis in order to achieve much needed im-
provement. We begin by defining what the behavior probabilities are when one
speaks of impaired memory and we indicate that specific behaviors are what
are lacking in the brain injured and that there exist many techniques to shape
these behaviors. Our approach is not to deal with memory as a cognitive
internal process or as a physiological brain dysfunction (since nothing can
restore brain tissue), but to treat the head injured as individuals who are
missing certain behavior repertoires and who also have organic damage.
Many strategies of cognitive rehabilitation begin with the hope of improv-
ing "recall," as if the now-missing behavior is still present but the patient
cannot reaccess it from storage. A behavioral conceptualization of memory,
however, has to do with the altered probabilities of certain actions. When we
say a person or animal has remembered something, what exactly do we ob-
serve? When remembering takes place, a behavior that was learned at time Tis
seen again at time T + X; after a delay, the behavior is still present and resem-
bles the behavior seen at original time T To a cognitive psychologist, memory, a
reification of the behavior of remembering, is an internal search for informa-
tion in storage; with the brain injured, the search is unsuccessful because the
information is inaccessible. To the behavior analyst, accessibility of memory is
replaced with probability of a response occurring, with the response in this case
being remembering. For the brain injured, the behavior of remembering is often
of lower probability than with the uncompromised person. The probability of
the person remembering (i.e., behaving), even if near zero, can still be made
more likely to happen with behavioral procedures (Wesolowski & Zencius,
1994). The cause of any alteration in performance may follow from a brain
injury, but in as much as that is a medical-physiological issue, the restoration
of memory activities per se do not require attention to organicity. The issue
becomes one of installing (restoring) specific behavior repertoires. The brain
cannot be repaired; the concept of memory as an internal process is really only
a hypothetical entity; therefore, rehabilitation efforts should emphasize behav-
ior management.
SPECIFIC TECHNIQUES: WHAT DOES AND DOES NOT WORK

The specific remedial strategies for dealing with memory deficits can be
divided into three main classes: (1) practice drills, (2) strategy training, and
(3) external memory aids. We shall discuss representative literature from each
class and critique its success. We try to indicate the differences in approach
when the problem is considered a memory process versus a behavior deficit.
8 • MEMORY REHABILITATION 125
Practice Drills
Glisky and Schacter (1986) point out that despite a near-total lack of
empirical evidence supporting the efficacy of repetition and practice drills in
treating memory disorders, such efforts are the most widespread. The logic
behind such an approach is not without support, since data do indicate that
repetitions or rehearsals can increase the probability of recall (but only of the
specific material rehearsed) with the normal subject (Ebbinghaus, 1913). With
the increased involvement of microcomputers in rehabilitation, memory prac-
tice drills have gained additional impetus (Levin, 1991).
Typical computer-assisted packages are those that provide patients with
repetitive practice and exhortations to "remember" digits, letters, or words
displayed on a video monitor. The idea is, apparently, that the memory process
can be strengthened by practice, and once the strength has returned, then most
previous memories can be recaUedlrestored.
While there is some evidence that a memory-disordered patient can learn
specific bits of information by repeated practice, there is no evidence that such
practice can improve memory in general (McGlynn, 1990; Wilson & Patterson,
1990). The ability to remember is not the same as developing muscular
strength, improving with repeated use; repetitive drills produce no significant
transfer to other tasks, stimuli, or everyday life (Glisky & Schacter, 1986). We
suggest that what one is actually attempting to do is to increase the probability
of a response in the presence of specific stimuli. Increasing the number of
repetitions with reinforcement is how that is accomplished. It would be a very
curious finding indeed to have a human subject who, even with some head
injury, did not come under the influence of behavioral contingencies (e.g.,
Fuller, 1949). For example, many dozens of experiments have been reported
wherein nonhuman subjects were trained, subjected to brain insult, and then
reexposed to the training regimen with various levels of recovery retained or
regained (Wood, 1990). Additional research showed that amnesic animals and
humans perform comparably when the same instruments are used to assess the
depth of amnesia (Squire, Zola-Morgan, & Chen, 1988). One feature in such
research is the level of motivation that is possible with nonhuman subjects. We
are not as likely to employ as severe contingencies of control (i.e., shock avoid-
ance, food deprivation) with humans as we might with monkeys.
The use of computers for memory drills appears to be based more on
practicality than proven effectiveness in ameliorating memory disorders (Glisky
& Schacter, 1986; Williams, Harley, & Malec, 1991). While many drill-and-
practice studies report minor improvement over weeks of therapy, other studies
have noted progressive improvements with such patients over years of observa-
tion, without any specific remedial therapy. Such studies must always distin-
guish treatment results from spontaneous recovery (Mandleburg & Brooks,
1975).
Given the absence of support for practice drills, computer assisted or not,
the focus of cognitive rehabilitation might best turn to other applications of

computers (Levin, 1991).
Strategy Training
Another widely used strategy that is supposed to improve memory is that
of visual imagery (Yates, 1966). Recent reviews of therapy with this type of
treatment conclude that brain-trauma patients cannot produce, or at least
experience great difficulty in producing, their own imagery (Wilson, 1987). If
such patients are provided with verbal descriptions of images, they appear to be
able to then use the image to aid recall with varying degrees of success (Wilson,
1987). Also, the common belief that exaggerated or bizarre visual imagery is
superior to more normal modes of imagery is not supported by research (Wool-
en, Weber, & Lowry, 1972). Recent controversy has revolved around encourag-
ing people to try and remember "forgotten or repressed memories" using
imagery, especially guided imagery. Cognitive psychologists, with something of
practical utility to say for a change, have shown that the "memories" produced
using such imagery are more of an elaborate reconstruction than accurate recall
(Loftus, 1993). We conclude that the use of imagery as a remedial memory
therapy has proven to be of very limited value (Wilson, 1987). Mateer,
Sohlberg, and Youngman (1990) argue that memory-retraining techniques that
employ either visual imagery or verbal mediation can actually exacerbate atten-
tional and memory disorders. They point out that substantial "effort" is re-
quired to use such techniques by people with already-compromised repertoires.
Inability to "attend" is also a frequent complaint about brain-injured patients.
Techniques for increasing the ability to remember have rarely acknowledged or
adequately considered the deficiencies of this prerequisite behavior (Hopewell,
Burke, Wesolowski, & Zawlocki, 1990).
Another commonly employed practice technique is that of "concept re-
hearsal," either verbal or written (Wesolowski & Zencius, 1994). The verbal
repeating of information to be remembered seems likely to result in recall, with
the average person as well as with the memory impaired, especially if the
disabled person can remember to initiate and maintain this behavior. Talking
to oneself will not, as such, lead to a general improvement in the ability to
remember (Martella, 1994). What it actually does is to bring the controlling
variables into the present. Written memoranda rehearsal does provide a more
permanent form of the information, and this aid is most effective with clients
that can self-initiate memoranda for rehearsal behavior. Both verbal and writ-
ten instructions for rehearsal can increase recall (performance) with clients
whose amnesia is not severe and if they can "remember" to use the strategy
(Glisky & Schacter, 1986).
Merely repeating verbal information, however, will not ensure future re-
call, but it can be effective in bridging temporal gaps between the acquisition of
information or behavior and later use or performance. Rehearsal can also bring
remembering behavior under the control of a variety of stimuli, all of which can
serve to aid recall (Donahoe & Palmer, 1993). Of course, the client has to be
able to remember the material long enough to rehearse it and to "remember"
to initiate rehearsal, which is exactly the problems associated with memory
disturbance! With the severely impaired patient, who is most prone to such
difficulties, other techniques have been reported to be successful.
The preview, question, read, state, and test (PQRST) strategy can be effec-
tive with severely impaired clients as it is with nonimpaired individuals (Wil-
son, 1987). While any degree of improvement is welcome, applying techniques
that a brain-intact student might use to memorize such lists as the cranial
nerves by name and in order may not work effectively with persons who have
lost many of the brain mechanisms/behaviors of the average person.
In summary, visual imagery and verbal or written rehearsal strategies have
not been shown to be effective. Severely impaired subjects may fail to use the
strategy or to be "overwhelmed" (stimulus overload) and confused by conflict-
ing or extensive demands on their attending skills (Hopewell et aI., 1990,
Mateer et aI., 1990).
Stimulus Equivalence
Green (1991) and Cowley, Green, and Braunling-McMorrow (1992) re-
ported a promising approach to reducing amnesia through the use of stimulus
equivalence procedures (Sidman & Tailby, 1982). Briefly, the procedure relies
on assessing a patient's ability to remember specific environmental cues (faces,
photographs, names) presented in different forms and then directly teaching
that other stimuli are "equivalent" to the intact and remembered relations
among the stimuli. Something of an incidental benefit of this explicit training is
that additional and totally untrained equivalent relations among the stimuli
emerge through generalization of the equivalence experience. For instance, a
person can be taught that stimulus A is equal to stimulus B, and that stimulus B
is equivalent to stimulus C. Without being directly taught, it follows from this
procedure that stimulus A is equivalent to stimulus C. Several studies show that
severely amnesic patients can learn equivalences across at least five stimulus
classes-names dictated by the therapist, photographs of faces, handwritten
names, nameplates, and names spoken by the clients themselves-and these
equivalent relations remained intact several months later (Green, 1991).
These researchers concluded that the relations were acquired and retained
because the patient's existing skills were exploited in attaching "memories" and
the learning was strengthened by both the old and new relations among the
training stimuli. In this case, the training was oriented toward specific behav-
iors that the patients needed to function more independently, instead of having
the patient directly learn all possible equivalences among the stimuli to be
remembered. The researchers identified the minimum requisite relations that
would have to be learned in order for the untrained relations to emerge. In
addition, correction and reinforcement contingencies were used, which varied
systematically as a function of the patient's responses.
While stimulus equivalence procedures produced significant improvement

in the recall (performance) of specific responses, the stimulus equivalence pro-
cedure is not widely understood and is rather complex to employ. This will
likely keep these procedures from being adopted very soon in cognitive reha-
bilitation efforts.
External Memory Aids

The types of external aids employed in memory therapy range from note
pads to microcomputers. If used judiciously and then faded away, specific
external prompts appear to be rather effective for assisting the memory-disor-
dered individual (McGlynn, 1990).
Fowler, Hart, and Sheehan (1972) seem to be the first to report an attempt
to remedy memory deficits by training a severely impaired client to refer to a
written daily schedule. A timer alarm that was set by a therapist prompted the
patient to look at and read a schedule of specific instructions as to what task to
perform next. Following successful training in the use of the timer and the
schedule, the therapist then faded out the patient's dependence on these prompts.
Eventually, the patient came to rely on a standard appointment book he carried
about and referred to for self-instruction. Follow-up data showed the patient
functioning with considerable autonomy for over a year (Fowler et aI., 1972).
Many studies in the rehabilitation literature are reported with single-case
examples. Granted, each brain injury is probably unique, but there needs to be
an extraction of some general principles that will relate to the rehabilitation of
a majority of such patients. This has not happened, probably due to the fact
that workers in this field come from all sorts of backgrounds, including educa-
tion, social work, psychology, rehabilitation, and others. Not only do each of
these disciplines have different philosophies, but within each discipline there
are widely divergent orientations.
Finset and Andresen (1990) reported success using self-instruction with
amnesic patients. In their studies, the environment was modified in order to
minimize errors and to exploit the patients' remaining abilities by ignoring
maladaptive behaviors and reinforcing only successful behaviors.
The use of memory aids, as other prosthetic devices are employed with
various disabilities, seems an obvious technique for assisting in the treatment of
behavior problems. They are not widely used, however, probably because they
require careful engineering and because brain-injured patients often do not
appear disabled and memory is considered a mental process, not a behavioral
disability. Nevertheless, external memory aids need to be provided in close
proximity in time to the desired action. They should be active and intrusive
rather than passive and subtle, such as an alarm compared to a written re-
minder, and they must be very item specific. Most memory prostheses do not
possess these characteristics. Glisky and Schacter (1986) noted that patients
rarely refer to their notes, and when queried about these reminders, they often
cannot recall what a note meant since it frequently lacked the necessary speci-
ficity.
These problems, although seemingly trivial and easily corrected, indicate

that the appropriate use of external memory aids, even simple ones such as
memoranda, will require specific staff and caregiver, as well as patient, training
in order to be successful.
Personal Computer Training

Several investigators have suggested personal computers (PCs) as possible
aids for memory-challenged individuals (Levin, 1991). As with any person,
basic computer literacy is a necessary prerequisite before patients could use a
Pc. Glisky, Schacter, and Tulving (1986) and Glisky and Schacter (1988,1989)
investigated the potential for memory-impaired patients to use PCs as teaching
machines. The methods they used were similar to those developed with Skin-
ner's (1958) teaching machines. These researchers called their procedure the
"method of vanishing cues," in that built-in retrieval cues were gradually and
systematically reduced across successive learning trials. In these studies, it was
demonstrated that amnesic patients could become computer literate, including
using computer terminology, program writing, and editing (Glisky et aI.,
1986). Their skills developed slowly relative to intact learners, and they were
very dependent on the cues. But learning to use 250 procedures and commands
by one subject with "dense" amnesia was retained at a 9-month follow-up
(Glisky & Schacter, 1988, 1989).
While gains such as those reported here are mildly encouraging, the speci-
ficity of such learning remains a major obstacle. McGlynn (1990) termed this
learning "hyperspecific" because of its lack of generalization, with the subjects'
performance closely dependent on the stimuli used in training and not likely to
be used with even minor changes in context or demands.
Research indicates that performance generalization can be facilitated by
teaching an amnesic to monitor their own behavior via "self-talk" or rule-
governed behavior, where contingencies between responses and consequences
are turned into verbal (overt or covert) rules (Wood, 1987; Martella, 1994).
Generalization training consists of three procedures-stimulus generalization,
response generalization, and response maintenance (Martin & Pear, 1992)-
and without attention to each of these procedures, little generality of training is
likely to occur. More often than not, little attention is given to generalization
training. A recently published "practical guide" in cognitive rehabilitation
gives very sparse attention to this topic. Wesolowski and Zencius (1994), in an
entire book on rehabilitation, refer to the word "generalization" only once.
CONCLUSIONS
From this brief treatment of the topic, it appears that it will be difficult if
not impossible to restore premorbid ability levels in brain-injured, amnesic
patients. In memory retraining, it may be that the major emphasis should not
focus on recovery of lost functions but rather on identifying the means of
compensating for behavioral deficits. Compensation activities may include es-

tablishing new ways of learning that complement the patient's remaining be-
havioral repertoire. Those studies that assessed a patient's abilities and were
then programmed to exploit the patient's residual behaviors demonstrated the
greatest gains (Fowler et aI., 1972; Green, 1991; Cowley et aI., 1992).
The rehabilitation of memory ability must be based on the patients residu-
al behaviors, and behavior modification processes must be used that are known
to strengthen behavior and produce generalization to new settings and new
response classes. In the introduction, we suggested that much cognitive reha-
bilitation therapy is not effective owing to a lack of empirically demonstrated
procedures primarily because of a misdefinition of what exactly was the prob-
lem. For example, the use of memory drills appears of little practical use, yet
they are still widely used. They work with the intact person, but have failed to
improve the behavior of the brain impaired.
Cognitive rehabilitation as a therapeutic discipline needs to develop some
professional unification and then to adopt well-founded empirical procedures
based on data, and it should be conducted as an interdisciplinary intervention.
Those studies mentioned above that borrowed and applied techniques from
differing theoretical orientations also demonstrated the most efficacy. For ex-
ample, Glisky et al. (1986) and Glisky and Schacter (1988, 1989) described
their approach to retraining from a cognitive psychology position; but, to
facilitate teaching and to minimize client errors, they also readily applied Skin-
ner's (1958) programmed instruction technique. Cowley et al. (1992) and
Green (1991) represent behavioral conceptualizations of cognitive processes,
and they, too, produced impressive results.
Defining the Problem

Three forces appear to be intertwined in cognitive retraining and each may
have its specific contribution. Neuropsychology as a conceptual and meth-
odological discipline might serve to further our understanding of brain func-
tion. This then might conceivably aid a therapist in selecting particular patients
for specific treatments. On the other hand, an etiology of a memory deficit
from a neuropsychological workup can only indirectly guide treatment. Most
patients are seen for memory retraining on the basis of the severity or type of
behavioral disturbance that they manifest, rather than because of a specific
neurological etiology (Wilson, 1987). Neuropsychology may tell us where in
the nervous system the trauma has occurred, but direct remedial therapies for
injury of the brain itself are still highly experimental (Kandel, Schwartz, &
Jessel, 1991). We question the utility of such theory in terms of effective therapy.
Cognitive psychology, which is rich in theory but poor in technique (Skin-
ner, 1974), also has little practical application to offer in-service rehabilitation
providers. Cognitive psychology says little about the specific techniques or
steps in learning or relearning behaviors or verbal skills (Wilson & Patterson,
1990). Levin (1991) argues that "cognitive" therapists are relying on a model
of cognition that is"nonbehavioral" and therefore yields ineffective and flawed

interventions for behavior disorders.
Neither neuropsychology nor cognitive psychology have helped much in
designing therapeutic procedures for memory retraining; therefore, we suggest
that future focus must be on behavior analysis in order to design effective
interventions. Behavioral approaches define the problem as deficiency of overt
behavior as assessed by behavior techniques. This enables the therapist to
gauge the nature and extent of real-life overt problems encountered by amne-
sic individuals. From a baseline of behavior, differential reinforcement can
then be applied to foster the use of a patient's remaining abilities and to
promote replacements (Cowley et aI., 1992; Green, 1991; McGlynn, 1990).
Systematic and specific generalization training must also be incorporated in
order to facilitate performance outside the training setting (Martin & Pear,
1992). Despite the contributions of a behavioral approach as recorded in vo-
luminous literature, such applications to memory impairment have only devel-
oped in the last few years and remain greatly underutilized (Mateer & Wil-
liams, 1991).
One might ask if standard learning paradigms are viable with the memory
disordered. A large body of literature has clearly established that respondent
and operant conditioning are effective procedures with brain-injured animals
and humans (e.g., Wood, 1990).
The effectiveness of behaviorally based treatment programs has been dem-
onstrated by thousands of investigations (e.g., Eames & Wood, 1985; Wood,
1987, 1990, and others). Eames and Wood (1985), for example, examined 24
head-injured patients, assessing levels of daily living activities, functional abili-
ties, and general psychological state. All patients were judged to have severe
losses, based on length of immediate posttrauma coma and depth of amnesia,
and most were unacceptable to other rehabilitation programs because of the
severity of their behavior problems. The interventions consisted of structuring
the environment with the use of a token economy (Ayllon & Azrin, 1968) and
applying a wide range of behavioral techniques in treatment, which included
and emphasized reinforcement of all appropriate and functional overt behav-
iors and no reinforcement for maladaptive behaviors. The results showed that
18 of the 24 individuals attained dramatic improvements in behavioral inde-
pendence and maintained those improvements at follow-up conducted over 6 to
39 months. The six who did not significantly improve either had a history of
psychopathology or "excessive" brain injury, with very poor medical prog-
noses for any improvement.
The lack of utilization of behavior analysis in cognitive rehabilitation
could be due to a number of factors. Possibly many therapists view behavioral
therapy as only applying to overt physical behavior, or, at best, many of them
incorrectly use the techniques (Wilson, 1987). Others may consider memory as
the exclusive domain of either cognitive psychologists or neuropsychologists.
But behavior analysts have long proposed that thinking, perceiving, and remem-
bering are all behaviors, and as a result these behaviors are subject to the laws
that govern all behavior (Skinner, 1957, 1974). As Skinner said, "We do not
remember experiences; we are changed by them."
Other therapists may go so far as to espouse "therapeutic nihilism," mean-
ing that they assume that little can be done to ameliorate the results of traumat-
ic brain injury (Wilson, 1987), and therefore the therapist serves a caretaker
and not a rehabilitation function. This attitude is reinforced by the ineffective-
ness of existing cognitive retraining programs. As nihilism is defined as rejec-
tion of existing standards and practices of a culture, perhaps therapeutic nihil-
ism will lead to the rejection of most existing cognitive rehabilitation programs
and therefore demand improvement. In view of the minimal gains accrued from
typical cognitive rehabilitation regimes, a radical change in approach is needed.
REFERENCES
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Cowley, B. J., Green, G., & Braunling-McMorrow, D. (1992). Using stimulus equivalence proce-
dures to teach name-face matching to adults with brain injuries. Journal of Applied Behavior
Analysis, 25, 461-475.
Department of Health and Human Services. (1989). Interagency head-injury task force report.
Washington, DC: US Government Printing Office.
Donahoe, J. W., & Palmer, D. C. (1993). Learning and complex behavior. Boston: Allyn & Bacon.
Eames, D., & Wood, R. (1985). Rehabilitation after severe brain-injury: A follow-up study of a
behavior modification approach. Journal of Neurology, Neurosurgery, and Psychiatry, 48, 613-619.
Ebbinghaus, H. (1913). Memory: A contribution to experimental psychology. New York: Teachers
College, Columbia University.
Finset, H., & Andresen, S. (1990). The process diary concept: An approach in training orientation,
memory, and behavior control. In R. L. Wood & I. Fussey (Eds.), Cognitive rehabilitation in
perspective (pp. 99-116). London: Taylor and Francis.
Fowler, R. S., Hart, J., & Sheehan, M. (1972). A prosthetic memory: An application of the
prosthetic environment concept. Rehabilitation Counseling Bulletin, 12, 81-85.
Fuller, P. R. (1949). Operant conditioning of a vegetative human organism. American Journal of
Glisky, E. L., & Schacter, D. L. (1986). Remediation of organic memory disorders: Current status
and future prospects. Journal of Head Trauma Rehabilitation, 1(3),54-63.
Glisky, E. L., & Schacter, D. L. (1988). Long term retention of computer learning by patients with
memory disorders. Neuropsychologia, 26, 173-178.
Glisky, E. L., & Schacter, D. L. (1989). Extending the limits of complex learning in organic
amnesia: Computer training in a vocational domain. Neuropsychologia, 27, 107-120.
Glisky, E. L., Schacter, D. L., & Tulving, E. (1986). Learning and retention of computer-related
vocabulary in memory-impaired patients: Method of vanishing cues. Journal of Clinical and
Experimental Neuropsychology, 8(3),292-312.
Green, G. (1991). Everyday stimulus equivalences for the brain-injured. In W. Ishaq (Ed.), Human
behavior in today's world (pp. 123-132). New York: Praeger.
Hopewell, C. A., Burke, W. H., Wesolowski, M., & Zawlocki, R. (1990). Behavioral learning
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rehabilitation in perspective (pp. 229-246). London: Taylor and Francis.
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(Eds.), Cognitive rehabilitation for persons with traumatic injury: A functional approach
(pp. 163-179). Baltimore: Brookes.
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persons with traumatic brain injury: A functional approach (pp. 117-126). Baltimore: Brookes.
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tive (pp. 68-96). London: Taylor and Francis.
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II
Education
9
Acting to Save Our Schools
(1984-1994)
R. Douglas Greer
Throughout much of his life, Burhrus Frederick Skinner (1904-1990) advo-

cated that science ought to act to save our world. Skinner was concerned about
the failure of the educational establishment to draw on a superior pedagogy
made possible by the science of behavior, particularly given the poor state of
American schools. He characterized the dilemma in the title of his paper as
"The Shame of American Education" (Skinner, 1984).
It has been more than 10 years since the most influential scientist in our
field characterized the condition of American schools as shameful, a view held
by other behavior analysts who also specialize in education (Axelrod, 1991;
Engelmann, 1991; Greer, 1983, 1989). What, if anything, have behavioral
educators done in the last decade to disseminate our science in the schools and
to increase our knowledge base of teaching and schooling practices?
There are only certain ways in which a science of the behavior of individu-
als can contribute to saving our schools. Nevertheless, if we are to have schools
that work, those parts of education that our science can improve (i.e., pedagogy
for better educational outcomes, noncoercive management, and improved mea-
sures) are the ones that must change (Axelrod, 1991; Greer, 1983, 1992;
Keller, 1968, 1978, 1982; Skinner, 1984a). This chapter identifies recent con-
tributions (1984-1994) of behavior analysis to education. The contributions
that I have identified fall into the following categories: (1) research findings
R. Dougla, Creer • Teachers College and Graduate School of Arts and Sciences, Columbia
University, New York, New York 10027.
137
138 II • EDUCATION
(tactics, strategies, theories); (2) progress in the measurement of pedagogy and

schooling in behavior analysis, and evidence of convergence with sciences of
education devoted to groups; (3) conceptual changes in the science (Zuriff,
1986); and (4) advocacy efforts to expand the findings and methods of behav-
ior analysis in American schools.
The period, 1984-1994, was chosen because there were some important
events in our science that framed the decade. It was a brief 10 years ago that the
annual Banff (Canada) conference on "behavior modification" devoted its 16th
international conference to education. The conference was dedicated to the
contributions of B. F. Skinner to education on the occasion of his 80th birthday.
The theme was "designs for excellence in education" (West & Hammerlynck,
1992).
The year 1984 was a notable watershed for other reasons. It was the year
in which a committee of members of the Association for Behavior Analysis
presented its findings in a report, "Follow-up on Follow-through," to the gen-
eral membership of that organization (Greer, Graf, & Lindsley, 1984). The
newly established Cambridge Center for Behavioral Science included a presen-
tation on education as one of three papers at its first annual meeting of the
board (Greer, 1989). It was also the year that the proceedings of the first
conference on behavior analysis and education at Ohio State University were
published (Heward, Heron, Hill, & Trapp-Porter, 1984). The Association for
Behavior Analysis charged a committee to formulate the organization's posi-
tion on educational matters (partially as a result of the "Follow-up on Follow-
through" report) (Barrett et aI., 1991), which would again result in the asso-
ciation's official position on education 10 years later. Finally, Skinner (1984a)
published his paper on the shame of American education in the American
Psychologist.
The close of the decade, the year 1994, is notable also because: (1) the
proceedings of the second conference on education at Ohio State were pub-
lished 10 years after the proceedings of the first conference were published
(Gardner et aI., 1994); (2) it was the 90th anniversary of Skinner's birth; (3) the
Association for Behavior Analysis (ABA) made available, in pamphlet form, a
statement on its official position on education that had been provoked in part
by the report, "Follow-up on Follow-through," given in 1984 (Barrett et aI.,
1991); (4) the Cambridge Center for Behavioral Studies began a public infor-
mation service on educational innovations from the science; and (5) Sigrid
Glenn, as president of ABA, arranged a training session for behavioral educa-
tors at the 1994 annual convention to learn how those who practice our science
in school settings might lobby more effectively for the promulgation of behav-
ioral applications in schools. Thus, the events surrounding the decade frame 10
years of educational activity.
9 • ACTING TO SAVE OUR SCHOOLS 139
THE ZEITGEIST AND CONTEXT FOR EDUCATIONAL REFORM

IN THE UNITED STATES (1984-1994)
The period was replete with reports decrying the poor state of American
schools. Blue-ribbon committees for educational reform produced white pa-
pers suggesting what should be done. The administration of then-President
George Bush launched the "Education 2001" effort to make the United States a
leader in education, probably in reaction to the poor showing that America's
students were making in international comparisons. There were several funded
efforts by corporations and foundations to reform education as well (e.g.,
Darling-Hammond, 1993). Educational reform was in the forefront of political
and public concern throughout the decade, with concerns for health reform
edging out education more recently.
Despite the climate for educational reform, none of the efforts gave serious
consideration to the need for a science of pedagogy as the key to better educa-
tion. It is, therefore, understandable that the science that is most concerned
with effective pedagogy did not receive attention from those who were leading
the reform movements. While many behavioral educators regretted that our
science was not enlisted to reform our schools (myself included; see Greer,
1992), the fact is, neither educators nor the public regarded pedagogy as a
problem. The efforts that were made were organizational ones rather than
reforms that embraced classroom interaction (e.g., changes in the size of
schools, decentralization, teacher empowerment). Perhaps it was to our advan-
tage that a science of behavior and pedagogy was not associated with national
efforts to reform education. That is, while the politics of educational reform
reverberated in the halls of legislatures and in the literature of education
throughout the decade, little evidence exists to suggest that any of the well-
publicized reform efforts made any substantial inroads in correcting the poor
outcomes of American schools.
The real innovations in education did not occur in national forums or in
the large efforts that have been funded by the government and foundations,
because these efforts disregarded pedagogy. Has our science advanced to the
extent that we can act more effectively to save American schools when peda-
gogy is recognized eventually as the problem (Lovitt, 1994)?
INNOVATIONS IN MEASUREMENT PROCEDURES
Arguably, the most important contribution that the science of the behavior
of the individual or behaviorology made to education was measurement. Mea-
surement and the instruments of measurement are the keys to any science. The
operant chamber and its operant unit of measurement established the experi-
mental science of behavior, just as instruments and units of measurement deter-
mined other sciences (Skinner, 1956).
The applications of our science to pedagogy taught us also that a science of

teaching must be a strategic science. This involves the continuous direct mea-
surement by teachers and other educational professionals of student responding
in real time (Greer, 1983, 1989, 1991, 1994d). It is a strategic science because
when the science is practiced in a sophisticated manner in the classroom or
throughout the school system, it requires continuous measurement and ongo-
ing analyses of the controlling contingencies. Bushell and Baer (1994) more
recently characterized this feature of our science as "close continual contact
with the relevant outcome data." Measurement has driven most, if not all, of
the behavioral contributions to education. These include: (1) teacher assistance
interventions (Sulzer et aI., 1988); (2) the comprehensive application of behav-
ior analysis to schooling (Greer, 1992); (3) Direct Instruction (Kinder & Car-
nine, 1991), (4) echobehavioral analysis (Greenwood, Delquadri, & Hall,
1979); (5) the personalized system of instruction (Keller, 1968); (6) precision
teaching (Lindsley, 1991); and (7) programmed instruction (Skinner, 1968).
Have we learned anything important about educational measurement?
We may be converging on a standard measure, or at least a better measure of
schooling within behavior analysis. Three chapters from the 1994 proceedings
of the second Ohio State University conference on behavior analysis indepen-
dently came to the conclusion that such a measure was in the offing (Greenwood,
Hart, Walker, & Risely, 1994; Greer, 1994d; Heward, 1994). In the same period,
educational research that was concerned with the behavior of groups (as distinct
from our science which concerns the behavior of the individual among other
differences) made the move from allocated academic time to engaged academic
time as an improved predictor of school-wide or classroom-wide achievement
(Brophy & Good, 1986; Delquadri, Greenwood, & Hall, 1979; Rosenshine,
1983, personal communication; Rosenshine & Stevens, 1986). In short, educa-
tional research moved closer to the recognition of the importance of direct
measurement, and behavior analysis has provided the crucial next step. How-
ever, these measures were still of the appearance of learning (e.g., "engagement
or on task") and not the measurement of learning outcomes.
The group of behavior analysts at Juniper Gardens introduced the measure
of opportunity to respond (Delquadri et aI., 1979). Heward (1994) charac-
terized this as "active student responding." Several studies suggested that the
opportunity to respond was a robust predictor of school achievement (Green-
wood et aI., 1994). In retrospect, opportunity to respond probably was the
most important contribution of the 1984 proceedings from the conference at
Ohio State University. Ten years later, Heward (1994), in a chapter in the
proceedings of the second conference, provided a summary that documents the
movement toward an outcome measure of schooling at the level of pedagogy
both in behavior analysis and in the group sciences concerned with education.
Measurement has become a concern even in less-scientific educational
circles (Perone, 1991). Educators are increasingly disenchanted with indirect
measures (e.g., standardized achievement tests or projective tests devoted to
psychological constructs) because they are not useful for instructional purposes
at the level of the individual. A recent trend promotes the direct assessment of
accomplishment (Perone, 1991). Such a record of accomplishments results in
portfolios of students work, although the sophistication of that measurement
calls out for the tools of our science.
The research devoted to the behavior of groups (see The Educational
Researcher, American Educational Research Journal, Journal of Educational
Psychology, Exceptional Children, Review of Educational Research) shows that
classrooms in which teachers measure learning directly (e.g., actual student
response) and frequently showed greater group "mean" gains, and they are the
classrooms in which students were more engaged (Rosenshine & Stevens,
1986). We can extrapolate reasonably that these were the classrooms with more
opportunities to respond, active responding, and more learn units. There can
be little question that the behavioral models of education have been the most
measurement-intensive approaches to education in the history of schooling.
The research at Columbia University Teachers College on the "three-term
contingency trial," or what we later came to call the learn unit, was still
another step in identifying a basic unit of teaching (Albers & Greer, 1992;
Diamond, 1992; Greer, 1994d; Greer, McCorkle and Williams, 1989; Se-
linske, Greer, & Lodhi, 1991). Our research suggested that the learn unit,
together with criterion-referenced objectives, is a primary predictor of educa-
tional effectiveness as well as an authentic, valid, and reliable count of both the
process and the outcome of learning. The learn unit includes opportunity to
respond, the student's response, the teacher antecedent-consequence, and the
student antecedent-consequence (see Greer, 1994d for a detailed description).
It is an interlocking three-term contingency between the teacher and the stu-
dent, and it is an immediate outcome measure as well as a measure of the
instructional process. We have also used the learn unit, together with criterion-
referenced objectives of instruction, to determine cost-benefits of schooling
(Greer, Phelan, & Sales, 1993; Greer, 1994d). In the schools that use behavior
analysis on a system-wide basis (the comprehensive application of behavior
analysis to schooling, or CABAS), we measure all of the learn units received and
objectives achieved by all students in all curricular areas and have done so for
some time (Greer et aI., 1989; Greer, 1992).
We found that a teacher observation procedure that determined the accu-
racy and rate of learn units presented by teachers in brief observation sessions
was a valid predictor of student achievement, because it predicted the frequency
of correct responses of students to learn units and the number of objectives
achieved by the teachers with their students (Greer et ai., 1989; Ingham &
Greer, 1992; Lamm & Greer, 1991; Selinske et ai., 1991). Still other measures
of the rate of accomplishment of specific administrative and supervisor tasks
(i.e., outcome measures of tasks accomplished related to instruction and child
care) predicted the number of learn units taught by teachers and in turn the
achievement of objectives and correct responses by students (Babbit & Greer, in
progress; Greer et ai., 1991; Ingham & Greer, 1992). The accuracy of teacher
presentations (e.g., whether or not the teacher antecedent and "postcedent" is
faultless) and the rate of those learn unit presentations by teachers with a
sample of their students in the teachers' classes predicted the number of learn
units taught and the number of student correct responses for the entire class
over the period of the week in which the observation was done (Greer et aI.,
1989; Ingham & Greer, 1992).
This line of research (e.g., opportunity to respond, learn units, and active
student responding) suggests that we have learned more about what we should
measure and that measure has corroboration in at least two literatures and at
least three behavior analysis laboratories. Perhaps the learn unit as an out-
growth of opportunity to respond, active and engaged student responding, and
the operant is leading the science of pedagogy to a solid outcome and teaching
process measure that embraces both teaching and learning. This inquiry may, in
turn, provide a robust unit of measurement for a science of schooling similar to
what the operant provided for behaviorology (Skinner, 1938).
Still another trend in measurement was a renewed interest in rate of re-
sponding (Johnson & Laying, 1994; Lindsley, 1991). The learn unit is analyzed
in rate forms. Opportunity to respond has not been presented primarily as rate;
however, it, and active student responding, are obviously incipient rate mea-
sures since they deal with allocated or actual academic time. The Morningside
Generative Model of Education (Johnson & Laying, 1994) also uses rate mea-
sures of comparable units. Perhaps we are beginning to take Lindsley's (1991)
advice seriously.
In summary, the new trends suggest that we are making progress in mea-
surement in a science of pedagogy. If improved measurement results in the same
advances that have occurred in other sciences, then our new advances in mea-
surement bode well for the study of pedagogy using the strategies of a science of
the behavior of the individual (Greer, 1994b). Perhaps the interest in the more
general educational community in portfolio measurement and in outcome mea-
surement has established the context that will support our new measures on a
wider basis.
NEW AND IMPROVED TACTICS
There are several new tactics developed recently that add to the arsenal of
teacher operations and which teachers can use to improve their students' cor-
rect responding. A few of these are: (1) constant and progressive time delay to
more closely approximate errorless learning (Schuster, Griffin, & Wolery,
1992; Wolery, & Holcombe, 1993); (2) expanded use of general case instruc-
tion that results in greater desired stimulus generalization (Kinder & Carnine,
1991); (3) more extensive data on scripted and carefully sequenced curriculum
(Becker, 1992; Kinder & Carnine, 1991) affirming the importance of well-
designed curriculum coordinated with behavioral pedagogy and frequent re-
sponding; (4) classwide peer tutoring (Greenwood et aI., 1989) that results in
increased response opportunities and more complete learn units; (5) group
contingencies for academic responding that affirm the prior research in group
contingencies for social behavior (Axelrod & Greer, 1994); (6) Lovass' (1987)
25 -year follow-up on the longitudinal effects of behavioral instruction on autis-
tic children demonstrating heretofore unheard of gains for this population; (7)
applications of behavioral procedures to the teaching of mathematics (Peira &
Winton, 1991; Johnson & Layng, 1994); (8) tactics to use Skinner's (1957)
conception of communicative behavior for teaching verbal repertoires (Donley
& Greer, 1993; Sundberg, 1985; Schwartz, 1993; Williams & Greer, 1993)
and the related "naturalistic" or milieu teaching operations or extensions of
incidental teaching (Hart, 1985; Halle, Baer, & Spradlin, 1981; Warren, Mc-
Quarter, & Rogers-Warren, 1984); (9) effective procedures for teaching reading
at the preschool level (Weisburg, 1994) building on the direct instruction
research (Becker, 1992); (10) tutoring dissemination operations (Miller, Bar-
betta, & Heron, 1994), and benefits for tutors (Greer & Polirstok, 1982); and
(11) tactics for teaching students contingency management (Mithaug, Martin,
Agran, & Rusch, 1988; Mithaug, 1993). These are but of a few new additions
that have emerged in the last decade. None of them are totally new; rather, they
build on prior science.
Several strategies and tactics for dealing with inappropriate or so-called
"maldaptive behavior" have developed over the decade. They include, but are
not limited to: (1) functional analyses to isolate the controlling variables for
"bad behavior" (Carr & Durand, 1985; Iwata et aI., 1994; Rast, Johnston, &
Drum, 1984) as a means of determining what intervention to use rather than
directly applying differential reinforcement or punishment tactics; (2) a pack-
age of operations for dealing with truancy and school vandalism on a school-
wide basis (Mayer, Butterworth, Nafpaktitis, & Sulzer-Azaroff, 1985); (3) the
use of increased learn units together with the avoidance of punishment opera-
tions to lower or eliminate assaultive, noncompliant, and self-injurious behav-
ior (Kelly & Greer, 1992; Kelly, 1994; Greer et aI., 1989); (4) tactics for
increasing appropriate social interaction for young children with delayed social
skills (Sainata, Strain, & Lyon, 1987).
Much of the research has involved students with disabilities, but that
should not be surprising considering that the principal funding for research and
training grants from the US government has been for the education of students
with handicaps. Research, too, follows the laws of behavioral selection. Al-
though some found this latter trend disappointing, others have noted that
teaching strategies that work for students who are the most difficult to teach
obviously pay dividends in the building a science of pedagogy for all children.
CONCEPTUAL CHANCES
Conceptual changes are more difficult to pinpoint in terms of dates; how-

ever, there have been several important changes in the theories of the science
and in the epistemology that are important for education. There are three areas
where the change occurred: (1) shifts in the epistemology; (2) findings in the
science that portend exciting new inductively derived theories; and (3) expan-
sions of the science of pedagogy to a science of schooling. Of course, in a
science such as ours, theory comes slowly and grows inductively out of con-
verging findings in research (Sidman, 1993).
Epistemology
The change in epistemology is best characterized by the change in the
terminology for the epistemology of our science that has evolved recently. The
term used by Skinner (1976) in the 1970s was radical behaviorism; it was a
term that gained widespread usage (Michael, 1982). More recently, the term
that is used to characterize our science is behavioral selection (Palmer & Dona-
hoe, 1992; Vargas, 1993). The term behavioral selection, or behavioral selec-
tionism, places the science of the behavior of the individual in a conceptually
consistent continuum with the natural selection epistemology that character-
izes the biological sciences. That is, the environment shapes the phylogeny of
the species, and the environmental consequences for the individual selects the
repertoires of the individual at the level of ontogeny. Skinner (1984b) also
suggested that something similar operates at the cultural level for groups (see
also Glenn, 1988).
Still another change was the increased usage of the term behaviorology as
the name of the science associated with the epistemology of behavioral selec-
tion. Psychology has become an umbrella term that includes everything from
group sciences and behaviorology to nonscientific practices. Behaviorology
denotes the science of the behavior of the individual with particular reference to
the role of postcedents as selecting mechanisms and is drawn on equally by
psychologists, social workers, medical workers, as well as educators (see Var-
gas, 1991, for a precise description; see also the journal Behaviorology).
What does this mean for endeavors in behavioral education? One impor-
tant effect is that the new conceptualization places the behavior of the individu-
al in a much larger scientific context. It suggests that the interrelationship
between the phylogenetic and ontogenetic contingencies of the individual and
the contingencies of others involved with that individual (e.g., teachers, par-
ents, principles, and the community) need to be incorporated in our science of
pedagogy; indeed, we now need a science of schooling that expands our contin-
gency analyses, not just a science of pedagogy.
New selectionistic applications to artificial intelligence research suggest
other influences at the level of pedagogy for complex human behavior (Brooks,
1994). That is, a parsimonious approach to teaching complex or problem-
solving repertoires may reside in greater mastery and fluency of the more
simple components of the repertoire rather than a conception requiring an
internal picture or cognitive structure that heretofore has pervaded much of the
work in artificial intelligence and cognitive psychology (see also Johnson &
Layng, 1994).
Research Directions in the Basic Science

Four directions from the basic science that hold promise for education are:
(1) stimulus equivalence, (2) the matching law, (3) establishing operations, and
(4) verbal behavior [i.e., Skinner's (1957) conception of communicative behav-
ior]. These research areas did not begin in the last decade, necessarily, but their
potential application to education has achieved prominence in this period.
Stimulus equivalence research provides behavioral education with strate-
gies for teaching students stimulus-response relations that have the potential to
result in other stimulus-response relations that emerge without direct instruc-
tion (Sidman, 1986). The concept also provides a possible solution to the
question as to how children give responses that were not heretofore traceable to
environmental events. A lack of such data in the past led to the evocation of
internal mechanisms independent of environmental events by some (Bandura,
1977).
Most of the behavioral selectionistic approaches to curriculum have
treated different behaviors associated with the same stimulus as independent.
To wit, Lindsley's (1991) statement that "behaviors are independent" (see also
Davidson, 1978, for a treatment of the biospecificity of contingencies within
the same orgasm). Other and common approaches to curriculum assume, for
example, that if a child can point to a color, they can also name a color since
they have come to "understand" what is meant by the color. Or, when a child
identifies a term associated with a concept on a multiple choice exam, the child
has shown understanding. In those cases in which a child does not respond
with a construction response associated with their multiple choice response to
the same stimulus array, some psychological constructs invoke a "processing"
structure as solely at fault. Good behaviorally designed curriculums make no
such presumptions; rather, these curricula teach that responses are indepen-
dent, and when they automatically emerge, that is the exception rather than the
rule (Englemann & Carnine, 1982; Holland & Skinner, 1961). This has served
behavioral education well in the past, possibly explaining some of the good
results associated with these curricula. It should still serve as the rule of thumb
until the data show us otherwise. However, what stimulus equivalence offers is
the potential to identify certain instructional sequences that can explain and
therefore lead to new curricula and teaching operations. These can then func-
tion to produce new stimulus response relationships on the basis of the teaching
operations. Such findings would demystify some important areas of instruction
and multiply the effects of certain types of learn units on the acquisition of a
broad array of instructional objectives.
Matching Law
The matching law tells us more about the multiple sources of reinforce-
ment and multiple responses selected by those multiple reinforcers in the envi-
ronment (Herrnstein, Loveland, & Cable, 1976). The construct holds promise
for telling us about reinforcement control where there are multiple contingen-
cies operating, as is the case in classrooms and elsewhere. In a series of studies
over several years, Kelly (1994) found that by increasing the learn units received
by students who were self-injurious or assaultive, the latter responses could be
eliminated and recovered by manipulating the numbers of learn units without
using punishment operations, thereby changing both reinforcers and responses
as a result (Kelly & Greer, 1992). Thus for a student with few reinforcers and
few response classes, the addition of new reinforcers and new responses re-
sulted in the decline in the alternate response when both the alternate assaul-
tive-self-injurious responses and consequences were still available and not
punished. This is also still another step in the elimination of coercive processes
in education.
The matching law suggests that we need a greatly enlarged analysis of both
responding and reinforcement in the development of a more sophisticated sci-
ence of pedagogy and schooling. This data-based construct provides new strat-
egies for the classroom, and schooling as a whole, particularly as we seek to
incorporate the teaching of contingency management to students as the process
of self-management (Greer, 1994a,c).
Establishing Operations
Michael (1982) provoked new interest in the study of motivation or what
he termed motative variables, with special attention to the concept of the
establishing operation that was first introduced in Keller and Schoenfeld
(1950). Establishing operations are now known as the key to the emission of
the mand verbal operant or "spontaneous speech" (Lamarre & Holland, 1985;
Sundberg, 1985; Williams & Greer, 1993) and the probable function of tactics
like time-delay (Halle et ai., 1981). Establishing operations are not restricted to
verbal behavior, however, but can be invoked for use in tactics for training
discriminations (McCorkle & Greer, 1994) and increasing food consumption
by children who did not swallow or ate less than they should (Greer, Dorow,
Williams, McCorkle, & Asnes, 1991). The establishing operation is also re-
lated to response deprivation (Aschelmann & Williams, 1989), wherein de-
pressing a response opportunity below baseline rates acted to evoke the previ-
ously nonpreferred activity to function as a reinforcer momentarily for another
response (see also Premack, 1971).
The construct of the establishing operation provides the strategies and
tactics for creating momentary reinforcers, when others are not available at the
moment, by the application of brief environmental operations that can be used
by a well-trained teacher as needed. The construct also suggests strategies that
may be used to make use of competing contingencies when those competing
contingencies interfere with instruction. The construct provides new resources
to determine the motivational variables associated with imitation emitted by
young children (McCorkle & Greer, 1994). Perhaps the renewed interest in
motivation will even provoke interest once again in conditioned reinforcement
as an objective of instruction and as a potential source for generalized stimulus

control.
Verbal Behavior
Verbal behavior was the contribution that Skinner himself believed was his
most important (B. F. Skinner, personal communication, March 17, 1977). Yet,
it has only recently received the attention that it justly deserves. Catania, Mat-
thews, and Shimoff (1982) demonstrated that the theory of verbal behavior was
a rich repository for explaining reinforcement schedule effects with humans.
Moreover, his work suggests a kind of "contingency-shaped" control by verbal
behavior.
Lodhi and Greer (1989) showed that young children can serve as both
speaker and listener in an incipient form of self-editing. In the comprehensive
application of behavior analysis to schooling (CABAS) schools, we use written
forms of self-editing to teach problem solving as written verbal behavior (Hog-
in, 1994) and the existing verbal repertoires of students to determine instruc-
tional grouping rather than age levels alone (see Greer, 1994b).
The analysis of the controlling relations of verbal behavior over nonverbal
behavior and the training of such relations hold promise for the analysis of self-
management as verbally controlled contingency management once verbal and
nonverbal correspondence is in the student's repertoire. The constructs embod-
ied in verbal behavior promise new means and new objectives for curriculum.
A SELECTION 1ST-DRIVEN SCIENCE OF SCHOOLING
There are signs that our applied science of education has moved beyond
pedagogy to embrace the concept of a science of schooling in addition to that of
pedagogy. One piece of evidence of this trend is embodied in the work of
Greenwood et al. (1994), as well as other scientists at Juniper Gardens. It is also
evident in the systems approach in the CABAS model of schooling developed by
the scientists at Columbia University's Teachers College. Both of these ap-
proaches move beyond the classroom into the school as a whole and the sur-
rounding community as sources for contingency analyses of schooling as a
larger enterprise.
A Theory of the Prevention of Developmental Retardation

Seminal work by the Juniper Gardens group provides a strong data-based
argument of the importance of opportunity to respond in the school and in the
home as a means of explaining the cumulative effects of inadequate schooling
on developmental retardation possibly even at the generational level.
We face the well-known, persistent, diverging developmental trajectories in
basic skills; that is, the gap between low- and high-SES students. This gap is
not just a static difference in the skills of the school, however, with increas-
ing age, it becomes a gap in academic competence, standard of living, and
quality of life that is transmitted from one generation to the next. The
lifelong effects of poor instruction for the learner and society are transfer-
able to the larger society in terms of a lower collective pool of basic aca-
demic skills. (Greenwood et aI., 1994, p. 215)
While their data have not yet included all of the cross-generation evidence,
it is close at hand and their theory has an existing array of compelling data.
Their research affirms that opportunities to respond are as important in the
children's homes as they are in the school. A daily loss of opportunities to
respond (and we add lack of complete learn units) for students from low-
socioeconomic status schools and homes has a cumulative detrimental effect
that is multiplicative, not just additive. The result is that the lack of adequate
instruction in the schooi coupled with inadequate learning opportunities in the
home lead to disastrous outcomes. When these effects are transmitted from
generation to generation, the results paint a dire picture for everyone.
I suggest that their data also indirectly point to the declining effects of the
existing educational practices for schools that must educate an increasingly
diverse population. Perhaps our schools are no better or worse than they ever
were; they simply must be better for the current demands of students and
society. Schooling that teaches to groups and serves only to select out those
who have better learning opportunities in the home just does not work! While
some educators have noted that the call for educational reform has been contin-
uous throughout the recorded history of schooling at every level, and the cur-
rent call for reform needs to be viewed in that light, the Juniper Gardens data
support the contention that the current need for reform is not exaggerated.
Moreover, the need is for more effective pedagogy in the schools and the home
if we are to stem the rising tide of failure.
These data and the theory point to the need for a systemic and broadened
view of schooling, one that incorporates the home as well as the school. If we
are to provide a broader analysis of pedagogy to include the home, perhaps
there is a need to look at all of the roles of the school and the community in
terms of an expanded study, not only of pedagogy, but also of the controlling
variables associated with schooling-an enlarged contingency analysis. I use
the term schooling to mean all of the pedagogical, management, and adminis-
trative processes and their outcomes that impinge on the impact of the school
and the home on the acquisition of repertoires that the school is to produce.
Schooling, as we define it, includes pedagogy in the school and home as well as
the interlocking contingencies between school professionals, parents, and the
community at large.
At Columbia University's Teachers College, we have inductively arrived at
that conclusion after over two decades of research in ever-wider applications of
behavior analysis, first to classrooms and then to entire schools. With each
application, we have expanded the components of what we mean by schooling.
We characterize our work as a behaviorological systems approach to schooling
and use the acronym CABAS (i.e., comprehensive application of behavior anal-
ysis to schooling). The system is the interlocking relationships between these
components, and our behaviorological systems approach invokes the science of
the behavior of the individual at all of the relevant levels as the method of
analysis and intervention.
The CABAS Systems Approach

The data base for the model is summarized elsewhere and I shall not
attempt to reiterate that work here; rather, I point the reader to the relevant
summaries and their references (Greer, 1992, 1994b). The most recent version
of the system includes students, teachers, parents, supervisors, administrators,
psychologists, speech therapists, the university, and the community at large as
represented by the boards of the school. CABAS is a learner-driven systems
model, and the parents and the students are the primary customers, with the
needs of the community as objectives that serve the parent and student best.
How does one ensure that these statements are forms of verbal behavior that
control our day-to-day activities? We do this by maintaining continuous mea-
surement of the instructional, supervisory, and administrative outcomes, to-
gether with continuous contingency analyses.
The student measures include all of the learn units received, including
correct and incorrect responses in allotted school time and objectives achieved
by each student in each curricular area. The teacher measures are the multiple
teacher rate-accuracy observation scores collected daily and weekly and the
learn units taught and objectives received in each teacher's classroom weekly.
The supervisor measures include all of the objectives and learn units for all
classrooms and rate per hour of tasks accomplished that have the potential to
increase student learning or that result in services (Greer et aI., 1989). The
parent measures include their learn units in parent education instruction, cor-
rect-incorrect responses, and the objectives that they have achieved as well as
the learn units and objectives that they have accomplished with their children.
The measures for the board and the community include the learn units, correct-
incorrect, and objectives for the students, teachers, parents, and the supervisors
that were achieved each year. These measures are used to provide a cost-benefit
analysis annually by dividing costs by learn units and objectives achieved
(Greer, 1994d; Greer et aI., 1993).
There are four curriculums. They are (1) the students' curriculum and the
related inventory, (2) the teachers' curriculum (individualized and delivered via
the personalized system of instruction [PSI]) and module portfolio, (3) the
supervisors' curriculum and module portfolio, and (4) the parents' curriculum
and inventory. The student curriculum involves a spiral introduction of academic
and social objectives by standard curricular categories and by verbal behavior
repertories. These are also arranged according to progressive academic mastery-
fluency categories, progressive self-management or contingency management
repertoires, and by a listing of the students' communities of reinforcers.
The teacher curriculum includes individualized objectives based on the

teachers' existing repertoires and the types of students in their class. The curric-
ulum is arranged for each teacher in clusters of ten modules at a time. Each
module includes three components: (1) concepts of the science (verbal behavior
about the science), (2) classroom practices (contingency-shaped repertoires),
and (3) strategic contingency analysis repertoires (verbally mediated reper-
toires).
The supervisors' curriculum includes advanced pedagogy repertories like
those of the teacher and individual professional and school-wide targets. Cur-
ricular objectives for the parents, teachers, and supervisors are arrived at mutu-
ally by the parties involved. All of this must be done in a mutually reinforcing
environment such that each role results in reinforcers that serve the students
and all of the other members of the community.
To date, we have been successful to various degrees in seven schools in the
United States and one residential program in Troina, Italy (Greer et aI., 1989;
Lamm & Greer, 1991; Selinske et aI., 1991). Also, we are currently involved in
a small way with three public school systems in New York State. All of the
schools served students from all economic and ethnic backgrounds and the
schools were all publicly funded. Most have been small privately run schools
for students with public funding and the students have been classified as having
various handicapping conditions. Our new applications have been with stu-
dents with no developmental handicaps but with behavioral or "learning dis-
ability" classifications. Our data to date show four to seven times more learn-
ing after the system is put into place compared to the baseline (Greer, 1994b;
Greer et aI., 1989; Lamm & Greer, 1991; Selinske et aI., 1991).
What is our most important discovery? I believe it to be that in order to
have maximally effective schools we must use our science continuously on a
systems-wide and strategic basis. This step moves us from building a science of
pedagogy to building a strategic systems science of schooling.
ADVOCACY EFFORTS AND OTHER INDICATIONS

OF INCREASED EDUCATIONAL ACTIVITY
There is evidence that the members of our scientific community have been
increasingly more active in educational matters, including a number of activ-
ities that can be characterized as advocacy. First, what indications are there that
our science is more actively involved in scientific issues for pedagogy and
schooling? During the decade, several milestones have occurred that suggest
that behavior analysis is increasingly involved in research on education. First, a
new journal devoted to education exclusively was inaugurated. The Journal of
Behavioral Education has provided behaviorists in education with a forum
devoted exclusively to pedagogy and schooling. During its first year it received
submissions in quantities that were comparable to those of the Journal of
Applied Behavior Analysis (N. Singh, personal communication, June 1993).

The number of submissions have continued to rise and the number of data-
based papers now exceeds commentary.
There are several factor that have contributed to this success. First, a
significant number of the members of the Association for Behavior Analysis list
their occupation as educationally related. Much of this is probably related to
the elevated position that behavior analysis holds in special education, where
behavioral operations constitute the pedagogy of choice. We may conclude that
there are a significant number of educators who describe themselves as behav-
ioral educators. If behavior analysts are to influence education, they must be
there as full-time members of the educational community, not as visitors who
simply assist teachers (Greer, 1992). There is evidence that we are doing just
that.
Teachers as Strategic Scientists

The educational papers in the early issues of the Journal of Applied Be-
havior Analysis reported studies that introduced tactics to improve the lot of
the teacher. The behavior analyst was a visiting consultant in the classroom.
The early work of Hall and his associates, however, predicated the develop-
ment of the teacher as researcher and eventually as strategic scientist. This
trend was enhanced by the efforts of the precision teaching group who place
the teacher in a data-based decision-making role. Direct instruction brought
curricular matters into the behavioral fold and developed procedures to main-
tain the quality of teacher uses of the direct instruction curricular material.
More recently, the ecobehavioral group has looked to the classroom to find
existing practices that work. The CABAS effort seeks to build teachers who
are sophisticated strategic scientists of behavior and supervisors who are not
only scientists of pedagogy but also scientists of schooling. All of these efforts
suggest the promulgation of teachers as strategic scientists. This differs from
behavioral research done by psychologists who are assisting teachers who are
scientifically naive.
Interest in Educational Research in Behavior Analysis

Evidence of the interest in behavioral research in education includes the
following milestones. The Journal of Behavioral Education (jOBE) devoted an
issue to the contributions of B. E Skinner to educational innovations that
summarized the status of the behavioral models of education. The renewed
interest in education has also been reflected in the Journal of Applied Behavior
Analysis (jABA). In 1992, JABA published a special issue devoted to education
entitled, "Behavior Analysis and the Educational Crisis." JABA also published
a collection of articles devoted to behavior analysis and education (Sulzer-
Azaroff et ai., 1988). Taken together, the increase in publication activities sug-
gests that there is significant research actlVlty in the field; admittedly, the
majority of that work involves students with handicaps.
The second conference at Ohio State University on behavior analysis and
education was devoted to "measurably superior tactics," and the proceedings
of that conference have played a significant part in this chapter. Chapters in the
proceedings summarize important activities, ranging from efforts with infants
and toddlers to effective interventions for stemming the tide of adult illiteracy
(Johnson & Layng, 1994), to interventions with college students (Jackson &
Malott, 1994). Those involved with using behavioral tactics to teach behavior
analysis have formed an active significant interest group (SIG) in Association
for Behavior Analysis (ABA) and have reported on data in the last two ABA
conferences. Summaries of the research in precision teaching (Lindsley, 1991),
programmed instruction (Vargas and Vargas 1991), direct instruction (Becker,
1992; Kinder & Carnine, 1991), CABAS (Greer, 1992), and the personalized
system of instruction (Buskist, Cush, & de Grandpre, 1991) suggest vigorous
activity. Precision teaching has also reactivated its journal and its annual con-
vention.
Advocacy
Efforts that qualify as advocacy in the last decade include: (1) the report
commissioned by the ABA on the "Follow-up on Follow-through," showing the
neglected finding that behavioral strategies were superior, particularly those of
direct instruction (Greer et aI., 1984); (2) Skinner's (1984a) paper noting the
neglect of behavioral strategies at a time when our schools were in obvious
crisis; (3) the formation of a committee to determine the position, if any, that
ABA might take on education (Barrett et aI., 1991); (4) the completion of an
issue of Youth Policy (a journal published particularly for the nations' lawmak-
ers) devoted to tested behavior analysis strategies and models for education; (5)
the use of educational reform as an annual conference theme for ABA at its
1993 annual convention; (6) the publication of the position of ABA on educa-
tion in a pamphlet entitled, "Rights to Effective Education" (Barrett et aI.,
1991); and (7) numerous editorial commentaries advocating the adoption of
behavioral strategies to salvage schools in the United States (Axelrod, 1991;
Lindsley, 1991).
While the advocacy efforts have taken a decade from inception to fruition
in some cases (i.e., the formation of the committee to determine ABA's educa-
tional position to the publication of the pamphlet on the "Rights to Effective
Education"), the fact that the effort has been maintained across the decade is, I
believe, a positive sign. It is important that the advocacy remain procedures-
oriented rather than another professional trade advocacy. The latter type of
advocacy results in status maintenance, and the harmful effects of status main-
tenance have been detrimental to most, if not all, attempts to engender effective
systems approaches to schooling (see Bushel & Baer, 1994).
CONCLUSIONS AND CAUTIONS
We have acted to save our schools over the last decade-both as scientists
and as advocates of a science of pedagogy and schooling derived from and
contributing to a science of the behavior of the individual. First, our science of
pedagogy is converging on a robust measure of schooling that combines the
behaviors of the student and the teacher. It is a measure that predicts schooling
outcomes and suggests valid ways to determine the costs and benefits of various
pedagogical and schooling efforts. Second, several new tactics have been devel-
oped, including operations that expand our pedagogical arsenal for academic
and social instructional. The behavioral models of schooling have made new
contributions to our capacity to build better schools. New journals and impor-
tant conferences have developed from the educational thrust in our science.
Behavioral educators constitute a significant proportion of scientists. Third, we
have made important changes in our epistemology and developed at least three
new research-driven theories that look more like new behavioral principles
everyday. We have seen how these latter changes are particularly important for
our educational efforts. Our science has been more frequently characterized as
behaviorology. Educators, psychologists, social workers, and other profession-
als draw from and contribute to that science. Fourth, we have expanded our
science of pedagogy to incorporate a larger vision of schooling. There are even
signs that we are developing a science of schooling as well as expanding our
existing science of pedagogy. Fifth, we have made some consensus-based efforts
to advocate for a broader dissemination of what we know could improve our
schools.
While we cannot point to an impact on national efforts to reform Ameri-
can schools, we are more capable of doing so now than we were 10 years ago.
What if "the powers that be" had eagerly embraced all that we knew at the
beginning of the decade and we were given carte blanche to fix our schools? If
the educational platform of ABA ("Rights to Effective Education") had been
made the national credo for American schools, we would have made some
important strides. Direct instruction curricula could have improved our literacy
rate for sure, and we would have more precision teachers, personalized system
of instruction tacticians, competent programmed instruction experts, CABAS
experts, ecobehavioral experts, and applied behavior analysts who were expert
in education. This would have resulted in better educational outcomes, but we
would not have built American schools that could maximally incorporate our
science. Why do I believe this to be the case?
We simply did not know enough. We could not have provided enough
experts to accomplish the task, even though much expertise existed. We needed
to know more about the environments of schooling, effective measures of edu-
cational outcomes, a more global knowledge of the contingencies of schooling,
a more precise epistemology, better environmental explanations for self-man-
agement, problem-solving, the development of self-editing repertoires, to men-
tion a few deficits in our schooling science. Most of all, we did not have a cadre
of behavioral educators. Generally speaking, we were still behavioral educators
dropping into schools for a brief visit at the beginning of the decade. In the last
10 years, more of us have taken up residence in schools. We now have special
expertise in schooling from the perspective of educators who are both strategic
scientists of pedagogy and strategic scientists of schooling.
While we still cannot save all of our schools, we do have the know-how to
save a few. If we do so and continue to expand our science, we can save more.
Who knows, perhaps we will get even more requests to do so. If we do, we can
do much better than we could have done a decade ago. We few have acted to
save our schools. Perhaps more educators, parents, and school boards will join
our effort in the next decade. If so, more contingencies will fall into place for us
to act more effectively and more widely.
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10
A University for the

Twenty-First Century
E. A. Vargas
INTRODUCTION
We all know the picture well. Each year hundreds of thousands of students
enter institutions of higher education: universities, technical schools, state and
private colleges. Many drop out and many are dropped out. Most achieve less
than they are capable of accomplishing. These outcomes underline the dismal
quality of higher education. The failures are not personal. They are institution-
al. Many of the brightest and the best are dimmed and diminished by the
instructional organizations they enter.
The portrait fits every country. Academics continually pilgrimage to other
countries in the hopes that they will find a solution for their higher education
problems at home. Delegations of Japanese professors visit universities in the
United States and delegations of American professors visit universities in Japan.
French academics visit English universities. English academics visit French
universities. They observe each other's teaching practices. They discuss com-
mon problems. They hold international conventions, international conferences,
and international workshops. Visiting academicians arrive and propose solu-
tions to the host country's educational problems. Their hosts nod, looking for-
ward to the opportunity when they can go and pose solutions to the educational
problems of the visitors. The opportunity will arrive easily and soon enough.
E. A. Vargas • Department of Educational Psychology and foundations, West Virginia Univer-

sity, Morgantown, West Virginia 26506.
159
Everywhere, everyone encounters the same problems of ineffective teaching.

Everywhere, everyone tries to solve it with similar solutions. Everywhere, de-
spite everyone's best intentions and their most exuberant rhetoric, the problem
remains unsolved.
Many solutions to the teaching problem have been offered. The proposed
solutions fall into three categories: requirements, tools, and market forces
(Vargas, 1988a). Requirement solutions are simple: increase standards for
people so they would conduct themselves properly, and then the problem
would be fixed. The reformers demand that teachers teach better, that students
study harder, that administrators manage more wisely, and that parents social-
ize more effectively. Obviously, requiring more from everyone does not work.
Many students, teachers, administrators, and parents are trying their best and
still not succeeding. Tool solutions enthusiasts promote every new communica-
tion gadget as the salvation of the teaching enterprise. The computer is now
hailed as the latest savior. Just press a key and a package of instruction, perfect
in prescription, will be delivered without having to put up with the messiness of
the teacher's inadequacies. But what the computer presents is only as good as
whoever programmed the presentation. Tools, from erasers and chalk to multi-
media centers, do no more than our capability to teach well. Tools only deliver
what has been designed for them. Market solutions promoters wish to arrange
the economy, through vouchers or other means, to operate like an invisible
hand to cull out those schools that cannot teach and to sustain those that can.
But millions of parents already pay as much as they can afford for the most
expensive education chargeable at universities and colleges that choose only the
finest students. These selective market-arena schools teach no better than any
other. All three putative fixes-increased requirements, better tools, and un-
leashed market forces-have long been suggested and still are proposed. All of
these fixes have been tried without success.
None have worked. The large number of students-often rigorously se-
lected-who fail provide all the evidence needed for that conclusion. And none
of the solutions offered will work as long as people attempt to solve the prob-
lem from the traditional perspective of human behavior, with the customary
technology of teaching, and within the framework of the current organizational
structure.
THE CONVENTIONAL WISDOM: BEHAVIOR, TEACHING,

AND ORGANIZATION
Everyone demands of the educational establishment that its effect on hu-

man behavior not be by magic and not be by chance. Whatever else instruction
is, it must be a rational and systematic effort to change human beings; specifi-
cally, to change their repertoires. And it must accomplish more than simple
change; the change must predictably improve those repertoires. Individuals
who formerly could not, would now describe the relation of geographic isola-
10 • TWENTY-FIRST-CENTURY UNIVERSITY 161
tion to speciation, discuss the implications of monetary policy to inflation, and

point out the use of Russian folk music by Rimsky-Korsakov and Stravinsky.
Institutions of higher education must produce persons with better repertoires
than those demonstrated at entry.
How higher education institutions attempt to change people by improving
their repertoires reflects how those given the responsibility to teach interpret
behavior. Interpretation is inescapable. For of the essential three components in
the teaching situation, two consist of behavior. One component is the curricu-
lum: what must be learned. A second is the teacher who engages in the behav-
ior of teaching what must be learned. A third is the student who engages in the
behavior of learning (Figure 10.1). How the men and women who make up
educational organizations deal with these components depends on what they
define as responsible for the behavior with which they must work, their own
and others. Based on their explanation, often intuitive, they set up teaching
technologies to produce the performances they desire.
Behavior: The Transformation Paradigm

Technological applications such as teaching are driven by the dominant
paradigm of explanation within the behavioral sciences; currently, the transfor-
mation paradigm. Stripped to its essentials, it asserts: Some sort of physical
event in the environment impinges upon the sensory apparatus of the organism.
This apparatus, such as an eye or ear, converts physical energy into the organ-
ism's type of physiological event. The physiological event is further modified by
more central structures and processes, some assumed and some verified, inside
the organism. The modification is called a perception. What the organism
perceives in that physical event, now a stimulus input, is represented in how it
responds both externally and internally. The structures and processes that mod-
ify stimuli further transform the perception into types of information that are
stored and which then or later initiate responses, which when grouped, are
called performances (Figure 10.2).
What must be learned
Teaching behavior Learni ng behavior

Figure 10.1. The basic components of the learning situation.
Event
~
~
S { ~~,)}
Response
Figure 10.2. The transformation paradigm.
Teaching: The Presentation Model of Instruction

The transformation paradigm, stated or unstated, has led, and continues
to lead, to the traditional presentation model of instruction. In the presentation
model of instruction the faculty member presents information and students
receive it. The presenter controls the content of the information that is received,
controls the mode-usually oral and in person-in which the information is
presented, and controls the rate at which it is presented. The student receives
this input and displays various types of output, primarily in the form of test
scores (Figure 10.3).
Any of a variety of delivery modes of instruction exemplify the presenta-
tion model of instruction and its underlying rationale of transformation of
information, but the lecture procedure is most typical. (However, what occurs
in any delivery mode of instruction is explained the same way. For example, a
discussion group is seen simply as an opportunity for the student to transform
information, but to do so in a more lively way, since it is asserted that that
modality encourages lively processing of what is said or shown to the student.)
In any university in any country, the "lecture," lasting more or less an hour, is
the most common form of presentation. In a lecture it is assumed that the
material presented means the same, that is, the same content is communicated
to every student. It is equally assumed that everyone will be motivated to
learn,that is, the instructor provides an assignment and the students provide the
responsibility for doing it. Those who do not learn are failed on the basis that
Transformation
Input source Input processes Output
J
Information ---I"'~ J--..... Performance
Figure 10.3. The presentation model of instruction.

they were incapable or were undesirous of learning. They thus deserve to be

failed. I remember, when I was an undergraduate, a large class of several
hundred students, perhaps a thousand, where on the first day the instructor
appeared on the stage, flanked by his graduate assistants. His first words were,
"Look around to your right and left. One of those students will be gone by
midterm." His attitude was more than complacent. He seemed almost pleased
at the prospect, since the rest of his speech addressed the rigor of the course, not
what anyone was to learn. And the seats around me were empty by midterm,
and emptier yet by the final. Failures are individual. But the presentation model
treats students as all alike for the instruction they receive.
The presentation model of instruction thus leads to batch processing of
students. The students are organized by groups to encounter the same informa-
tion in the same modality and at the same rate and at the same time. The batch-
processing procedure holds equally true even when material is presented with a
high-tech tool such as the computer-the student cannot control the type of
material presented and the rate at which it is presented. And batch processing is
clearly apparent in that ornate presentation mode known as "multimedia,"
since most multimedia presentations are designed within the framework of the
lecture procedure of instruction. A multimedia presentation batches students
together for a lecture session with visuals.
In turn, batch processing enjoins certain outcomes in the framework of
physical plant, instructional time, and subject matter quantity. The architecture
of school buildings accommodates batch processing. Buildings, sometimes with
special titles such as "auditoriums," "theaters," and "multimedia centers,"
consist of spaces with chairs where batches of students are collected for instruc-
tional presentations. The school calendar complies with the logistics of batch
processing. Everyone starts a unit of instruction on the same date and contacts
it over the same frame of time, such as a semester or a quarter or even a week,
and the same ending date is set for everyone. Since within that time framework
no basis, and thus no standards, exist for how much material is to be presented,
the amount of subject matter presented differs from instructor to instructor,
from department to department, from discipline to discipline, and from year to
year as departments and faculty change. Credentialing in the same subject
matter only vaguely represents what was achieved at different times by different
instructors.
Such vagueness is exacerbated by the evaluative techniques of the presenta-
tion model. Evaluation consists, typically, of grading on the normal curve, and
the possibility that all, or even a majority of, students can be brought up to
levels of excellence is derided by the charge of "grade inflation." Such an
accusation would be appropriate if there were a real standard of grading. But
there is none. The current grading system disguises the failure to teach effec-
tively. Grading on a curve allows shifting of standards to accommodate the
results obtained. An instructor can always appear to maintain rigorous stan-
dards simply by shifting the cutoff points on the curve for the different grade
labels. Furthermore, the instructor can easily disguise the failure to teach by
using an average that always produces a few "As." The students are not com-
pared against a standard of what they should know and what they should be
taught. They are only compared against how other students performed. Thus,
even the" A" grade, much less any other, is suspect with respect to the quality
of the repertoire it implies. A student may be ranked as excellent, an "A," in his
or her repertoire, but possess an inadequate command of the subject matter,
even as judged by the instructor's own rating scale. These scales shift according
to quality of students, demands of instructors, and even fiscal and political
pressures on an educational institution. It is no surprise that there is no correla-
tion between undergraduate grades and later occupational success. Underpin-
ning the ineffective technology of instruction in higher education is an inade-
quate and misleading method of measurement.
Largely as a result of this means of measurement, which misses the oppor-
tunity to improve teaching behavior immediately and directly, efforts to im-
prove teaching performance come largely from outside the arrangements for
instruction-the typical presentation type of course structure. Faculty are
urged to do better. Rewards are offered-more money, a higher position, dis-
tinction. Penalties are given for ineffective teaching-threats, no promotions,
unpleasant teaching assignments. But nothing works. For example, the doctoral
program of a university department was suspended. After over 2 years of
committee meetings-among faculty, among administrators, among faculty
and administrators-both faculty and administrators finally agreed on a new
graduate program of presumably better quality. But the same subject matter
continued to be taught in the same way. The faculty merely changed the labels
of their courses. Such outcomes are not uncommon after every brave new effort
at curriculum and teaching reform. University instruction continues at its same
level of quality despite Teacher-of-the-Year awards (what if every teacher were
excellent?), end-of-the-semester student questionnaires, up-and-over work-
shops, and hortatory wisdom circulars from teaching centers.
These efforts at quality control fail because faculty members and adminis-
trators observe only the final result of however the student learned. They typ-
ically cannot and traditionally do not observe what produced the learning. The
faculty member and administrator operating with the presentation model ob-
tain samples of the student's repertoire, after it is in place, at the end of an
instructional unit. Only at that point do they find out, very roughly, how much
or how little the student knows. They can only guess, quite tenuously, why the
student might or might not have learned. Such sampling of students' perfor-
mances occurs on at least one occasion, most often only two or three. The
sampling instrument is the same for all students, lasts the same amount of time,
and is given at the same time. The sample of the student's performance is
matched against a template of correctness and ranked according to how other
students performed in terms of that template. Depending on the degree of
match and relative ranking, a student's performance receives a qualitative label
that designates how successfully the student "acquired" what was presented.
Those who are successful, even though they may not know much, are moved
along and finally certified with the same diploma. Those who did not meet the
minimal standard go into the reject bin and at some point are dumped out of
the university. In the presentation model of instruction, even with repeated
presentations of the same course, neither the quality of students' performances
nor that of faculty presentations improves.
Organization: The Disciplinary Structure

The organizational structure of the university grows out of the instruction-
al assumptions and logistical procedures of the teaching technologies of the
presentation model. The division of labor for teaching is simple: people expert
in a subject matter. The disciplinary structure of the university presumes
"teaching" to be synonymous with "presenting a subject matter." There is
therefore one academic faculty: subject-matter experts who are brought to meet
with students in order to transmit knowledge and who are expected to engage
in research in order to maintain and advance knowledge. This organization
structure gives no allowance for the expertise and amount of time necessary to
deal with the complexity of instruction and of student differences.
Conclusion
Regardless of how much poetry is expressed about the uniqueness of each
student and about enhancing each student's problem-solving and creative po-
tential, the transformation paradigm produces technologies of "teaching," lo-
gistical arrangements, evaluation procedures, and organizational structures
that give little or no room for the variation in student repertoires. It also does
not allow for the variation in teacher quality. The presentation model assumes
equal knowledge, skill, and desire to teach, but more importantly, provides no
means by which those presenting can become better at instructing. It is no
surprise that, based on transmission of information, focused on presentation,
and dependent on disciplinary knowledge, such a teaching technology and its
organizational structure have failed. They will continue to fail-regardless of
objectives, regardless of assessments, and regardless of incentives. These efforts
attempt to adjust, even coax, the technology and the organization to better
performance. We must no longer try to tease out more performance from the
persistent failures. We must put in place an entirely new model of teaching and
its attendant university structure.
A NEW UNIVERSITY MODEL: ACTIONS, SHAPING SYSTEMS,

AND STRUCTURE
To put in place a new university system requires a revamping of our think-

ing regarding behavior. The buzz of the buzz phrase "cognitive revolution" has
deafened the realization that no revolution in substance has occurred, merely a
relabeling of the stimulus-organ ism-response analysis that reaches as far back

as the earliest speculations on why people behave as they do. The traditional
analysis depends on agencies within the person to interpret the world it en-
counters-its stimuli-and then based on that interpretation, those agencies
determine the person's performances-its responses. But if a person and its
presumed causal agents are not made the axis of analysis, then an alternative
framework of explanation presents itself. [For further discussion of these
points, especially with reference to the science of behaviorology, see Cook
(1993) and Vargas (1991, 1993, 1994b).]
Actions: The Contingency Paradigm

The alternative explanatory framework by which we can understand be-
havior, and thus derive a different model of instruction, is the contingency
paradigm. Its governing assumption is that actions are contingent on events
both accidental and designed. This ordering of explanation focuses on the
variability of actions and on selection processes that over time shape behavioral
properties. The focus follows Darwin's (1859) analysis of the change of species
over time and his explanation for those changes through natural selection.
Natural selection excludes, or perhaps more accurately, makes redundant a
prior agent for the change. Skinner's (1987) comparable analysis of individual
actions excludes the necessity of prior agents and uses the process of selection
by consequences to explain how contingent consequences, in the shifting and
complex context in which actions occur, change and shape those actions.
Contingency analysis begins with actions and the effect these actions have
on an immediate milieu. These actions are not responses. The starting point of
the analysis is not what incites the actions-what agent may be responsible.
The analysis starts with the actions themselves and how the consequences of
those actions alter the probability of their future occurrence. In short, the
increase or decrease of any activity is contingent on the result that follows from
it. When this two-term contingent relation occurs frequently in the presence of
a prior event, the event becomes paired with the two-term relation and the
event, in turn, either increases or decreases the chances of that two-term rela-
tion occurring. Further terms may be added to the basic formulation (for
example, the four-term contingency of a conditional discrimination) depending
on the degree of complexity of the analysis (Figure lOA).
The terms of analysis, the variables linked to each other, may refer to
events located either inside or outside the body. These events may be physical,
biological, or behavioral. Physical and physiological variables, such as those
involved in the operation of vision, are taken into account but only as their
effects contingently modify behavioral variables. How, for example, is an action
of "seeing" what is not present contingent on the prior consequences and the
current effects that are behaviorological? The contingent relations between
behavior and other events defines a system of variables, whose domain is
constrained only by the boundaries of the analysis. Since relations between
167
,
10 • TWENTY-FIRST-CENTURY UNIVERSITY
I ---------,
] -,
I''--1-,
1
1
..
;If
E
/
"-
E-{ I
I A..( I
L
C
I
"'C ...
'- L - - - --1
N-term contingency relations
A = Action
C = Consequence
E = Event
All arrow lines equal contingency relations
Figure 10.4. The contingency paradigm.
variables in the system are contingent, they are therefore probabilistic. Proper-
ties of behavioral events are a function of selection by consequences and the
situation in which this selection takes place, but there is no inevitability to any
action. Behavior may be determined, but the framework of explanation does
not assume nor require an epistemology of determinism.
Shaping Systems: The Shaping Model of Instruction

The contingency paradigm leads to a radically different model of instruc-
tion: the shaping model of instruction. The model addresses the most obvious
but most overlooked feature of any set of students-their variability. Students
vary in height and weight and hair color and skin tone and the dozens of other
physical features by which people are distinguished. But students exhibit more
than just physical variability. Behavioral variability also characterizes any stu-
dent group. Students vary enormously in what they do and how they do it. For
those who must teach a group of students, the pertinent aspects of the vari-
ability they encounter are those directly related to the subject matter (e.g., the
differences in what students know of it and how they differ in how well they
solve problems with what they already know) and those aspects that will
indirectly affect their performance (e.g., the differences in how well they man-
age their study time and in how much they differ in enthusiasm to learn a
subject).
Such variability demands an instructional technology that tailors instruc-

tional conditions to the differences of the pertinent behavioral characteristics of
students. No one would think of delivering the same size of suit to a class of
students and insist that all fit into it-somehow. Even uniforms are fitted to the
wearer. The same material, color, and style are used, but adjusted to the wear-
er's physical characteristics. Obviously, when a uniform subject matter is pre-
sented to a set of students, it must be adjusted to their behavioral variability. It
makes no sense to present the same material at the same time and in the same
manner to a set of students some of whom know the material already and
others who do not have the slightest inkling of what the instructor is talking
about.
As an instructional technology, the shaping model of teaching keys on the
variability of the individual characteristics of the student. In the design of
instructional conditions, the shaping model builds on those varying charac-
teristics in the following ways. When students encounter the content of a
subject matter, these students control the level at which it is presented. Depend-
ing on their performance (a host of factors here: rate of error, degree of interest,
and so on), students shift to more detailed levels of exposition or skip ones that
they already know. What should be learned is kept the same: objectives and
their standards; what varies is degree of exposition and type of instructional
activities and difficulty of exercises, and these vary according to student back-
ground. Logistics arrangements also vary for individual students: Students
access instructional material when they need it. Contact with a live instructor,
for example, is not necessarily at a set time or with a set number of other
students. Delivery modality types also vary, for what is important is not wheth-
er a given instructional modality is multimedia or some other, but the degree of
control the student exercises over that modality. Some students prefer, or learn
best, through listening or reading or seeing, or by combining these so-called
"learning styles." Students also vary considerably in how fast they wish to have
a subject delivered. A book is a good example of a teaching tool where students
can control the setting, the time, and the rate at which they contact the subject
matter. To whatever degree possible, the design of student control over instruc-
tional conditions takes into account individual differences. By facilitating indi-
vidualized control by students over the delivery arrangements of the material
they encounter, the shaping model of instruction controls student performance.
The shaping model instructs through student-paced modalities designed to
accommodate the entry level of students, the rate at which students learn, the
problem-solving skills they initially exhibit, and whatever aspects of creative
behavior (however defined) they demonstrate. Variability drives instructional
design in all dimensions of a student's repertoire across all components of the
technical means of instructing. But not only students vary.
Teachers and instructional systems also vary. Teachers come to an instruc-
tional arrangement with varying amounts of knowledge in the subject matter,
with varying degrees of skill in presenting it orally, with varying kinds of
sociability in dealing with students and their problems, with varying expertise
(usually nil) in how to use different delivery modes to organize and present a
subject matter, with varying sophistication in how to measure student perfor-
mance (most measures are merely a count and a percentile), and with varying
enthusiasm about the instructional task. The potential for variation also must
take into account the number of components possible within any instructional
system, the complexity of those components, and the interaction between
them. Despite this variability in those teaching and therefore an expected vari-
ability in how they teach, university courses exhibit few differences since most
simply operate within the framework of the presentation model. But eventually
in the shaping model, specific instructional outcomes exhibit the effect of its
inherent cybernetic characteristic.
The shaping model operates from feedback initiated by the interaction of
student behavior with instructional arrangements. Instructional arrangements
consist of the material that all students must learn at specified standards, the
modes that deliver the instructional material, the logistics that deal with differ-
ing transit speeds as students contact instructional material, the incentives that
maintain performance activity at a high level, and the measurement procedures
that record every student, teacher, and system interaction. As the arranged
instructional conditions change students' actions, these student actions in turn
change the actions of those who design the instructional conditions. The prod-
uct outcomes of teaching actions are the instructional system components fash-
ioned through consequating feedback. In the shaping model of instruction, the
behavior of teaching becomes shaped by the consequences of its actions. Not
only do students learn from a shaping system of instruction, but so do those
teaching (Figure 10.5).
It cannot, however, be expected that an instructional system just designed
t-
Outside the
Instructional system.
- and shaped by
biological and SQClal
conditions.
Figure 10.5. The shaping model of instruction.

within the framework of the shaping model will attain success immediately, or
that an instructional staff will immediately learn how to teach efficiently. Just as
the performance of students is slowly shaped, so is that of the instructional staff
and the instructional system. Improvement cumulatively builds toward a spe-
cified set of standards. The technical task of shaping a complex "repertoire" of
student, teacher, and system demands high standards, patience at not achieving
them at first, and an incremental means by which those standards can be
reached. The instructional setting should be seen as an opportunity to shape,
concurrently and cumulatively, three sets of behavior-those who are learning,
those who are teaching, and the system by which such learning and teaching
takes place. Such cumulative shaping requires cycles of measured effort.
It takes more than one iteration of an instructional system operating with-
in the shaping model of instruction to evolve the instructional technologies,
and their coordination, by which complex repertoires can be produced. It may
appear as if during that time that an instructional system is slowly being shaped
through its errors as well as its successes, and that therefore a certain number of
its students are consigned to failure. Let us look at this unavoidable fact in
perspective. Dawkins (1986), an evolutionary theorist, talks about how com-
plex organic forms and actions, the intricacy of the eye, for example, are
produced through cumulative selection. Such effects can occur through the
cumulative effect of natural selection given the availability of time. It allows
ineffective "characteristics" eventually to be weeded out, but is a wasteful
procedure. Cumulative selection is the current procedure in higher education.
Higher education institutions select the best repertoires for admission. While
other considerations may enter into admissions criteria, educational institu-
tions do not start by selecting those with the bottom half of scores in grades,
entry exams, and recommendations. Once in, students must teach themselves
(study skills is a misnomer for self-teach skills) for they mostly encounter the
PAT lecture procedure-present, assign, test. Those skilled at self-teaching and
skilled at self-management pass the courses. (Sometimes not; even with high
IQ's and hard work, many students are flunked in courses such as calculus or
poetry.) They are selected to go on by being given a certifying label of rank, a
grade. But no shaping by the instructional staff of the student's repertoire is
taking place. And certainly no cumulative shaping of the instructional system
occurs. With cumulative selection, no systematic improvement occurs in teach-
ing technology. With cumulative shaping, little by little, proficiency in teaching
effectiveness occurs, and slowly but surely, student repertoires, and their num-
bers, improve. I
Just as the lecture procedure exemplifies the presentation model, a cu-
IThis may be as good a place as any to mention that the distinctions between natural selection and
cultural shaping, at least as exemplified in a process such as cumulative shaping, are at least three:
(1) an immediate prior improvement within the lifetime of a given repertoire is passed on to
another; (2) an objective and its standard are denoted in advance against which the shaping of
behavior is assessed; and (3) there is no necessary change, for future cultural effect, in the
biological substrate at which a given repertoire may be located.
mulative shaping cybernetic (esC) system exemplifies the shaping model. Each
type of instructional technology requires its own setup. A detailed description
of a particular ese system, however, takes us outside the scope of this chapter,
especially since a given ese system reflects the concerns of its designers and the
needs of its setting and students. Furthermore, the consecutive feedback ar-
rangements for the three spheres of student, teacher, and system behavior
demand powerful technologies, such as errorless learning procedures, at every
phase of an instructional operation. As a consequence, a given ese system
manifests a complexity whose vital details are lost when summarized. A hint of
this complexity can be illustrated by discussing, briefly, the significance of only
one process component of a cybernetic system, evaluation. Evaluation starts
with, and requires, measurable behavioral objectives.
Any instructor asks the question: What should students learn? More ex-
actly, at the end of a course of instruction, what should students do that they
could not formerly do? It would appear that no one should object to such
reasonable concerns. But many in higher education do object when those con-
cerns are given substance as behavioral objectives. Apparently there is a great
deal of misunderstanding about behavioral objectives. Most are written badly,
in that they are not behavioral. They address some vague quality such as
"students will understand such and such" without describing what it is that
students are doing that denotes that "understanding." But correcting a badly
written objective is merely a matter of better skill, and more importantly, of
the feedback arrangements that measure actions such as "understanding." A
more pertinent obstacle is the cultural resistance in educational institutions,
especially higher education, to specify in explicit terms what students should
do to demonstrate mastery of instructor requirements. The usual reaction by
those who argue against behavioral objectives is that such objectives kill the
heart and soul of what education is all about. They argue that objectives make
all students uniform in what they do, robotizing them to the point that no
room is given for imaginative and creative expression and for latent learning.
(The latter expression vaguely stands for what students learn on their own
when not explicitly taught. Apparently instructors who cannot, or do not,
teach students what they should have been taught can offer themselves the
consolation that students learn something anyway.) It should be found ironic
that those who deliver lectures-an instructional technology that deals with
students uniformly and that provides little give with respect to student varia-
tion-protest against measuring instructional effectiveness on the basis that
such measurement results in uniform outcomes. More to the point, all instruc-
tors have "objectives." They are operationalized in "tests." Any casual inspec-
tion of test items reveals the objectives of instructors. These instructors con-
flate their measuring instruments with their objectives. But more profound
reasons exist for specifying behavioral objectives (other than if implicitly there
they should be well done), and a bit of background is necessary to explain
why.
We must first consider what apparently is feared and that is a set of
identical student copies, all behaving the same way. There is merit in such an
objection. It implies that what is desired are differences between students; in
short, variation among them. Such variation presumably pays off in a greater
probability of effectively dealing with shifting future circumstances that no one
has fully anticipated. A uniform sameness in everyone implies a readiness to
behave the same way to a specified situation. If that specified situation changes,
then no one is prepared to deal with it.
Such an analysis has merit as far as it goes, but it does not go far enough.
Some actions will never need to change. Within a framework of specified rules,
a + b = b + a, will always be the case. For most individuals, in whatever
circumstances they find themselves, force equals mass times acceleration will
always be the case. Obviously differences among people with respect to the
similarity of these repertoires is not desired, for then later some students will
not deal as well as will others with a social and physical world for which those
identical actions are effective. The objection to behavioral objectives primarily
arises because it is cast at the wrong level of analysis. It focuses on students,
instead of actions. Some actions must be similar for all students, regardless of
where or when or who they are, and other actions must differ. Objectives are
written accordingly.
There are three goals or ambitions or aims-however one wants to put
it-that ·all instructors desire for their students. All instructors want their
students to be knowledgeable in the subject matter that is being taught. All
instructors want their students to be able to solve problems in what they
encounter with that subject matter. All instructors want their students to pro-
vide useful, unique expressions of that subject matter. In short, they want
students to possess knowledge, have problem-solving skills, and be creative.
These are the three basic types of repertoire any system of higher education
requires of its students: mastery of a subject matter, problem-solving skills in
that subject matter, and creative expression with that subject matter. Objectives
must address these three domains of knowledge, problem solving, and cre-
ativity.
With respect to the variation of student behavior, the objectives of a CSC
system must therefore meet two demands, which, on the face of it, appear
irreconcilable: convergence and divergence of the entering repertoires of stu-
dents. Student behaviors must be shaped both to be more and to be less alike.
On the one hand, however repertoires differ when first taught, by the end of
instruction they must demonstrate the same performance by converging to the
knowledge domain objectives. Actions are shaped to behave in a uniform way
and display a uniform topography. Convergence of varied student behaviors to
a uniform product is especially relevant in mathematics and the sciences. But it
is true for other subjects as well. There is only one right answer to how many
symphonies Brahms wrote. Regardless of what answer students may have given
prior to taking a music course, they end up, if taught properly, selecting or
saying or writing the right number. Obviously within any course, any instruc-
tor demands the same answers with respect to that instructor's defined tem-
plate of correct answers_ 2
On the other hand, creativity objectives demand that student actions differ
more when students leave than when they entered an instructional setting. The
objectives of the instructional staff is to increase the variation in student behav-
ior and bring about greater divergence. Perhaps in addition to being asked to
solve a given equation, students are taught how to provide a visual representa-
tion of an equation, then asked to provide an equation and its visual represen-
tation that differ from any seen in class and the text. Or having learned the
principles of musical composition, students may be asked to compose a short
piece in a style that pleases them. Either goal requires that each student furnish
a product that differs from that of any other student. Objectives in the creativity
domain designate divergence of end actions.
The problem-solving domain presents a more complex picture for shaping
convergence and divergence in behavioral variation. There are problem-solving
procedures that all students should know; for example, the algorithm for solv-
ing the quadratic equation. With these algorithms, a uniform convergence of
problem-solving activities results. Other problem-solving activities are not as
easily specified. They depend a great deal on how one looks at a problem. [For
an informal but insightful discussion, see Feynman (1985, 1988).] This variety
of problem-solving perspectives would be strengthened and enhanced so that
students would diverge even more in their manner of solving problems. Wheth-
er an instructional system must make more convergent or more divergent the
variation in behavior with which it deals depends on the performance domain
addressed, and that in turn decides how objectives are specified.)
Performance objectives address not only student performance, but esc
system performance as well. The range of objectives for student performance
lies in the knowledge, problem-solving, and creativity domains. The range of
objectives for CSC System performance lies in the process domains. Objectives
from the different domains of objectives of each range interact with each other,
so that, for example, knowledge domain objectives intersect with delivery
mode objectives. There are easily half a dozen ways for a student to encounter
the difference between gametes and zygotes. Content objectives cover what-
"It is not possible to penetrate further into the topic, but two points must be mentioned: (1) Al-
lowing a student to select from one of two or more alternatives any of which may be correct still
defines the range of selection responses that are correct, and such a consideration is also true of
constructed responses such as essays. The criteria by which matches to the instructor's template
are judged are simply more complex. (2) The noisy battles over curricular issues at every level of
the school system reveal the silent acknowledgment of desired uniform convergence.
'The cultural transmission models of Cavalli-Sforza, Feldman, Chen, and Dornbusch (1982, p. 20)
assert that "transmission through teachers increases homogeneity within a population and creates
greater variation between populations in space and time" than does transmission from parent to
child. An implication that resides in the statement is the outcome of effectively teaching objectives
in the knowledge domain: Those within a population are made more alike in what they know and
thus more different from others in any other population setting.
must be learned in the different domains of the student's repertoire and process
objectives cover how such learning will occur. These latter objectives address
types of activity in which students will engage and modes of delivery by which
instruction is presented.
To keep the illustration brief, one aspect only of the interaction between
content and process objectives will be described. It is well known that if a
student only reads and hears about a subject matter, it limits that student's
skill. To develop a sophisticated repertoire in any subject, the student must not
only hear and read what others say or write about a subject matter, the student
must contact it directly. A critical distinction prevails between behavior gov-
erned by what people say about a set of events and behavior governed by those
events directly contacted. Instructors pay rough attention to the distinction by
having labs and practicums and other hands-on activities, but instructors do
not systematically attend to the distinction between event-governed and ver-
bally governed behavior (Vargas, 1988b). Most instruction in higher education
consists of people telling other people what to think or say or write about a
given subject. Most of what students learn of a subject matter takes place
through what is said or written about that subject matter. But subject matters
can be arranged so that students directly contact the events being talked about,
even in subjects such as history and mathematics. The proper interaction be-
tween verbally governed and event-governed behavior combines what must be
learned quickly with what must be known uniquely.4 These process objectives
link to all content domain objectives. To ensure a full range of student experi-
ences, a basic instructional design matrix is set up, with type of content objec-
tives on one side and type of process objectives on the other. A number of
different matrices organize the variety of teaching arrangements that students
will encounter. Table 10.1 portrays one possible matrix.
Table 10.1 is not the only matrix that would portray interactivity between
content and process objectives. Other matrices would portray the relations
between content objectives in the different domains of student repertoires de-
sired-knowledge, problem solving, and creativity-and process objectives
such as delivery modes. The interaction between process and content objectives
suggests a range of delivery modes. Obviously if a student is to sketch a cell
from viewing it in a microscope, that is the delivery mode and the setting
should be a laboratory. Labeling from a picture presents the possibility of a
number of different delivery modes-a page, video, overhead, computer, and so
on. These design aspects should be noted because behavioral objectives proper-
ly handled promote a number of creative possibilities for instructional arrange-
ments. Finally, these matrices combine with other design parameters such as
cost. The third parameter of cost results in a series of three-dimensional ma-
4The experiences that others pass along with respect to a subject matter shortens the time in
learning its essentials, but also frames how a subject will be viewed. Interactions with the detailed
and ambiguous properties of a subject take longer, but shape an idiosyncratic proficiency.
Table 10.1. Content and Process Objectives Interaction
Process objectives
Knowledge domain Verhally governed Event-governed
COIltcnt O/Jlectives
I. Given a picture of a cell without Viewing a cell in a microscope,
labels, the student will name the student will sketch and
its various parts. label its various parts.
II. Etc. Etc.
Ill.
IV.
V.
Etc.
trices that cover all aspects of the objectives of an instructional system for the
system itself, for the teaching staff, and for the students.
Objectives help organize the design effort. The number of ways in which
students should be taught, and can be taught, are many. Each way addresses a
concern of both process and content experts. Most of these concerns are over-
looked or ignored in the traditional course. Connecting process and content
objectives ensures teaching arrangements that do not overlook any concerns.
But the most important aspect of instructional design when process and con-
tent objectives interact is the linking of measurement and evaluation indices to
the type of behavior taught to the student. In its most stark sense, such a design
principle should be easily realized. Students should not be asked to read a
manual on how to drive a car and then be tested on that manual by being put in
a car and asked to drive. In short, the student is not taught to react to the
subject matter material in one way and then tested in another way. Yet such an
instructional truism is commonly violated. It is easy to do so when instruction-
al design proceeds in the haphazard manner that is currently standard practice
in higher education.
The primary reason for specifying the objectives for a esc system is to let
everyone (administrators, other instructors, parents, the public, students) know
what is to be achieved and to facilitate measurement of what has been achieved.
Objectives are closely tied to the evaluative arrangements through which an
instructional team redesigns the esc system. Such redesign zeros in on the
effectiveness of the various components through which students are taught.
Defining explicitly the skills all students must demonstrate leaves no one in
doubt as to what students are learning. But how well objectives are being
achieved can only be assessed against a background of prior mastery.
A esc system obtains measures of the entry repertoires of all students. A

number of corollaries follow:
1. If instructors assess how well students perform before they are taught,
only then can how much any given procedure improves their performance be
known. It would seem common sense that instructors cannot take credit for a
high-quality performance on the part of a student if that student already knew
the material before it was presented.
2. Such entry assessment with each instructional system allows a proper
comparison between those institutions that select only superior applicants and
those institutions that accept all applicants, no matter how poorly prepared.
Equal success between these two types of institutions implies superior teaching
technologies in the second.
3. The students that lack prerequisite skills for the intellectual content of a
esc system shift to another instructional system in order to be taught those
skills. When students do not have the algebra skills to learn calculus, the wrong
way and the expensive way to find out is by having them do poorly in a calculus
course and fail, and thus waste their time and efforts. As important, and
typically overlooked in the celebration over so-called "tough grades," is that
with every inadequately taught repertoire (much less the failures) the organiza-
tion squanders resources. Such waste is inherent in the grading scheme of the
presentation model of instruction.
4. More appropriately, since esc systems aim for mastery of all objec-
tives, specific data on prerequisite skill deficits, and their effects, provide the
cost-benefit basis for not allowing inadequately prepared students entry into
the higher education system. Part of the resource allocation to higher education
is misdirected and therefore the allocation amount to higher education is mis-
leading when instead of going to instruction at the higher education level,
resources are allocated to the remediation of deficits from the secondary school
level. Such a fiscal practice shrinks the resource base for higher education and
lets the secondary school system off the hook. How student performance is
measured has public policy as well as labeling outcomes.
Measurement must be more than just grading a student product, such as a
test performance. It must serve evaluation. In turn, evaluation buttresses the
quality control function. When evaluation serves a quality control function, it
increases the quality of the product the organization is producing and increases
the quality of the operations producing that product. A standard is specified,
either for the product or the process that produces it, or for both. Measures are
taken of the product and of the process. The results of these measures are
compared against the designated values of the standard. If results match or
surpass the standard, efforts are made to sustain the match. If measured results
do not match, the discrepancy compels greater efforts to increase the quality of
the operation and of the product. These and other consequences drive efforts to
attain desired quality. Evaluation efforts linked in a feedback relation to the
technical processes of instruction-to the means by which process and content
objectives are achieved-defines the quality control endeavors needed, but

currently missing, in higher education.
Quality control efforts work differently with the instructional technologies
of the presentation and the shaping models of instruction. The focus in the
presentation model of instruction, as typified by the lecture procedure, has been
to improve and to control presentations, and through this improvement, pre-
sumably enhance student performance. The focus in the shaping model of
instruction, as exemplified in a CSC system, is on initiating quality control
procedures so that student, teacher, and system performances can be controlled
by the quality of their efforts in relation to each other's actions and to a set of
objectives.
CSC systems, crafted within the shaping model of instruction, create in-
ternal conditions that bring about quality control efforts as a natural part of
the teacher's job. Teachers directly and continuously contact the reciprocal
interaction of the student with the instructional material during the time stu-
dent performances are affected. Thus, they encounter what was responsible
for improvements, or lack of improvements, in student behavior, where such
effects occurred, and when they occurred. The intersecting contact of student
behavior with instructional phases becomes the shaping condition for instruc-
tional systems designers. A continuous measurement system allows the teach-
ers to acquire the data by which they can make a fine-grained assessment of a
CSC system in any part-instructional, fiscal, motivational. These data are
compared with the instructional system's objectives and their standards. Ad-
justments are made, and can be made, in any part of the system while it is
operating. There need not be an artificial time period, such as a semester, for
students to benefit from improvements in instructional arrangements. It be-
comes unnecessary and irrelevant to control teaching behavior from the out-
side. A preoccupation with quality becomes an integral part of the job. Curi-
osity and a desire to be effective become the driving elements for those who
teach. Quality control naturally ensues from the point-to-point contact be-
tween teaching behavior, learning behavior, and instructing conditions as the
outcomes of these contact interactions are measured against a set of stan-
dards. Effective teaching and thus enhanced learning intrinsically reward
teaching actions.
Blaming the student, as well as the faculty member, becomes irrelevant.
Instructional conditions are responsible for the learning that occurs, and the
drive for quality control initiates constant attempts to change those conditions
to obtain better results. leachers are put in a situation where they innovate as
an outcome of the teaching process. Quality control measures reveal discrepan-
cies between what has been achieved and what must be achieved. Let's say, for
example, that on the first cycle of an instructional system, a number of students
fail to meet a given standard. Since the students' performances were a function
of the instructional conditions, their performances can no longer be curved and
those on the bottom half dropped from further instructional effort. Something
different from what was initially attempted must be tried until an effective
procedure is found. The conditions bearing on teaching behavior do more than

promote innovative behavior. They impel it.
An innovation replaces a prior process by a different one. Quality control
is the means by which to assess the new process and thereafter maintain or
improve it. These means, primarily consecutive feedback interacting with quali-
ty standards, supply the data through which innovation takes place. Since
quality control procedures require a detailed and continuous measuring of the
independent instructional variables intended to produce learning changes and
of the dependent learning performances that actually were produced, those
teaching contact the effects produced as these occur and, more importantly,
continuously contact how those effects are produced. The data necessary for
appropriate actions become available "on-line" and available immediately. In-
structors try activities that may work, and find out quickly whether they do
work. A history of standardized innovations shapes effective instruction.
If this partial example of a CSC system appears rather complex, almost
overly complex, it appears that way because it is that way. Even so, the por-
trayal does not catch all of the complexity of the instructional situation. The
portion of the demands of the instructional mission with which faculty do work
is so simplified that it caricatures requirements. University faculty make a
simple effort on a complex task because it has not been given the intellectual
and organizational resources appropriate to the difficulty of that task. Provid-
ing those resources will come at great cost. Any innovative effort is expensive,
both fiscally and emotionally. Yet for what that innovative change will cost,
faculty will more than gain in the young people no longer discarded because
their "teachers" did not know how to educate them effectively, and those
faculty more than gain in the organizational resources now efficiently used, and
the public more than gains in a university more rigorously accountable to those
who support it.
Structure: The Instructional Team and Bifaculty Organization

An innovation solves a problem not previously answered. It discovers a
phenomenon not previously known. It produces savings not previously avail-
able. Though innovations often are slowly accepted, everyone recognizes their
importance and thus urges their occurrence.
Thus everyone exhorts teachers to innovate; to do something new, hope-
fully better, with their classes. Have they? Of the hundreds of thousands of
faculty members now presenting information in the thousands of universities
throughout the world, how many are innovating any procedure in their classes?
So few, that new attempts at teaching occur more by accident than by design.
Are the overwhelming numbers of faculty members incapable of solving in a
new and unique way even the simplest problems of teaching? Do they lack
intelligence? Creativity? Desire? To say "yes" is at best circular logic and at the
worse favors the blame-the-person mode of analysis. We would make more
progress by addressing the question, "What are the conditions under which
innovation can occur?"
We first examined current conditions in the university at the level of in-
struction, since those are the conditions under which no or little innovation is
happening_ Given the prevalent feature of those teaching conditions, the pre-
sentation model of instruction, how could the teacher innovate? The faculty
member does not know how_ The typical faculty member knows little or noth-
ing of the technology of instruction drawn from the behavioral sciences, and a
stray workshop here or there does not correct the deficit. (Would one know
how to produce solar-powered engines from a stray workshop here or there on
the physics of solar energy?) And as current measurement procedures make
clear, a faculty member cannot innovate unless that faculty member contacts
the events responsible for the student's learning. Furthermore, being a full-
time expert in another subject matter, from anthropology to zoology, keeps
faculty members busy, and additionally, that is where faculty members' inter-
ests lie.
Another factor must also be considered: the organizational structure in
which an innovative procedure must operate. The current university structure is
a relic encrusted with ineffective and inefficient ways of reaching its goals. New
behavioral technologies get some attention for a while and then disappear.
Attempted innovations in higher education come and go. The personalized
system of instruction (PSI) was perhaps the most successful instructional sys-
tem innovation in higher education. There were numerous applications in
many disciplines, and faculty in many countries from Brazil to Samoa at-
tempted teaching with it. The research literature reported its seeming superi-
ority to conventional teaching methods. 5 But despite its success and apparent
effectiveness, its use has greatly diminished; fewer teach with it today and even
fewer now publish research on it. Innovations such as PSI come and go because
they are attempted in an organizational structure designed to accommodate
models of instruction that fit only the current organizational structure. Such
a structure easily accommodates new physical technologies. Communication
technologies such as television and computers and multimedia (apparently the
"edutainment" locution for a movie) readily patch into the current organiza-
tional arrangements. They function as more efficient delivery modes; efficient
in the sense of reaching more people with the same packaged material. They are
not more efficient in the sense of teaching more material at lower cost. The
current organization structure ignores or misuses the potential for interaction
that the new physical technologies bring, since it cannot easily accommodate
the necessary behavioral technologies. Though presentations may now be deliv-
ered to greater numbers of people, no change has occurred in the organization
that would allow quality control instructional feedback systems to operate.
'But see Eshleman and Vargas (1996) for a contrary opinion.

Behavioral technologies that are radical variants, such as the esc system, can
successfully operate only within a university organization that completely dif-
fers from the current one.
An organization is a coordinated division of labor that transforms what-
ever it works on from some defined raw state to a finished product. A complex
endeavor necessitates complex skills divided among a number of people. The
principle is obvious and widely practiced, but that principle is not applied to
teaching. Everyone talks about the complexity of teaching. Practices belie those
words. In practice, teaching is carried out as if it were the simplest thing in the
world. Ample evidence of such an assumption is provided by the university'S
division of labor. The university's division of labor is inappropriately orga-
nized, and so its teaching mission is carried out by subject matter specialists
who batch-process students. But to produce in all students a repertoire highly
sophisticated in the sciences, the arts, and the humanities, skilled, and creative
in any subject from mathematics to music, from physics to painting, from
anthropology to architecture, certainly acquires as much organizational com-
plexity in its division of labor as, for example, producing an automobile. No
administrator with the responsibility of producing a car would turn the job
over to a person with a hammer and a few sheets of metal simply because he
knew how to drive a car; but, in higher education we turn the extraordinarily
difficult endeavor of producing a complex repertoire over to a person with a
piece of chalk and an available blackboard simply because that person knows
what to say about a subject. It is not surprising that, regardless of our concerns
and our conferences, so much failure occurs. The failure is not the student's,
nor the faculty's, nor the administrator's. It is systemic.
As an organization, the university requires, manages, and produces new
knowledge and creates new knowledge-based repertoires in students. As such,
to use recent descriptors of the modern organization, it should be an "informa-
tion-based organization." The university's collaborative arrangements must
reflect the changes that have occurred since the fourteenth century in the behav-
ioral sciences, in information and instruction technologies, and in high-tech
skill-demanding societies.
Unless we change the organizational structure under which instruction
takes place, esc systems are not possible. The delivery of instruction must
involve faculty expert in all aspects of the instructional process, and that faculty
must be organized so its coordination facilitates its instructional efforts. Other-
wise, any instructional innovation derived from the esc system will not last.
The esc system itself will soon wither, and probably not take root, in the
current university with its traditional division of labor.
No one person can perform all the functions necessary for effective in-
struction, as that involves becoming expert in the design of an instruction
system, expert in the content of a curriculum, expert in the modes of delivery of
that subject, expert in the writing of computer programs to measure innumer-
able interactions and effects, expert in the logistics by which students individu-
ally contact subject matter delivery modes at different times and places over
varying dates, and expert in the quality control techniques by which the in-
structional system is evaluated, refined, and reinvented_ Each function demands
its own sophisticated repertoire. Even if it were possible for one person to be an
expert practicing artist or biologist and yet also be expert and motivated
enough to know all aspects of the design of the functions of an instructional
system, that person would not have time to carry out all of the operations
involved in the complex endeavor of a system of instruction. Anyone of the
component operations, for example, designing and producing material to be
delivered through various modalities, requires a full-time commitment. Yet
presumably keeping up with a discipline is a full-time job. So where does the
time, much less the expertise, come for dealing with the difficult problem of
shaping a complex repertoire? It is simply not there for anyone person. As with
any complex operation, teaching calls for a distribution of its functions and
their tasks across several people.
Effective teaching requires a team of people to design and to operate
instructional systems. The proper division of labor further requires that the
characteristics of the instructional systems team match the process necessities
of instructing. Since instructional systems must be designed, delivered, oper-
ated, and evaluated, there must be experts for each of these component func-
tions. The complexity of the differing component processes of esc systems
requires an equally complex division of labor. In addition to the process ex-
perts-people expert in design, delivery, logistics, and evaluation-instruction
obviously requires individuals expert in what is to be taught. The content
expert thus becomes a member of the instructional systems team and formu-
lates the thematic content of the instructional system. Instruction consists of,
and should be, a full-time team effort by the instructional system team produc-
ing and recycling instructional systems that aim for continually higher effective-
ness and efficiency.
The presence of instructional system teams as part of the division of faculty
labor radically changes faculty roles. Faculty hired in subject matter areas such
as anthropology, biology, or chemistry are no longer employed as teachers.
They are hired as full-time researchers in their subject matter areas. They join
instructional systems teams as they desire and as others need them for a specific
teaching mission. The types and number of subject matter experts hired directly
reflect explicitly defined university goals in disciplinary areas in which the
university wishes to be outstanding. These goals would not be an outcome of
accidental factors, such as number of students wanting to major in a given
career or such as amount of contract money tempting irrelevant efforts with
respect to basic disciplinary issues. Faculty hired to teach reflect the differing
specializations in the processes of instruction. Instructional experts in these
processes make up the instructional faculty. The instructional faculty divides
into instructional system teams, the basic division-of-labor teaching unit. In-
struction is no longer a matter of one person in a room talking to a group of
students. It is teams producing esc systems that teach students in a variety of
settings. The organization of the faculty conforms with the complexity of the
variation in student behavior and of the differing demands of instructional

objectives and conditions.
This new division of labor of the teaching mission requires a new adminis-
trative organization of the university. Currently the university is organized in
terms of division of knowledge-a structural division, not in terms of its two
prime functions of research and teaching and the expertise necessary to carry
out both of them. This current and traditional organization overlooks the
complexity of both teaching and research. Such complexity is addressed by
organizing the teaching teams as the teaching faculty and organizing the disci-
plinary faculty as full-time researchers in research centers.
Presently, the university has one faculty, supposedly expert in both teach-
ing and research. These people are supposed to be expert and productive both
in investigating their subject matter and in getting others to learn it. It is
assumed that if they know a subject, such as anthropology or biology or
chemistry, they will be able to teach it. Both studies and casual observation
prove otherwise. In order to teach well, one must know as much about how to
teach as what to teach. The poor state of university teaching shows that such
expertise is rarely the case. Even research productivity suffers under the current
arrangement of labor of the faculty. Scholarly productivity in almost all univer-
sities is low, and only a minority of faculty members ever publish in their
subject area. It is quite clear that present university arrangements do not facili-
tate either effective teaching or productive scholarship. Instead of exhortations
or blame, a more effective solution would be to change to an organizational
structure under which both effective teaching and productive research would
occur.
The faculty in the new university would be assigned a full-time effort
committed to either research or to teaching in order that both be done well.
Instead of one faculty with two roles, there would be two faculties, each respon-
sible for one of the prime missions of the university. One faculty would be the
teaching faculty. The other faculty would be the research faculty. The teaching
faculty would have its own academic dean and be organized into instructional
teams. The research faculty would also have its own academic dean and be
organized into research centers. These research center would address issues
within the traditional content areas of the university, such as biology, chemistry,
music, and so on. When feasible and when needed, a faculty member from one
of the research centers would join an instructional team for the production of a
particular instructional system. Both faculties would be under the coordination
of the vice president for academic affairs and both faculties would be evaluated
by how effective they are within their own domain of expertise, either that of
teaching or that of research. A fairer and more accurate accountability arrange-
ment would result (see Figure 10.6 for a partial diagram of this organizational
structure. )
The new organization structure emphasizes flexibility, decentralization of
control, and formal dissemination of information from critical client groups.
The design, production, management, evaluation, and redesign of instruction
Vice-President.
Academic Affairs
I I
Instructional facu~y Research facu~y
t I
Instructional Documentation
systems teams and information teams Research teams Research teams
Support-base data Research findings

~
Research findings
Figure 10.6. Partial organizational model.
by instructional system teams implies a cluster-type organization-a collabora-

tive effort of teams of people whose size, members, and jobs may change. The
instructional faculty partitions into instructional systems teams and informa-
tion and documentation teams. The instructional system teams are made up of
specialists in the processes of instruction and in the thematic content areas of
instruction. Team members transfer according to assignments, and assignments
switch according to overall objectives of the university. Faculty members expert
in evaluation, for example, may shift their efforts from assessing an instruction-
al system in biology to one in astronomy. Due to new university goals, an
experienced instructional system team may take on the challenge of a curricu-
lum in ocean ecology. Hierarchical levels of control are deemphasized. For
example, coordinators of instructional systems teams may interact directly with
the vice president for instruction. Information and documentation teams inter-
act directly with various sectors of the public, the professions, and the political
sphere such as government. These information and documentation teams di-
rectly access demographic, economic, and other data vital to the university's
teaching, research, and service missions, and after analysis of these data, move
them to appropriate sectors of the university. The library function, for example,
is no longer to be thought of as storing books and documents, but as dynamic
interactions with data bases. The information and documentation unit would
thus connect with worldwide data bases through the Internet and other com-
munication networks. A curriculum planning council would provide the means
by which instructional and research faculty would interact in order to plan
current and future curricula.
This chapter concentrated on the teaching function of the university, since

defects there are so glaring. But clearly the research function also needs to be
revamped. Disciplinary faculty are called upon to serve two masters: the univer-
sity mission to produce knowledgeable students and the disciplinary mission to
improve its state of knowledge. Faculty sacrifice effort in one to carry out the
demands of the other. The current solution of university administration to this
dilemma is to urge, sometimes demand, that faculty become soft-money entre-
preneurs; to write proposals for grants that would support them in full-time
research work with an occasional teaching responsibility as desired. 6 That is
not the only motive, or even the primary one for administrators. Almost all of
the overhead money from the grant goes to administrators and makes up for
shortfalls in public funding and provides means for private, that is, not publicly
specified, projects. The shortcomings of such a state of affairs are well known.
Soft-money barons wield disproportionate influence not only by becoming
insulated from normal countercontrols from faculty and administrators, but by
administrators pandering to them in a number of ways such as quicker-than-
usual promotions and multiple appointments to university committees. Not
only does the ethos of collegiality get lost in this shuffle, but so do issues critical
to the disciplines. What drives research efforts is what will bring in money. This
consideration, while not always at odds with a discipline's interests, is not
necessarily in tune with them. Government bureaus are under heavy pressure
by legislative bodies to justify the immediate benefits to the public from the
expenditure of public funds. It is hard to make the case when competing for
funds against a bigger highway or a football stadium that money to investigate
the significance of the sex life of the frog to evolutionary theory deserves a
higher priority. Not much money is given for "pure unadulterated curiosity,"
and the basic researcher seeking grant money is up against the usual scenario
that she must state what she will discover when she is not even quite sure
herself. The current organizational arrangements erode this critical public
function of disciplinary-driven research.
The university must have an organizational structure that facilitates (per-
haps the proper word is "restores") the basic role of its research faculty as
"dispassionate inquirers after truth." Though a clumsy cliche, this statement
still points to research work driven by what is important in an area of knowl-
edge rather than by concerns that are political or pecuniary. Funds for the
research mission would be apportioned to university faculty for the differing
research endeavors in research institutes, and it would no longer be pretended
that the yearly budgetary allotment given to, let's say, the physics department,
is supporting research in physics when most of it is supporting the teaching of
physics. The research faculty would work within research institutes dedicated
to a given research mission. (The term "research" includes work in the arts and
6Undergraduate teaching responsibilities therefore fall on the shoulders of graduate students and
part-time contract faculty. The hiring of part-time contract "faculty" is destroying faculty authori-
ty in higher education and turning the teaching enterprise into piecework.
humanities.) Such a mission would address questions whose consequences of

discovery lie far in the future. When dedicated to such a mission, such an
arrangement does not preclude funds from outside agencies. The dedication to
a particular research mission facilitates obtaining private sector funds and
increases the chances of scientific and scholarly breakthroughs.
And it is not only the organization of the research function that will
change with a change to a shaping instructional technology and a bifaculty
structure; so will other organization subsystems. The radical shift in the system
of instruction and in the division of labor of the faculty calls for changes in
supporting elements within the university. The critical organizational sub-
systems are administrative and fiscal, planning, management information, and
telecommunications. The details of their reorganization are beyond the scope of
this chapter. But one example may illustrate the impact of quality control
instructional systems. Currently the operation of all organization subsystems
are linked to student numbers. But a shift to CSC systems that meet quality
control goals with all students connects accounting, registering, and other
functions to targeted repertoires. Accounting costs will be based on degree of
effective and efficient quality change in student performances; the information
function of the registrar's office will change from tracking by identical time
division of batch-processed students to inventorying by the varying time points
at which students achieve the criterion of excellence in a subject matter; and
telecommunications systems will no longer present talking heads, but will
deliver interactive instruction that shapes creativity and problem-solving skills.
Therefore, administrator roles also change. The function of specialized
roles, such as those in the fiscal and planning areas, alters. There is a greater
emphasis on quality control and on management through collaborative rela-
tionships. For example, instructional systems designers and fiscal administra-
tors would work together in assessing costs for instructional systems both for
instructional systems as such and as a proportion of overall university expenses.
The critical characteristics for administrators are thus expertise in quality con-
trol processes and information systems and an ability to delegate effectively
within a decentralized structure of organization. One further brief aside: Many
administrative positions in the university, particularly those demanding spe-
cialized skills, are currently filled with nonfaculty members. Faculty, however,
are also placed in administrative positions such as dean or provost (unfor-
tunately seen as a promotion). For a number of reasons too far afield to discuss
here, this type of traditional staffing, meant to maintain faculty authority, now
contributes to the demise of faculty authority. It may be time to move to the
kind of authority structure of the hospital. No one pretends that in order to
administer a hospital that the chief administrator needs to be or should have
been a first-rate medical doctor. Hospital administrators are professional ad-
ministrators specialized in hospital administration. Universities already engage
in this practice in the office of the presidency, bringing in generals and business
executives to run that office. Such a practice demonstrates clearly that no
particular accomplishments are necessary in either teaching or research to
provide overall administration to the university. Decentralization of authority

follows automatically, in time, when it is acknowledged that the expertise
necessary for effective decisions resides only at a particular process level.?
Conclusion
A great deal of attention has been given to "reengineering the organiza-
tion." This effort has been primarily directed at the industrial organization. A
number of organizational experts have pointed out that the prevalent model of
organization for the industrial firm is one left over from the nineteenth century
organization of work and better suited for the technology of that time. To
become more effective, the industrial organization (as well as other types) must
change-and change in their entirety. It is not sufficient to have a better pro-
duction technology, whether in producing cars or repertoires. To take advan-
tage of that better technology, organizations, whether industrial or education-
al, must restructure their control, coordinative, and communication systems.
As organizational experts put it, organization should center not on tasks but on
processes.
Also focused on processes is this proposed reengineering of university
organization. This model of the university calls for a reorganization of the
university based on the separation of research and instruction faculty and a
division of labor of instructional faculty teams based on the instructional pro-
cesses of design, delivery, logistics, and evaluation. The older traditional model
is built on the disciplines to which faculty belong and the vague tasks related to
how faculty are supposed to transmit their lectures. The lecture method of the
older model does not take advantage of new advances in the behavioral sci-
ences, in the information sciences, and in managerial and organizational theo-
ry. An enclosing cycle ensues: The older model cannot take advantage of these
advances since its traditional instructional method constrains organizationally
what can be done. Management experts point out that to operate successfully,
the industrial firm must dispense with an organizational model that is over a
century old. I am making the point that in order to operate successfully in the
twenty-first century, the university must dispense with an organizational model
that is over six centuries old.
SUMMATION
Entrepreneurs are few in any endeavor. They are practically nonexistent in

education. People like the taste of success, but they fear the bile of defeat. And,
7More than one reason is impelling a shift to team operations in the university. In an editorial of an
issue of the Inter-American Journal of University Management devoted to university leadership,
Gerard Arguin (1994, p. 3) states, "Today, however, in the organizational sphere, we seem to be
increasingly leaving behind a theory based essentially on the personality of the leader in favor of
the notion of the team which corresponds more to the nature of a complex organization such as
that of a university. The University, in effect, is a highly decentralized, multiple-structure organiza-
tion. "
they feel that fear, the anxiety of an uncertain future, before they encounter any
success. So no action is taken. No risk is attempted. Risk is inherent in an
innovation, since an innovation is by its very nature something that has not
been attempted before. Therefore, most attempts to change a situation step off
in a direction sanctified by tradition and conspicuous for timidity.
Prior attempts to change the university have been piecemeal. A bit here
and a bit there, and these attempted bits have left it much like it was before.
Over time the university reverts to its usual practices. The university has grown
larger, speeded up its operations, changed its curriculum, and become more
diverse in its public functions, but in the very heart of how it carries out its
prime missions of teaching and research, it has not changed since its beginnings
in the fourteenth century. A single disciplinary faculty is organized to teach and
to research as it always has. The evolution of the university's organization
appears to be stuck. It has become an organizational dinosaur lumbering into
the twenty-first century.
It is as true in education as it is in business or any other endeavor: If there
is to be an organization that operates more effectively and that meets the rising
demands of its changed social milieu, it must be a new species of organization.
This requires a revolutionary change in the spectrum of efforts that carry out
university functions. It requires a change in explanations of behavior, from
mysterious brain processes that those teaching can only infer, to explicit and
observable conditions that they can manage; a change from a teaching technol-
ogy based on the transmission of information by a subject matter expert to the
design and operation of shaping systems by a team of instructional experts; and
a change from a single faculty that handles both the teaching and research
missions to two faculties, one for the teaching mission and one for the research
mission. Every feature responsible for the organization called the university
must be changed and changed in concert with one another.
Acknowledgments. Portions of this chapter were prepared earlier in docu-

ments for the Secretaria de Educaci6n Pubilica, Mexico (see Vargas, 1992,
1994a). My thanks to D. A. Cook, J. D. Ulman, and Julie S. Vargas for helpful
comments on an earlier version of this chapter.
REFERENCES
Arguin, G. (1'1'14). Towards a new conception of university leadership. Inter-American Journal of
Unil'l!rsity Management, 7. 3.
Cavalli-Sforza, L L., Feldman, M. W., Chen, K. H., & Dornbusch, S. M. (1 '182). Theory and
observation in cultural transmission. Science, 218, 1'1-27.
Cook, D. A. (1'193). Behaviorism evolves. Educational Technology, 33, 62-77.
Darwin, C. (185'1). The origin of species (6th ed.) New York: Appleton and Company. (UI'18
printing date)
Dawkins, R. (1'186). The hlind watchmaker. New York: Norton.
Eshleman, J. W., & Vargas, E. A. (19'16). The personalized system of instruction: A critical
evaluation from a cyhernetic systems context. Manuscript submitted for publication.
Feynman, R. P. (1 '185). Surely you're joking, Mr. Feynman! New York: Norton.
Feynman, R. P. (1'188). What do you care what other people think? New York: Norton.
Skinner, B. F. (1987). Upon further reflection. Englewood Cliffs, N]: Prentice-Hall.

Vargas, E. A. (1988a). Teachers in the classroom: Behaviorological science and an effective instruc-
tional technology. Youth Policy, 10(7), 33-34.
Vargas, E. A. (1988b). Verbally governed and event-governed behavior. The Analysis of Verbal
Behavior, 6, 11-22.
Vargas, E. A. (1991). Behaviorology: Its paradigm. In W. Ishaq (Ed.), Human behavior in today's
world. New York: Praeger.
Vargas, E. A. (1992). La evaluaci6n academica como proceso para el control de cali dad y la
innovaci6n. In V. A. Arredondo (Ed.); Evaluaci6n, promoci6n de la calidad y financiamiento de
la educaci6n superior, (pp. 75-93). Mexico City: Secreta ria de Educaci6n Publica.
Vargas, E. A. (1993). From behaviorism to selectionism. Educational Technology, 33(10), 46-5l.
Vargas, E. A. (1994a, January). The university system of the state of Quintana Roo. Consultant's
Project Report. Morgantown, WV: Author.
Vargas, E. A. (1994b). Behaviorology and the other behavioral sciences. Behaviorology. 2(1), 17-
28.
11
The Primacy of the Initial

Learning Experience
The Incredible Gift of learning
Jacob Azerrad
Two very important goals for the species Homo sapiens are (1) survival of the
individual, and (2) survival of the species. To achieve these goals within the
genetic structure of the species Homo sapiens eating behavior was guaranteed
by way of food being a very powerful reinforcer. Also within the genetic struc-
ture of the species Homo sapiens, survival of the species was guaranteed by
making sexual behavior a very powerful reinforcer. As stated in the Bible, man
was told to "be fruitful and multiply." There is no doubt that once again those
goals were fulfilled, because this was also the "nature of the beast." The result
has been survival of the species, with 6.5 billion people on this small planet
Earth.
For other species, instinct is a major part of the genetic makeup. The ant
and bee, for example, for the most part behave in fixed ways because their
behavior is governed by their genes. The species Homo sapiens, however, has
been given a very precious gift, the gift of learning. This gift of learning, in
addition to a powerful brain, will enable humans to take charge of their world.
They will learn to fly like the birds at speeds that will exceed the speed of
sound; they will learn to send color pictures around the globe and beyond; they
will learn to escape the bonds of gravity and travel to the moon and back safely;
they will build tall buildings and bridges and will learn to discover cures for the
Jacob Azerrad • 19 Muzzey Street, Lexington, Massachusetts 0217J.
189
most threatening of diseases; they will also learn to alter their own genetic
makeup, and thereby correct genetic defects. Humans will be able to do all of
this because they live in a universe that is orderly. Day will follow night,
summer will follow spring, and comets will travel the universe and will make
their rounds in an orderly manner with precision.
The combination of brain power, lawfulness within the universe, and this
incredible gift of learning will enable humans to work to achieve what Thomas
Jefferson said was his God-given right to life, liberty, and the pursuit of happi-
ness. In order to achieve this, there must also be, in addition to laws of physics
and biology, laws of behavior for this species called Homo sapiens:
1. A lawful universe.
2. A species called Homo sa/liens with an advanced brain.
3. The incredible gift of learning. This incredible gift of learning has made
nurture the primary factor in human behavior.
B. F. Skinner (1953) viewed human behavior as learned, governed not by

inner unseen causes but by the consequences that follow the behavior. On the
other hand, Eda Le Shan (1969) views human behavior in a radically differ-
ent way:
I do not agree with the new breed of psychologists who are telling parents
that there are formulas for childraising. These psychologists, called behav-
iorists, have their roots back with Pavlov and his salivating dogs. They
believe in conditioning that people can be made to behave in certain ways
by conditioned responses. They are right about white rats; it works very
well on them. It also works on people for short periods of time. But to my
relief and delight, conditioning (which is learning) does not have lasting
effects, and sooner or later the marvelous unpredictability of human beings
comes through again.
The ridicule of Skinner's understanding of human behavior is not dissimilar

from ridicule that others have experienced before him when they denied man a
feeling of being unique and special.
Pope John Paul II forgave his would-be assassin, Mahmet Ali Agca, but it
took the church well over 350 years to forgive the alleged heresies of Galileo
Galilei. As late as May 1983, the New York Times reported that "Vatican
sources said it was doubtful that the Holy See would ever fully reverse the
judgment passed on Galileo" (p. A12). Why is this so?
As Homo sapiens, we find it very difficult to accept the fact that in this vast
universe we are not special. What, you may ask, was Galileo's heresy? Galileo
said that we, on planet Earth, were not at the center of the universe, we were
not special. Charles Darwin, in his theory of evolution, stated that biologically
we were not a unique being created in the image of the almighty. Though
Darwin was not subjected to house arrest as was Galileo, his thinking was met
with equal, if not greater, resistance.
Today, a man of equal stature, B. F. Skinner, the late professor of psycholo-
11 • THE INITIAL LEARNING EXPERIENCE 191
gy at Harvard University, is being subjected to the same fate as Galileo and

Darwin. Galileo said we were not special, not at the center of the universe.
Darwin said we were not special biologically. And Skinner said that we were
not special behaviorally.
For far too long, the field of psychiatry has set the tone of our understand-
ing of ourselves, for reasons that have little to do with the worth of their
therapeutic procedures. The profession of psychiatry has made us feel special
for 100 years by operating totally apart from the scientific method with a
theory so vague, so lacking in precision, that it is virtually untestable. They
have, however, more than made up for their lack of therapeutic methodology
with techniques of persuasion that are without equal. The profession of psychi-
atry is much like the "emperor with no clothing." The time has come for the
public to view the emperor's garb for what it truly is.
B. F. Skinner's and Charles Darwin's understanding of the world are not
inconsistent with a belief in God. There is not one set of laws of behaviors for
lower animals and another set of laws of behavior for this "unique" being
called Man. There is biological simplicity and a universe in which matter and
energy arc one and the same, the ultimate simplicity. (See Azerrad, 1985,
unpublished manuscript.)
A mother nursing her child gives of herself, her milk, to nurture this tiny
being. We never question the need to nurture the child's physical being. But
there is a form of nurture, equally important, by way of warmth, love, and
physical contact. Experiments on monkeys clearly indicate that the physical
contact between mother and infant is extremely important in determining fu-
ture development. Without physical contact there are serious negative develop-
mental consequences (Harlow & Zimmerman, 1959). The fact that infants
need this physical contact and warmth above and beyond nurture in terms of
their physiological needs was also clearly demonstrated in the material depriva-
tion studies of Rene Spitz (1949). Spitz studied two groups of children born to
women prisoners. The conditions of the groups differed, he said, "in one single
factor-tbe amount of emotional intercbange offered" (p. 149). In one institu-
tion tbe children were raised by their own motbers. In tbe second, tbey were
raised from the tbird montb by overworked nursing personnel; one nurse bad
to care for from 8 to 12 cbildren.
Spitz found tbat the group raised by their own motbers did better by all
standards of development. Tbey were healthier, had a lower mortality rate,
grew faster, were better adjusted, and were happier tban the babies in tbe
foundling home. Tbe most striking finding was tbe mortality rate. In the group
that stayed with their mothers, there were no deaths during tbe 2-year period of
the study, whereas in the foundling home 37% of the infants died. Spitz, wbo
coined the term marasmus to describe tbis, reports tbat "the higb mortality is
but the most extreme consequence of tbe general decline, both pbysical and
psychological, wbich is shown by cbildren completely starved of emotional
interchange (p. 149).
The mother's milk of children's behavior is love, warmth, and pbysical
contact. "He is doing it for attention" is the repeated explanation of why

children misbehave. It may sound trite, but it is so true. He is eating because he
is hungry is also a truism. Children who misbehave for attention are not neces-
sarily hungry for human contact. Usually they are not attention deprived. More
often than not they are simply behaving in this way because it is immediately
effective in bringing human contact much like the overweight person who eats
to excess because it is immediately satisfying. Often children who misbehave
the most are getting an abundance of attention and human contact and are not
attention deprived, just as the overweight person is not food deprived.
The mother's milk of behavior is attention and love, but we must look
upon this milk as milk of varying quality. Though the ultimate reinforcing
consequences for children's behavior is human contact, this contact runs along
a continuum from love, warmth, touching, and praise at one end to simple
attention on the other end. Human contact is so powerful a reinforcing conse-
quence for the child that it will nurture behavior even at very low-quality levels.
Yelling and screaming and anger from a person called mother or father is a
powerful reinforcing consequence and often is referred to as negative attention.
Annie Sullivan, Helen Keller's teacher, was labeled a "miracle worker" by
many. Not so obvious to most, however, is the fact that in reality Annie Sullivan
was the first known behavior therapist. She was the first individual to systemat-
ically apply the laws of human behavior toward helping a hurt human being, in
this case, a human being who went on to remarkable achievements. Helen
Keller, blind and deaf nearly from birth, was in every sense a human being with
vast potential. Her potential lay untapped because she was being given love for
the wrong behaviors. The following conversation from William Gibson's play,
The Miracle Worker (1957), illustrates this:
KATE (Helen Keller's mother): You know she began talking when she was six
moths old? She could say "water." I never saw a child so bright or outgoing.
It's still in her, somewhere, isn't it? You should have seen her before her
illness, such a good-tempered child.
ANNIE SULLIVAN: She's changed.
KATE: Miss Annie, put up with it. And with us. Please? Like the lost lamb in
the parable, I love her all the more.
ANNIE: Mrs. Keller, I don't think Helen's worst handicap is deafness or blind-
ness. I think it's your love. And pity. All of us here are so sorry for her. You've
kept her-like a pet, why even a dog you housebreak. No wonder she won't
let me come near her. It's useless for me to try to teach her language or
anything else here. (p. 74)
Fortunately for Helen Keller-and for the rest of the world-this was not the
final conversation Annie Sullivan was to have in the Keller household. She
remained, worked hard, and eventually changed the way Helen's family treated
her, and therefore changed the way Helen learned behaviors. What Helen
Keller's family was doing was giving a very destructive form of love: pity. She
was receiving love for the wrong behaviors, love when she least deserved it.
THE INCREDIBLE GIFT OF LEARNING
How do children learn? What I find fascinating about human behavior is

its variability. The reason for this variability is because of the gift of learning.
Most of us think of learning in terms of the three R's-reading, 'riting, and
'rithmetic-but learning begins long before the time of formal schooling. The
child's first teacher is his or her parents.
We must look upon childrens' behavior in a new way and a way that is so
simple it is radical. The best way to understand the gift of learning in children is
by way of a garden analogy. In a garden you have valued plants and weeds. The
role of the parent is to nurture the valued plants and eliminate the weeds.
How does the child learn and how do parents teach are crucial questions.
What is unfortunate is that we often overlook the extreme importance of early
learning experiences, and for the most part these extremely important teachers
called parents teach by the seat of their pants-without formal training.
Though we are becoming increasingly aware of the importance of nutrition in
terms of providing the child with good nutrition, our understanding of the
nurturing of behaviors is at an extremely primitive level.
ON THE NURTURING OF BEHAVIOR
Until just recently we seldom looked at behavior as a subject of study in

and of itself. The reason is simple: We were so fascinated by the alleged inner
workings of the "mind" that we overlooked what was right before our eyes-
behavior.
Sigmund Freud (1916), made the workings of the "mind," the uncon-
scious, a fascinating realm of study. It was and unfortunately still is to most far
more fascinating than behavior itself. His influence is a major contributor to
our inclination to look within rather than at behavior and environmental
conseq uences.
The workings of this fiction called the mind fascinate those who are the
most intelligent because they obtain their reinforcing satisfactions by way of
endlessly putting the pieces of the personality puzzle together. The most intel-
ligent people confuse behavior "understanding" with behavior control. They
are so fascinated by the process of putting the pieces of their personality puzzle
together that they overlook the fact that what really is important is behavior
change and an improved quality of life. That understanding will set you free is a
fiction. For adults this fiction is carried out by professionals using what freud
called the "talking cure," and for children play therapy.
But does insight and understanding change behavior? Does what Freud
said about making the unconscious conscious change behavior? The answer is
no. Studies that went to the very source of the theory, Freud's own cases,
indicate that this theory was flawed from the very outset. Frank Sulloway
(1987) reviewed the cases that Freud reported as his major successes and found
that they were in fact total failures. Freud was an excellent writer who distorted
the facts to fit his theory. Insight does not produce behavior change:
Freud published only six detailed case histories after he broke with Breuer
and developed the "talking cure" into psychoanalysis proper. Examined
critically, these six case histories are by no means compelling empirical
demonstrations of the correctness of his psychoanalytic views. Indeed,
some of the cases present such dubious evidence in favor of psychoanalytic
theory that one may seriously wonder why freud even bothered to publish
them. As Seymour Fisher and Roger Greenberg have commented in connec-
tion with their own review of the case histories, "It is curious and striking
that Freud chose to demonstrate the utility of psychoanalysis through de-
scriptions of largely unsuccessful cases." (Italics are mine.) (p. 251)
Sulloway continues:
These conversations were, so to speak, the Wolf Man's dying protest

against the false promises and disappointments of psychoanalysis. "Instead
of doing me some good," he exclaimed ro Obholzer, "psychoanalysts did
me harm," adding plaintively, "I am telling you this confidentially," (Sullo-
way, 1987, p. 260) In short, one must seriously wonder whether this fa-
mous case history was, as claimed, a therapeutic success and hence a dem-
onstration of freud's brilliant analytic powers.
Of course, the fact that the Wolf Man, Anna 0., and various other famous
psychoanalytic patients were not cured is not technically a refutation of
freud's clinical theories and claims. These cases can be admitted as failures,
or as only partial successes, and freud's theories still be correct. But re-
search since the 1930s has repeatedly shown that psychoanalytic patients
fare no better than patients who participate in over a hundred different
forms of psychotherapy. Freud maintained on the contrary that psycho-
analysis was the only form of psychotherapy that could produce true and
permanent cures-all other therapeutic successes being due to suggestion.
As Hans Eysenck has argued, the failure of psychoanalysis to achieve supe-
rior cure rates, as promised, should be taken as strong evidence of its
theoretical failure (pp. 260-261).
A new round of historical research on Sigmund Freud is challenging the

reputation of the founder of psychoanalysis. New revelations depict a Freud
who seems at times mercenary and manipulative, who sometimes claimed cures
where there were none and who on occasion distorted the facts of his cases to
prove his theoretical points.
The most startling discoveries, many not yet published, concern some of
Freud's most important cases, including the patients he referred to as "Little
Hans" and "Dora": "Each of Freud's published cases plays a role in the psy-
choanalytic legend," said Frank Sulloway (1990), a historian of science at the
Massachusetts Institute of Technology. "The more detail you learn about each
case, the stronger the image becomes of freud twisting the facts to fit his
theory" (p. C 1). The new historical work is just the kind of inquiry that Freud
dreaded. He burned many of his papers at different points m his life and
destroyed most of his case notes.
The belief that insight has curative powers and will change behaviors is
based on the medical or disease model of behavior. Those in the mental health
profession often refer to problem behaviors as symptoms or symptomatic of
some inner, intrapsychic, disease process called emotional problems.
Why is this way of understanding human behavior false for behavior but
true for diseases that affect the physiology of the human organism? The answer
was best stated by Hendrix (1990) in his book Getting the Love You Want. He
explains as well as anyone might why insight is not enough and only a very
small first step in the process of behavior and feeling change:
Years ago I was resistant to the idea of such a direct approach to the
alteration of my clients' behavior. Coming from a psychoanalytic tradition,
I was taught that the goal of a therapist was to help clients remove their
emotional blocks. Once they had correctly linked feelings they had about
their partners with needs and desires left over from childhood, they were
supposed automatically to evolve a more rational, adult style of relating.
This assumption was based on the medical model that, once a physician
cures a disease, the patient automatically returns to full health. Since most
forms of psychotherapy come from psychoanalysis, which, in turn, has its
roots in nineteenth-century medicine, the fact that they rest on a common
biological assumption is not surprising. But years of experience with
couples convinced me that a medical model is not a useful one for marital
therapy. When a physician cures a disease, the body recovers spontaneously
because it relies on genetic programming. Each cell of the body, unless it is
damaged or diseased, contains all the information it needs to function
normally. But there is no genetic code that governs marriage (or childrens'
behavior). Marriage (childrens' behavior) is a cultural creation imposed on
biology. Because people lack a built-in set of social instructions, they can be
trapped in unhappy relationships after months or even years of productive
therapy. Their emotional blocks may be removed, and they may have insight
into the cause of their difficulties but they still cling to habituated behaviors
(pp. 118-119).
A GARDEN OF BEHAVIORS
Many years ago when I would visit my parents who had retired to Florida
I would wonder at the large tree in their front yard, which I recognized as a
sheferlera (more commonly known as an umbrella tree). It was over 40 feet
high and had a trunk 1112 feet in diameter. Was this the same tree that I would
often see up north in a supermarket that sold ornamental plants? It was in fact
one and the same plant. Where I lived it was only 6 feet high and the diameter
of its trunk was no more than 1 inch. The same combination of genes in one
environment grew to a height of over 40 feet and in another environment a very
small plant. It was much like the tree on the top of a mountain that is stunted in
growth compared to the same tree at ground level that grows to full potential.
The same principles apply to childrens' behavior. What might parents do

to provide for their child's behavior what might be termed a Florida environ-
ment-a child who would, by way of a nurturing environment, more closely
achieve his or her genetic potential.
I visualized a garden of behaviors in which parents provide maximum
nourishment for their childrens' behavioral and feeling growth. Behaviors, like
seedlings in a garden, need to be nourished and that nourishment is provided
by consequences. Parents must also be taught how not to encourage weeds.
There are many weeds in this garden. What is unfortunate is that parents have
been encouraged to nurture weeds by those in my own profession. I once
walked into a child guidance clinic and on the wall was the saying, "Children
Need Love When They Least Deserve It." Without a doubt if you follow this
dictum you will be nurturing weeds.
Helen Keller during her early years, before Annie Sullivan came on the
scene, was a child whose parents felt sorry for her because she was blind and
deaf. They nurtured the weeds and in the process created a monster. Annie
Sullivan was the first behavior therapist and helped Helen fulfill her God-given
genetic potential by eliminating the weeds and nurturing these behaviors that
led her to become a woman of great achievement.
The Seeds
Children during their early years are "all eyes and ears." As a matter of
course they want to learn and what they learn is what they hear and see within
their environment. The seeds are provided by and large by parents. The seeds of
verbal behavior are everywhere and are an integral part of the child's environ-
ment. Parents seldom need training to nurture the seedling's verbal behaviors,
and almost without exception give their love, warmth, and praise for every new
word that the child imitates-MaMa, DaDa, ball, cookie. The result is that
children learn their native tongue with ease even though this involves the
learning of a very complex set of behaviors. Some children never stop talking
and the reason is simple: it is because of the incredible power of the conse-
quences of praise, warmth, and love immediately following imitated verbal
behaviors.
Verbal behaviors as a matter of course are always given a Florida environ-
ment. But there are other behaviors that parents often do not see. These behav-
iors are critical to the child's future growth and development and are the
foundation of feelings of self-esteem and achievement both social and aca-
demic.
But what are these behaviors parents seldom see? What are the behaviors
we seldom see because the other behaviors are noisy or because these behaviors
have been labeled symptoms of emotional problems. We have been taught to
analyze the weeds in the garden, and in the process we overlook what is most
important-those delicate quiet seedling behaviors that are the foundation of
success, happiness, and self-worth.
Parents must ask themselves what do I want to teach and encourage in this
garden of behaviors. Parents want their children to be independent and mature,
to become successful, and to feel a sense of worth and fulfillment as adults.
Parents want their children to be successful in later life in what Freud spoke of
as the two most important aspects of living, "Lieben und arbeiten" (love and
work). But success in love and work require behaviors, those quiet behaviors
that we so seldom see. These behaviors like the delicate seedlings in a garden
are in many cases destroyed by the abundance of weed growth, weed growth
that often is encouraged by way of talk and play therapies in and out of the
therapists' office.
Just what are these seedlings that must be nurtured and how must this be
done?
1. Speaking-verbal behaviors
2. Taking disappointment calmly behaviors (opposite of tantrums when
things do not go ones way):
• Waits patiently to go outside
• Left pool when it was time nicely
• Waited patiently for a drink at the library
• Went to the doctor, waited patiently in the waiting room for III hour
• Waited for ice cream patiently
• Waited for cookies at lunch time
• Left aquarium without a fuss
• Can we go to Nancy's house? No, we can't. She's going out today. Oh
well, maybe tomorrow.
3. Sibling caring behaviors (opposite of sibling rivalry)
4. Mother Theresa behaviors (those behaviors that are the opposite of
self-centered behaviors-thinking of the other person)
5. A thirst for learning behaviors
6. Friendship behavior-social skill behaviors
• Took turns playing games
• Shared fruit roll-up with Nick; it was the last one left
• Both Nick and Jay got movies; they could only watch one; Jay let
Nick watch his first
• Jay and Nick taking turns
• Said hello to his friend
• Said goodbye when leaving
• Went and played with others on arrival at school
• Melinda made plans to visit with friends
• Shared coloring book with Michael
• Amanda asked Kathy if she could play with one of her ponies and
Katy said yes, play with this one
• Kaitlin shares gum with Michael
These behaviors have one thing in common. They are all behaviors that reflect
increasing maturity and increasing steps toward adulthood. What is even more
important is that children, with few exceptions, want to be more like adults
and being called a big boy or a big girl is a very powerful consequence.
The extreme importance of early learning in childhood is in part a func-
tion of the fact that during these early years there is increasing evidence of a
critical period in terms of the learning behavior. Recent studies on brain func-
tion during these early years indicate that learning is facilitated in the young
child because of the abundance of nerve cell connections during this period
(National Public Radio, 1994).
1. The infant's brain doubles in weight and nerve cells sprout branches
that connect with other branches, with the number snowballing from
50 trillion to 1000 trillion in the first year of life. This exuberance of
connections is part of nature's design to build bridges between nerve
cells so that learning is possible.
2. Nerve cells put many more connections into place than they intend to
retain. And what determines the survival of connections is the experi-
ence of the organism.
3. So, each and every experience, each sight, each nose, each hug,
strengthens specific nerve cell connections in the brain. Some connec-
tions get stronger and survive, some get weaker and wilt away. Scien-
tists revert to a gardening term to described this thinning out of nerve
cell connections: They call it pruning.
4. Most of this sculpting takes place within the first decade of life. At the
level of each nerve cell connection, the name of the game is to use it or
lose it.
S. If you are brought up in a family where music is extremely important
and everybody's a musician, well then, certainly those are the kinds of
connections that might be strongly stabilized. If you are a baby in a
family where several languages are spoken, the nerve cell connections
that decipher the sounds of language are constantly being activated and
the child learns.
There is no doubt that many adult maladaptive behaviors are behaviors
learned in early childhood. They are adaptive at that time and continue
throughout adulthood in spite of the fact that the environment has markedly
changed. It is similar to rats deprived of food during the first weeks of life
engaging in hoarding behavior for life, though they are there;!fter given food in
abundance. Adults who were children during the Depression years also may
behave in ways that reflect maladaptive behavior patterns in spite of a radically
changed adult environment. Do we really need an unconscious to explain what
appears to be irrational behavior patterns? It is nothing more than learning
pure and simple.
Verbal statements by parents are also consequences. The young child has
no way of judging the accuracy of his or her parents pronouncements, and so
accepts them as gospel. Albert Ellis (1990) once said his mother told him that if
he masturbated, he would go crazy. It was not until he was 8 years old that he
realized the he had a crazy old mother. He then said that it took his brother
until age 11 before he realized that the pronouncements of mother were from a
nutty old lady. It is for this reason that the human condition must of necessity
begin with a better understanding of the tremendous impact that parents'
behavior, verbal and otherwise, has on the child who is all eyes and ears and
extremely receptive to environmental contingencies.
The Seedling Behaviors

The seedlings are the imitated behaviors. The positive, quiet seedling be-
haviors need more than praise. Five to ten seconds of praise can in no way
compete with the many minutes and hours parents often give contingent on
negative, seedling behaviors-the weeds. Parents must learn methods to nur-
ture these quiet seedling behaviors, which so often go unnoticed. The two basic
classes of positive seedling behaviors are:
1. Mother Theresa behaviors: Any behavior that indicates that the child is
other-person rather than self-centered. A subcategory is sibling caring
behavior, a behavior that needs to be nurtured as a first step toward
eliminating sibling rivalry.
2. Taking disappointment calmly behavior: Any behavior indicating that
the child has experienced a situation that did not go his or her way and
the response was relatively calm and accepting. This is what children
who have tantrums need to learn and is the opposite of temper tantrum
behavior.
What is noteworthy is that these classes of behavior have never been highlighted
by behavioral psychologists and yet are crucial to child development.
Children as part of growing up must of necessity learn to handle disap-
pointment and must also learn to be sensitive to the needs, wishes, and feelings
of others who live with them on this planet. Mother Theresa behavior is what
Richard Stuart (1980) talks about when he teaches couples to show caring in
his marital counseling method called caring days. Caring for others, a sensi-
tivity to the needs, feelings, and wishes of others, is essential in all human
relationships and is without doubt an indication that the child is mature, more
other-person rather than self-centered. Taking disappointment calmly is also an
indication of increasing maturity.
Steps to Sibling Caring: A Method to Nurture

a Positive Seedling Behavior
For years psychologists have taught us that sibling rivalry is normal. For-
tunately this is a myth. Parents can, using some very simple methods, change
sibling rivalry to sibling caring:
1. One must begin this process at times when there is no ongoing sibling
rivalry. The first steps toward solving childhood problem behaviors
always begin not in the midst of battle and conflict but at times of peace
and harmony.
At the time of the behavior:
2. In a small notepad, jot down specific examples of sibling caring:
a. A sister reading a brother a story.
b. A brother asking mother to buy his brother an ice cream so they
may both have this treat.
c. Sharing toys (what did they share).
d. Going along with the wishes of another even though the activity is
not a preferred activity-Thinking of the other person behavior.
e. Any thoughtful caring behavior between siblings: Be specific-what
was said, what was done?
It is most important to look for glimmers of sibling caring behavior on
which to build. Each week note two to three examples in your notepad:
• Even if they are brief
• Even if they are expected
• Even if he/she does them all the time
• No matter what the motivation may have been
At a later time (1/2 hour to 7 hours later and at your convenience):
a. Take your child aside-in private-vividly remind him or her of the
earlier sibling caring behavior. Using words, attempt to make that
behavior come to life again. Tell him or her what was done, what
was said, and so forth.
b. Then praise him or her-100% praise with no mention of less
caring behaviors of the past.
DO NOT SAY: "It is nice to see you being kind to your brother for a
change."
c. Then immediately tell him why this behavior is valued. MESSAGE: It
is valued because it is sibling caring. "It pleases me very much to see
you caring for your sister." "It makes me feel very good when I see
you acting thoughtful to one another as you were this morning."
d. On occasion, immediately follow this with 5-10 minutes of pleas-
ant time together-chat, a game.
DO NOT SAY: "Because you were caring I will playa game with
you." Just do it.
"How would you like to ... ?"
3. When you observe sibling rivalry, your response must be above all brief
and dull.
a. Do not attempt to find out how the fight began. No one ever begins
fighting.
b. Do not reason
c. Do not attempt to get to the root cause of the fight.
Your time immediately following sibling rivalry, no matter how positive or
negative, will only serve to encourage sibling rivalry in the future. You can
say, "No fIghting. I do not wish to discuss it." The child may say, "That is
not fair!" To which you will reply, "I do not wish to discuss it." Imme-
diately following sibling rivalry is not the time to engage in discussions of
fairness.
Time-outs
When they are young, children also need to be taught self-control. Young
children often bite, hit, kick, have tantrums, and may engage in destructive
behaviors when they are angry. Though logic and reason may be used initially,
it often fails to help the child learn self-control. The child who engages in these
behaviors is often given explanations as to why not to engage in these behaviors
many times and the words fall on deaf ears. Words or other stimuli that lack
meaningful consequences are often ineffective unless they have in the past been
paired with a meaningful consequence. It is akin to speeding behavior on a
highway followed by a brief sermon from a police officer without a monetary
fine. I recall a medical student who told me that he saved hundreds of dollars
every year while using the Massachusetts Turnpike on his way to Boston. When
I asked him how he did this, he said he made believe that he would throw the
required quarter in the toll booth. When I asked him what occurred, he said a
buzzer sounded and he was not going to let a buzzer control his behavior.
Children need more than hollow words or a buzzer to help them control some
of the more serious behaviors.
Parents who say they use time-outs when asked what they do often have a
running conversation with the child during this period or send the child to a
room full of reinforcers. Needless to say, this is not time-out reinforcement. In
order for 3-to-5 minutes of time-out to be effective, it must be time-out from all
reinforcing consequences:
• Nothing to look at
• Nothing to do
• No one to talk to
• Nothing to listen to
It must be as close to a total absence of reinforcing consequences as is humanly

possible. An example of the time-out method to be used in the home and only
in the presence of the immediate family is noted below and only for the follow-
ing behaviors:
1. Tantrums
2. Hitting
3. Biting
4. Destructive behaviors
5. Writing on walls
When you observe one of these serious, destructive, or dangerous behaviors:

202 " • EDUCATION
1. Immediately take him by the hand and say, "We do not have tan-
trums," and so forth. You must use the words, "We do not."
2. Seat him quickly in a small chair facing a blank wall.
3. You must be at all times within 1-2 feet of your child.
4. If he attempts to leave the chair, without saying a word, gently return
him to the chair with your hands.
5. Above all avoid a chase-a chase is fun-this is not fun time.
6. If he yells, screams, kicks the wall, curses, says he has to go to the
bathroom, ignore him. Do not say a single word.
7. He must remain in the chair a minimum of 3 minutes.
• Do not set a timer.
• Do not use an egg timer.
• Do not tell him how long it will be-for all he knows it is 300
minutes.
• Do not say, "Be quiet, sit still."
• No words.
8. If he tries to talk to you, do not answer him-not a word.
9. Use a watch-approximately 3 minutes.
10. After the 3 minutes, wait until he has been seated quietly for 5 sec-
onds. Then quickly got to him and tell him, "You have been quite well
behaved, you may now leave the chair."
11. If he refuses to leave the chair, say: "You may leave whenever you
wish." First words are "We do not."
Next words are, "You have been quite well behaved, you may now
leave the chair."
12. If he is in the chair more than 4 minutes, wait for 2 to 3 seconds of
seated quietly behavior.
Never allow him to leave the chair unless he has been seated quietly
for a minimum of 2-3 seconds.
13. If he wishes to talk to you about the incident afterward, the only thing
you may say to him is "We do not (insert behavior}." Say it over and
over again like a broken record.
SUMMARY
If we are ever to improve the human condition, it will be necessary to
understand those learning experiences during the formative years of a child's
life. For over 100 years, children's behavior has been viewed not as the result of
learning but as the result of deep-rooted unconscious conflicts within the
psyche.
If we are to make progress in terms of achieving our unalienable right to
the pursuit of happiness, we must begin to look at behavior in a new way.
Behavior must be viewed not as the result of unseen inner events but as the
result of consequences. The cause follows the behavior. One way of viewing
children's behavior is in terms of a garden of behaviors. Parents, by way of their

nurturance, must selectively reinforce specific classes of behaviors.
The child is surrounded by verbal behavior from the moment of birth.
When she is physiologically capable, she begins to imitate these verbal behav-
iors. These imitated behaviors as a matter of course are given an abundance of
nurturing. MaMa, DaDa, book, ball, truck, and so forth are nurtured by way
of immediate consequences of love, warmth, caring, and attention. The result is
children who never stop talking.
There are a whole host of other behaviors that we as behavioral psycholo-
gists must also consider noteworthy. Behaviors that are not only the founda-
tions of self-esteem but the foundations of mature adult functioning. We who
are behavioral psychologists must teach parents how to be sensitive to these
quiet behaviors that, during the formative years, need the same nurturance that
parents as a matter of course give to the child's first words. These behaviors
need more than praise. They need the equivalent of the nurturance given to
those very first verbal behaviors. They need praise, plus time, plus love, plus
attention.
Equally important, parents must be taught how not to nurture the weeds.
Because parents have been taught by professionals that problem behaviors are
the result of deep-rooted problems, deep-rooted conflicts, they often without
question give their attention and love in abundance immediately following
problem behaviors. On the wall of a child guidance clinic, a saying read,
"Children need love when they least deserve it." The result will be more, least-
deserve-it behaviors. Helen Keller is the ultimate example of a child whose
parents, with the very best of intentions, gave her love when she least deserved
it. The result is a child who today would have been labeled a "difficult child."
Annie Sullivan, her teacher, should be taken as the model of the first
behavior therapist. She was the individual who first was aware of the fact that
parents must be selective in responding to their children's behaviors. What
Annie Sullivan did was without a doubt a major accomplishment. She took
Helen Keller, the difficult child, whose parents had nurtured the weeds in
abundance, and by way of selective consequences taught her to become a
woman of great accomplishment.
REFERENCES
Azerrad, J. (1980). Anyone can have a happy child. New York: M. Evans.
Azerrad, J. (1985). Unpublished manuscript.
Cautela, J. R. (1970). Covert reinforcement. Behavior Therapy. 1. 33-50.
Ellis, A. (1990). Live at the Learning Annex (public discussion), New York.
Freud, S. (1916). Introductory lectures on psychoanalysis, Vol. 16. New York: Liveright.
Gibson, W. (1957). The Miracle Worker. New York: Knopf.
Harlow, H. F., Zimmerman, R. R. (1959). Affectional response in the infant monkey. Science, 130,
431-432.
Hendrix, H. (1990). Getting the love you want. New York: Perennial Library.
Le Shan, E. (1965). How to survive parenthood. New York: Random House.
National Public Radio (1994, October 4). All things considered (radio broadcast). Washington,
DC: Author.
New York Times (1983, May 10). (Galileo "heresies" still under study, pope says, p. A12.)
Skinner, B. F. (1953). Science and human hehavior. New York: Free Press.
Skinner, B. F. (1971). Beyond freedom and dignity. New York: Knopf.
Spitz, R. A. (1949). Motherless infants. Child Development, 20,145-155.
Stuart, R. B. (1980). Helping couples change. New York: Guilford Press.
Sulloway, F. J. (1987). Reassessing Freud's Case Histories. Isis, 82, 245-275.
Sulloway, F. J. (1990, March). As a therapist, Freud fell short, scholars find. The New York Times,
p. C1.
III
Developmental Disabilities
12
Improving the Human

Condition through
Communication Training
in Autism
Jennifer L. Twachtman
Tell me, and I'll forget. Show me, and I may not remember.
Involve me, and I'll understand.
-Native American saying
Intentional communication is more than just the words we choose or the

gestures and paralinguistic features (e.g., tone of voice, intonation and stress
patterns) we use to augment them. At its most basic level it is an active effort to
affect one's environment-the power to make adaptations and/or bring about
change in the human condition. Indeed, the human being's ability to communi-
cate may well be considered his or her "crowning" achievement. It is through
the use of a shared symbol system that we are able to code and express past and
present experiences, speculate about future events, deal with reality, and con-
template the imaginary. Notwithstanding its complexity, communication is
often taken for granted, given its perceived "universality" among human beings
and the apparent effortlessness with which it develops in most people.
Deficits in communication and social relatedness have been perceived as
defining features of autism since its earliest descriptions (Kanner, 1943; Rutter,
Jennifer L. Twachtman • Braintree Hospital Pediatric Center, 751 Granite Street, Braintree,
Massachusetts 02184.
207
208 III • DEVELOPMENTAL DISABILITIES
1985). These views have persisted throughout scientific investigation of the

disorder (Autism Society of America, 1994; Rutter & Schopler, 1987). Omni-
present as they are, however, the communication difficulties associated with
autism have been difficult to define, given that they may manifest themselves
differently from client to client. In some, language form and content may be
virtually intact. Even when this occurs, however, individuals with autism have
considerable difficulty using their language to effectively and appropriately
code and express their thoughts, feelings, and desires (Wetherby, 1986). Hence,
it is the use of language for social communication purposes that is particularly
emblematic of the disorder.
Unfortunately, the distinction between language (i.e., form and content)
and its use for social discourse (i.e., function) is one that is often overlooked.
Misguided clinical priorities that focus on vocabulary and syntax at the ex-
pense of the communicative functions that form their foundation can compro-
mise the child's ability to develop a truly functional communication system.
Thus, even well-intentioned treatment programs may unknowingly jeopardize
the child's grasp of the communicative process and limit his or her ability to
understand and use language effectively, with or without augmentation.
This chapter presents an intervention approach and accompanying ratio-
nale for involving individuals with autism in the process of communicative
development so that they may come to experience, firsthand, the power of
communication as an effective tool for satisfying needs and expressing thoughts
and feelings. Two central themes permeate the intervention strategies outlined
in the following pages. The first concerns the importance of developing a
dynamic communication system that "works" for the child from the moment
of its introduction, regardless of its place in the symbolic hierarchy. The second
relates to the concept of respect for the child and his or her unique perspective
as the framework within which to develop a treatment program that is individ-
ually tailored to the needs of each child. These important issues will be further
delineated after a brief overview of the symptomatology associated with autism
as it pertains to the child's perspective of and response to the environment.
Next, an intervention approach and corresponding decision-making strategies
will be presented from the point of view of the contexts within which it is
recommended that intervention occur. Strategies for determining the communi-
cative means most consistent with the child's level of functioning will also be
detailed. Finally, specific suggestions for the encouragement of speech, where
appropriate, and the reduction of non desirable verbal behavior will be articu-
lated.
UNDERSTANDING AUTISM: THE BASIS OF PERSPECTIVE
Integral to the development of an effective belief system within which to

make judgments and decisions, is the caregiver's understanding of the basic
features of autism. This necessitates an appreciation for how the individual
12 • COMMUNICATION TRAINING IN AUTISM 209
perceives and processes information (input) and how he or she uses that infor-
mation to interact with others (output). An understanding of input is partic-
ularly important because it not only forms the basis of the child's perspective, it
also governs the quality of his or her responses. Further, it is an essential
component of the framework of respect, which will be described elsewhere in
this chapter.
Input: Perceptual and Cognitive Characteristics

Abnormal response to sensation is a defining feature of the syndrome of
autism (Autism Society of America, 1994). Most simply, disturbances in senso-
ry modulation have been conceptualized as hyper- and hyporesponsiveness to
various stimuli (Ornitz & Ritvo, 1985). For example, one child may not re-
spond to certain sounds at all, appearing to be deaf. Another may respond to
the same sound in a volatile manner, appearing to be in pain. In addressing this
issue, Dawson and Lewy (1989) noted that many children with autism have
difficulty regulating levels of arousal.
Although it is possible for a single sensory channel to be affected, most
often the problem is more encompassing (Ayres, 1979); that is, individuals
with autism commonly experience difficulty coordinating sensory input across
modalities. This not only impairs their ability to make sense of the world, it
also compromises their ability to develop communicative competence, given
the latter's reliance on accurate social information (Courchesne, 1990; Gran-
din, 1990; King, 1989, 1990). It is worth noting that sensory distortions have
been substantiated in numerous personal accounts by individuals with autism
(Grandin & Scariano, 1986; McKeon, 1994; Williams, 1992).
These deficits do not occur in isolation; they are complicated by impair-
ments in other areas. For example, deficits in attentional processes (e.g., engag-
ing, maintaining, shifting, and disengaging attention) have been extensively
documented in individuals with autism (Courchesne, 1994; Dawson & Lewy,
1989; Wainwright-Sharp & Bryson, 1993). Interestingly, attention has also
been conceptualized as the link between arousal and aspects of cognitive pro-
cessing (Dawson, 1989).
Deficits in elements of higher-level information processing have also been
documented (Hermelin & Frith, 1985; Ornitz, 1989). Hermelin and Frith
(1985) have noted that children with autism generally do not encode informa-
tion meaningfully by using the properties of the stimulus or group of stimuli.
Other research has concluded that "the critical dysfunction in cognitive pro-
cessing appears to be in deriving the abstract information necessary for se-
quencing material and in transforming this information into symbolic repre-
sentations" (Sigman, Ungerer, Mundy, & Sherman, 1987, p. 115).
Difficulties in these areas have been proposed to account for the observed
disturbances in communication, language, social relatedness, and responses to
environmental stimuli seen in autism (Courchesne, 1990, 1994; Dawson,
1989; King, 1989, 1990; Ornitz & Ritvo, 1985). Specific manifestations may
210 III • DEVElOPMENTAL DISABILITIES
include "gaze aversion, social withdrawal, incessant questioning, ritualistic

behavior as well as motor stereotypies" (Dawson & Lewy, 1989, p. 55). It is
likely that these cognitive and perceptual characteristics are also reflected in the
child's commonly observed difficulties with generalization and the propensity
to rely on a prompt or cue (i.e., prompt dependency) to perform a task (Carr &
Kologinsky, 1983; Rincover & Koegel, 1975; Woods, 1987). Hence, it may be
said that the unique perspectives of children with autism are a direct reflection
of compromises in neurobiological functioning that "impact" their under-
standing of and responses to environmental events (Courchesne, 1994).
Before leaving this important topic it is worth noting that the cognitive
style characteristics of children with autism give rise to patterns of learning
and/ or interaction preferences. These are as follows: (1) preferences for visually
presented information (Mesibov & Burgess, 1994; Prizant & Schuler, 1987);
(2) need for structure and predictable routines (Clark & Rutter, 1981; Olley,
1987; Schopler, 1989); and (3) preferences for the concrete over the abstract
(Garfin & Lord, 1986; Mesibov & Burgess, 1994).
Output: Characteristics of language

As stated, one of the striking features of autism as it presents in young
children is the lack of conventional communication or the presence of language
that is not used functionally to reach goals. The absence of language can be
even more striking if the child had initially developed some words and then
subsequently stopped using them. Even when language does develop, it is often
used in nonconventional, ostensibly nonfunctional ways. For example, a child's
language may be characterized by echolalia, a tendency to repeat the words
and/or phrases of others, either immediately or some time after they are heard.
To the untrained listener, these repeated phrases may appear random and
without purpose; however, it has been demonstrated that both immediate and
delayed echolalia carries with it specific utterance functions (Prizant & Duch-
an, 1981; Prizant & Rydell, 1984). Notwithstanding, even when a purpose can
be established, this use of language is considered peculiar and nonconven-
tional.
In order to understand the nature of the communicative difficulties mani-
fested by the child with autism, it is necessary to determine which aspects of
language are consistently affected. Language has been divided into three com-
ponents: syntax (form/grammar), semantics (content/meaning), and pragmat-
ics (use/function). The first two refer to the message itself-how it is con-
structed. The last refers to what an individual does to insure that the message is
received by another.
Syntax
Grammatical development in autism has been explored by many re-
searchers over the past two decades (Cantwell, Baker, & Rutter, 1978; Bar-
tolucci, Pierce, & Streiner, 1980; Howlin, 1984; Pierce & Bartolucci, 1977).
Bartolucci et al. (1980) reported some differences in the acquisition and use of
grammatical morphemes; however, these were felt to result from underlying
semantic and cognitive deficits. Further, the syntactic systems of children with
autism have consistently been found to be rule-governed, as they are for typical
children (Bartolucci et aI., 1980; Cantwell et aI., 1978; Pierce & Bartolucci,
1977).
At present, the general consensus among reviewers of these works (Paul,
1987; Tager-Flusberg, 1989) is that the syntactic systems of children with
autism are similar to language-matched (MLU) typical children as well as those
with mental retardation and "childhood aphasia," although children with au-
tism may use these structures in a more restricted way. In addition, grammatical
development has been noted to follow the same developmental sequence in
high-functioning children with autism as it does for typical children (Tager-
Flusberg et aI., 1990). This holds true across a variety of syntactic structures
and for mean length of utterance as well.
Semantics
Semantic development was initially believed by many to be a primary
problem are in children with autism (Fay & Schuler, 1980; Simmons & Bal-
taxe, 1975; Tager-Flusberg, 1981a,b). It has been noted by Tager-Flusberg
(1989), however, that these studies do not distinguish whether the child's diffi-
culty stemmed from a lack of conceptual or semantic knowledge or a deficit in
the ability to use that knowledge. She additionally noted that it is unclear in
some studies as to whether the semantic deficits are related to the autism itself
or to more general cognitive deficits.
Recent research efforts have attempted to investigate semantic knowledge
separate from language use. It appears that at basic (single word) semantic
levels, children with autism do not have difficulty learning word labels for
concrete objects (Tager-Flusberg, 1985; Ungerer & Sigman, 1987), although
difficulty acquiring and using more abstract words (e.g., verbs, prepositions,
relational adjectives) has been reported (Menyuk & Quill, 1985).
Paul, Fischer, and Cohen (1988), however, reported that the sentence com-
prehension strategies used by children with autism were comparable to both
typical and language-disordered controls when matched on receptive language
level. Further, the longitudinal investigation conducted by Tager-Flusberg et al.
(1990) revealed that the majority of the subjects with autism followed the same
general pattern of lexical development as that of typical children and those with
Down's syndrome.
Pragmatics
In autism, the child's difficulty with communication extends beyond both
speech and vocabulary to the pragmatic bases of communication (Prizant &
Wetherby, 1987; Watson, 1987; Wetherby & Prutting, 1984). Pragmatics (i.e.,
the social use of language) may be said to be the "bridge" that enables the child
with autism to make connections between formal language skills and the use of
those skills to reach goals (Owens, 1991; Watzlawick, Beavin, & Jackson,
1967).
Investigations into pragmatic development indicate that significant differ-
ences exist between typical children and children with autism in the acquisition
of pragmatic functions (Wetherby & Prutting, 1984; Wetherby, 1986). Three
types of pragmatic functions have been presented by Bruner (1981, cited in
Wetherby & Prizant, 1992): behavioral regulation (the child manipulates an-
other's behavior to achieve an external goal); social interaction (the child draws
attention to self for purely social purposes); and joint attention (the child
directs another's attention to an object or event, to which both attend). In
typical children, these functions generally develop concurrently during the first
year of life (Seibert & Hogan, 1982). In children with autism, however, a
distinct hierarchy has been observed. Specifically, behavioral regulation is the
first type of function acquired, followed by social interaction and then by joint
attention (Wetherby & Prutting, 1984).
Joint attention in particular has been noted to be an area of significant
difficulty for children with autism (Curcio, 1978; Loveland & Landry, 1986;
Mundy, Sigman, & Kasari, 1990; Mundy, Sigman, Ungerer, & Sherman, 1986;
Stone & Caro-Martinez, 1990). This finding is particularly significant because
the establishment of joint attention is so crucial to the development of commu-
nicative competence (Bruner, 1975).
THE NEED FOR A SYSTEM

A communication system has been defined by Vanderheiden and Yoder
(1986) as "the integrated network of symbols, techniques, aids, strategies, and
skills that an individual uses to communicate" (p. 13). This includes all pos-
sible aspects of communicative behavior (both verbal and nonverbal) of which
language per se comprises the "symbols" component.
Most people can relate to the frustration experienced in conjunction with
minor communication breakdowns. A complete loss of a communication sys-
tem would undoubtedly result in more intense feelings of isolation and stress.
In such a situation, communicative attempts would likely be kept to a simple
level, in the interest of establishing some rudimentary basis for understanding.
It is fair to assume that most human beings would initially be quite motivated
to try to communicate because, having had a system, they understand the
power and importance of communication. A consistent lack of success, how-
ever, would likely have a variety of effects: (1) passivity (lack of motivation); (2)
powerlessness (lack of control); and (3) stress (anxiety). After this point, even
the most basic displays of intentional communication would likely not be
attempted.
Through parental and professional report, there is some preliminary evi-

dence to suggest that being unable to communicate needs is a high source of
stress for individuals with autism, as it would be for most people (Groden,
LeVasseur, Diller, & Twachtman, 1994b).lt would be logical to conclude, then,
that the development of a reliable communication system would help to reduce
stress in the individual's life, thereby enhancing the quality of that life. Children
who have developed the use of a reliable communication system have been
noted to display fewer observable indications of stress (operationalized as dis-
ruptive and self-stimulatory behavior) (Carr & Durand, 1985; Groden et al.,
1994b; Koegel, Koegel, & Surrat, 1992). As such, the provision of a reliable
communication system is of the utmost importance, especially when one places
a high priority on improving the human condition.
GETTING DOWN TO BASICS: THE FRAMEWORK OF RESPECT
The quality of our interactions with others is largely based on our belief
systems, within which are the attributions we make about the behavior of
others (Baron & Byrne, 1987). Attribution has been defined as "the process
through which we seek to determine the causes of others' behavior and gain
knowledge of their stable traits and dispositions" (Baron & Byrne, 1987,
p. 71). Indeed, how we perceive a given behavior will affect our response to it.
Given the transactional nature of communication (Watzlawick et al., 1967), it is
important that our attributions be as accurate as possible, since our behavior in
turn affects the clients' responses.
Attributions are of central importance to the establishment of a frame-
work of respect. The latter goes well beyond superficial social niceties to a
fundamental acceptance of another human being as he or she is. An essential
component of any humane treatment program, a framework of respect may be
conceptualized as an important building block for improving the human condi-
tion. Further, since clinical decision making may be shaped by the degree of
caregiver respect for the client and his or her unique perspective, it is necessary
to operationalize this elusive construct. Below are four elements considered
essential to the construct of respect as it relates to the provision of communica-
tion services in autism.
Attribution
This notion is particularly salient (and problematic) in autism given that
an individual's behavior may be nonconventional and/or undesirable. There is
a wealth of research that documents that disruptive behavior can serve a variety
of intentional communicative functions, as well as evidence that unintentional
behavior has message value (i.e., communicates) (Carr & Durand, 1985;
Donnellan, Mirenda, Mesaros, & Fassbender, 1984; Watzlawick et al., 1967).
The attribution of intentionality will have profound effects on the response
to an individual's behavior, and thus to the clinical decisions that are made.
Given this set of circumstances, it is easy to see that the untoward attribution of
presumed intentionality where it does not exist can result in erroneous judg-
ments and faulty clinical decisions. Consequently, it is essential that one's
attributions be suspended until the function of a given behavior within the
context in which it occurs is fully explored.
Initiation
Initiation refers to the proactive concept of taking the lead in communica-
tive interactions. It represents an essential part of the communicative process in
that it allows the individual to exert control over his or her environment. It is
the basic premise of this writer that all individuals have a right to be given a
communication system that they can use immediately, easily, and indepen-
dently to initiate communicative interactions for all targeted functions. A sys-
tem with such characteristics is defined as a reliable system. It is important to
emphasize the "immediacy" component of the definition-the system must
"work" from the first few trials of its introduction if it is to meet the standard
of functionality so essential to meaningful communication. It should be specifi-
cally noted that systems that incorporate the dimensions noted above generally
occupy lower "rungs" along the symbolic ladder. This does not preclude even-
tual progression to more sophisticated systems, it merely insures that the cho-
sen system will be effective for the child in the present.
The concept of initiation is of particular importance in autism since con-
versational initiation is usually deficient (Feldstein, Konstantareas, Oxman, &
Webster, 1982; Loveland et ai., 1988). It is often assumed, however, that such
individuals are deficient in all aspects of initiation. Careful observation, how-
ever, illustrates that this may not be the case. For example, a child who hits
others or leaves an activity to indicate that he or she wants to be finished with it
is initiating even though the behavior used is undesirable. Indeed, when the
definition of initiation is broadened to include nonverbal and/or nonconven-
tional communicative attempts, deficiencies in initiation are not as clear-cut
(Loveland & Landry, 1986; see also Seibert & Hogan, 1981, cited in Howlin,
1986). As stated above, however, qualitative pragmatic differences are observed
when these initiations are analyzed and subsequently compared with those of
typical peers or peers with language and/or cognitive delays.
Difficulties using readable, conventional means of initiation can lead to
several undesirable effects such as passivity (MacDonald, 1989) or stress
(Groden et ai., 1994b), the eventual outcome of which may be nonconventional
behavior (Groden, Cautela, Prince, & Berryman, 1994a; Koegel et ai., 1992).
Fortunately, the teaching of initiation may help to alleviate these behavioral
overlays. For example, Oke and Schreibman (1990) have noted that the disrup-
tive behavior manifested by a boy with autism decreased when he was taught to
initiate communication with typical peers. Interestingly, these effects were not
seen when the peers were the initiators.
Perspective
One of the main by-products of human interaction is the articulation of
one's perspective. Notwithstanding, central to effective interaction is an appre-
ciation for the perspective of the communication partner. Competent commu-
nicators seem to adroitly shift back and forth between expressing their personal
perspective and attending to the perspectives of others.
Unfortunately, the individual's perspective is not always apparent in au-
tism, given the neurobiological compromises that affect behavioral output, the
idiosyncratic nature of responses, and the contextual variables that mediate
those responses. Taken together, these factors make the task of determining the
child's perspective a complex and dynamic process. Thus, frequent, systematic
assessment and reassessment of the individual's perspective is necessary.
Ease
As stated earlier, communication is construed as being deceptively easy for
human beings. One of the components most illustrative of the concept of
communicative ease in typically developing children is the speed and relative
effortlessness with which their interactions occur. It is commonly known that
augmentative systems that function in place of speech require considerably
more time to employ (Kraat, 1986) and that even small increases in time can
significantly affect the flow of an interaction (Vanderheiden & Lloyd, 1986).
Further, such systems rarely reach the level of fluency (i.e., facility) characteris-
tic of normal communicative development (Kraat, 1986).
Another component of communicative ease in typical people concerns
their understanding of the pragmatic concepts and corresponding behaviors
necessary to function in a given interaction. As noted above, individuals with
autism demonstrate specific difficulty in this area.
A third component relates to the establishment of a one-to-one correspon-
dence between a given symbol and the actual object it represents (i.e., symbolic
representation). The child with autism slated to use line drawings to communi-
cate because he or she shows a rudimentary understanding of them is actually
being asked to perform two tasks-picture identification and requesting. Both
of these are often difficult for the child, even as individual tasks. In addition, it
appears that this difficulty is compounded when the tasks need to be inte-
grated, given the relatively common observation of satisfactory performance in
separate areas (e.g., picture labeling, requesting via natural gesture) but appar-
ent inability to integrate these to improve the efficiency of communication.
Consequently, communication systems that require a level of skill integration
that the child is not ready to incorporate with ease may compromise his or her
ability to initiate.
It is logical to conclude that the system that is easiest for the child to use
will be the one that will give him or her the most freedom and power to initiate
communication to satisfy needs and desires. Since the system that allows the
child to initiate may be at a lower symbolic level than the one that allows him
or her to merely respond (to adult directives or prompts), it may not be the
system that is preferred by adults. Notwithstanding, the notion of respect
dictates that it is the child's (not the adult's) preferences that should be at the
core of clinical decision making if true functionality is to be established.
IMPLEMENTING THE SYSTEM
Instructional Contexts
When asked to envision a situation in which one does not have a means of
communication, many people imagine being in a foreign country where the
language and customs are unknown. Through such contemplation, people
appear to feel that they have some insight into the "variation on the world"
that the individual with autism experiences. While this is true to some extent,
in actuality much is being missed. Specifically, viewing the situation of "being
in a foreign country" as an exemplar of being without a means of communica-
tion overlooks the underlying difficulties that can occur at a fundamental level
of communication. To elaborate, it is more accurate to say that in this situation,
one is contending with the barriers created by different language as opposed to
the lack of a communication system. Indeed, many examples of nonverbal
communication are consistent across cultures (e.g., six basic emotions are ex-
pressed very similarly on the face) (see Buck, 1984; Ekman & Friesen, 1975;
Izard, 1977). These nonverbal universals, combined with knowledge of the
process itself, would give one a communicative reference point (albeit a rudi-
mentary one) that is missing in autism.
This example illustrates the ease with which one may overlook the most
fundamental needs of individuals with autism. Such a propensity, coupled with
the unique pattern of linguistic and communicative features that these individu-
als manifest, requires the employment of qualitatively different instructional
strategies. These need to be tailored according to the features of autism, yet
must be flexible enough to serve the individual needs of this heterogeneous
population. To achieve these goals, it is necessary to integrate three contextual
reference points: pragmatic, situational, and behavioral.
The Pragmatic Context

As demonstrated, the pragmatic deficits inherent in autism impair the
basic reference point from which humans interact (i.e., social knowledge).
Thus, in addition to difficulties that compromise the development of the sym-
bolic "system of choice" (speech), there are concomitant difficulties in under-
standing how such a system (or any system) could be used to meet ones needs.
Many traditional intervention programs appear to place priority on the train-
ing of the symbolic system itself (i.e., vocabulary). Pragmatic considerations
(i.e., teaching the child how to use the system) often occur after the child is
taught to identify the symbols that represent its vocabulary.
In autism, such a focus is not sufficient. Rather, it is necessary that training

in initiation based on pragmatic functions define the development of a system. It
may be necessary to delay a focus on the development of a "complete" symbolic
system (with the full range of vocabulary) in favor of teaching basic communica-
tion strategies (with one or a few vocabulary items initially) that can be used
consistently and effectively (Twachtman, 1995). For example, the picture ex-
change communication system (PECS) developed by Bondy and Frost (1995)
focuses on teaching the child to initiate communication using pictures. To
achieve this, the child is taught to give a picture (as opposed to pointing to it) of a
desired item to an adult in order to request that item. The focus, here is on the
exchange, whereby the child learns to initiate, within the pragmatic hierarchy
characteristic of autism (i.e., requesting). The building of vocabulary is down-
played in favor of this focus, in that the child is exposed to one picture at a time.
Training in "prerequisite" skills such as eye contact, picture discrimination, and
imitation (e.g., Carr, 1982; Goetz, Schuler, & Sailor, 1979), necessary foci when
the priority is placed on vocabulary development, is not conducted. Preliminary
data have documented that most children learn the basic exchange very quickly,
and that 73'1'0 have eventually developed independent speech or speech aug-
mented by pictures or written words (Bondy & Frost, 1995).
Further, it must be stressed that de-emphasis of the symbolic system may
be necessary even if the child is able to understand, label, and/or discriminate
between pictures or is able to read words, since such abilities do not necessarily
indicate a readiness to use such stimuli for interactive purposes. This is partic-
ularly relevant for the child with autism because the pragmatic function of
requesting may, in reality, be the more difficult task than that which super-
ficially appears to be at a higher level. Wetherby and Prizant (1992) and
Wetherby (1986) stress the importance of teaching the child to use different
systems to communicate different pragmatic functions, if the child's communi-
cative competence varies between these (e.g., the child may request via a picture
system and protest via a push-away gesture).
The Situational Context

Communication occurs in many contexts. Watzlawick et al. (1967) have
stressed the importance of analyzing each context within which a given interac-
tion takes place. Failure to do so, they state, can lead to misinterpretation of the
interaction, and consequently faulty judgments. For example, a child who
independently requests food at snack time but does not do so on a field trip to
McDonald's is probably not just being stubborn or noncompliant. More likely,
he or she is being affected by the contextual elements of the situation (e.g.,
crowded, noisy, unfamiliar, etc.) and, as such, is unable to meet the demands of
the situation.
Thus, the situational context is as important to intervention as is the
pragmatic context. Therefore, functional communication should extend be-
yond pragmatically relevant situations to the actual settings where communica-
tion needs to occur or does occur via an unconventional means. Willard and
Schuler (1987) have stressed the importance of this facet of intervention for
individuals with autism. Through it, a child is taught to use a communication
system in his or her classroom and/or home or community setting, instead of in
a separate therapy room. Sessions, likewise, are not isolated blocks of time
where a child "works on communication," but rather real-life situations where
the child's means of communication must "work" at all times.
The Behavioral Context

Behavior modification techniques are not new to the field of autism. Early
literature is replete with detailed accounts of how they have been used to
increase desirable behaviors including speech production (Lovaas, Berberich,
Perloff, & Schaeffer, 1985), as well as how they have been used to reduce
nondesirable ones (e.g., Johnson & Koegel, 1982).
A problem with the early uses of behavior therapy is that many of the skills
learned, including speech, did not generalize from one situation or stimulus to
another (Fay & Schuler, 1980; Lovaas, 1979; Rincover & Koegel, 1975). To
encourage generalization and increase overall effectiveness, more recent litera-
ture recommends the merging of sound behavioral techniques with more func-
tional approaches (Carr & Durand, 1985; Charlop, Schreibman, &
Thibodeau, 1985; Koegel et aI., 1992; Koegel, O'Dell, & Dunlap, 1988). The
co-mingling of these techniques has resulted in increased generalization across
settings and referents (Charlop et aI., 1985; Krantz & McClannahan, 1993)
and in improvements in overall learning as well (Williams, Koegel, & Egel,
1981).
The behavioral context provides a structured setting within which to teach
the use of a system. In addition to the structure itself, two of its components are
crucial to intervention with individuals with autism. Together, these provide a
clear, concrete framework for intervention:
1. The use of natural reinforcers contingent on the use of the targeted
pragmatic function teaches the power of communication (Williams et
aI., 1981) in contextually appropriate situations.
2. The use of a modified discrete trial format (Koegel, Russo, & Rincover,
1977; Woods, 1987) in a naturally occurring routine (e.g., snack) gives
the child a way to perceive the communicative act (e.g., a request) as a
distinct act with a clear beginning and ending. In addition, it allows the
clinician to provide multiple opportunities for communication to occur
within a given situation.
The Importance of Communicative Means

When parents are asked what they want most for their child with autism,
many answer, "I just want him to talk." This priority, coupled with the uneven
pattern of strengths and deficits seen in autism, has created a focus on speech
(as opposed to other, nonverbal means of expression) as the key "end goal" in
intervention. This is often the case even when a child is initially taught to use
other systems (e.g., sign language or a communication book).
Notwithstanding the high priority placed on speech development, it may
not be the ideal vehicle for communication in children with autism. In fact, a
"blind" emphasis on speech in the absence of first building a communicative
base can seriously undermine the development of communicative competence
(Twachtman, 1988). Clinicians who serve young children with a variety of
communicative disorders recommend a shift in focus from the child's symbolic
level to what he or she does to communicate (MacDonald, 1982; Prizant &
Wetherby, 1987; Twachtman, 1988).
As with other augmentative system users (Vanderheiden & Lloyd, 1986),
symbol selection decisions for children with autism are often determined by
"the highest ... level in the hierarchy that the child is able to readily recognize
as representative of the vocabulary items necessary for functional communica-
tion" (Mirenda & Schuler, 1988, p. 38; see also Mirenda & Schuler, 1986).
Two potential difficulties may arise from a reliance on this principle.
First, in cases where the child is capable of using those forms he or she can
produce, there is a danger of progressing too quickly from one symbolic level to
another in a manner where the "old system" is taken away in favor of a more
sophisticated one. This may be confusing for the child who may need more
experience with the former system before moving on to the latter. Such experi-
ence may take the form of expanding use of the original system across settings,
people, and exemplars. In this case, it is important to note that the child may
not be able to use the more sophisticated means independently. Thus, he or she
would require some level of prompting in order to use the system. In such
circumstances, it is believed by this writer that instructing the child to use a
communicative means that he or she cannot use independently may help to
create prompt-dependency in communicative interactions. Consequently, com-
municative and language intervention must begin with the system that will
allow the child to communicate with a high degree of comfort, that is, one that
will "work" for him or her by allowing immediate, easy, and independent
access to the communicative process.
Second, it is the contention of this writer that the traditional tendency to
encourage the child to use the "highest symbolic level" to communicate often
does not fit with the developmental process and characteristics seen in autism.
This is because the production of words or sentences and the use of these to
communicate are not always equal. Specifically, the function of a "communica-
tive" behavior (e.g., speech) may not correspond to traditional interpretation.
For example, Hurtig, Ensrud, and Tomblin (1982) have found that question
production did not serve the conventional function of "request for informa-
tion." Rather, it served to initiate conversations. In addition, several re-
searchers have documented the variety of communicative functions served by
echolalic utterances (Prizant & Duchan, 1981; Prizant & Rydell, 1984).
The ability to initiate is a stated "requirement" for an augmentative com-
munication system to be considered appropriate (e.g., Vanderheiden & Lloyd,
1986). In practice, however, clinical decisions appear to conceptualize the

"ability to initiate" in physical and cognitive dimensions rather than pragmat-
ic ones. Thus, if a child can physically use the system and understand what its
symbols represent, it is considered to adequately serve the function of initia-
tion. In autism, pragmatic considerations are equally as important as cogni-
tive ones because: (1) the child's pragmatic abilities strongly determine how
well he or she is able to initiate; and (2) as explained above, children with
autism may have difficulty with the integration of pragmatic and cognitive
tasks.
Determining Communicative Means

It is of paramount importance to determine the preferred means of com-
munication for the child with autism vis-a-vis pragmatic function and situa-
tion. As has been stated by Wetherby and Prizant (1992), children with autism
may use different means for different functions [e.g., a child may use pictures to
request and natural gesture (i.e., push-away) to protest]. In addition, children
may use one communicative means for all functions, but use different levels of
that means for different functions (e.g., short verbal sentences for requesting
and single words for commenting).
Two assumptions are made by this writer when determining communica-
tive means: (1) those who are able to communicate intentionally will use the
means which is easiest for them; and (2) a key factor in the determination of
which system is "easier to use" is the individual's ability to initiate quickly
using that system.
Because level of initiation is a crucial factor in this determination, it is
important to systematically assess it during communicative interactions. A data
sheet that allows for a clear delineation of the effectiveness of the child's means
is presented in Figure 12.1.
The data sheet is constructed to allow the collector to tally each occur-
rence of communication for a given function. Two means (or two levels of the
same means) may be assessed simultaneously; space is provided to list up to
four examples (vocabulary words or concepts) for each means. As stated else-
where, one means may not be exclusively dominant for the purpose of initia-
tion. Therefore, the ideal means should be assessed for each pragmatic function
within a given situation.
Several different means should be assessed initially, with continuing assess-
ment occurring as the child progresses. An advantage of the data sheet is that it
can function as the data system for a particular communication goal even if the
child is not moving to a more sophisticated system.
It is additionally important to note that the child's preferred system should
not be construed as static (Wetherby & Prizant, 1992). As language and com-
municative competence develop, the symbolic level used by the child should
evolve to accommodate his or her growing needs.
EFFECTIVENESS OF COMMUNICATIVE MEANS
Name _ _ _ _ _ _ _ _ _ _ _ _ _ Unit _ _ _ _ _ _ _ Date:. _ _ _ _ _ __
Communicative Function: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Staff. _ _ _ _ _ __
Setting _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Prompt Level
Spon- Multiple
taneous + Verbal: + Gestural: + Physical: Prompts Model
(/)
Q)
D..
E
ro
x
W
(/)
c
ro
Q)
~
0)
>
~
u
'c
:::J
E
E
o
u
r·------+- - - ----------+- -----+--- ----+----
'----
• If possible, write example of the verbal, gestural, and physical prompts given
Figure 12.1. Effectiveness of communicative means.
A PARADIGM FOR DECISION MAKING
Because the communicative needs of the child with autism are many and
varied, prioritizing treatment steps may be a difficult task. Several decision-
making guides have been designed to ease this process. For example, Carr and
Durand (1985) use a child's problem behaviors as their reference point for
decision making. First, they developed an assessment method to identify the

situations in which problem behaviors were likely to occur. Following this, they
used the assessment data to choose appropriate communicative behaviors to
replace the problem ones. Although this technique represents consideration of
an important factor in the decision-making process, other factors need to be
considered, as well. Specifically, this procedure does not provide a way to
determine the most effective communicative means within which the child may
execute the replacement behavior. As noted above, the communicative means
chosen will have a significant effect on the child's ability to initiate the targeted
communicative function.
The five steps presented provide a decision-making paradigm that takes
into account the child's needs with respect to both problematic situations and
communicative ability:
1. Consider the pragmatic hierarchy. (1) Determine how the child's com-
municative attempts fit into the categories of behavioral regulation, social inter-
action, and joint attention. (2) Use the hierarchy to determine where the child is
(Wetherby & Prizant, 1992). For example, if the child has difficulty regulating
behavior, focus on this area and deemphasize the others. The hierarchy should
help to determine directions for treatment.
2. Determine the situations where a system is needed. It is recommended
that many situations be chosen to teach the child that communication can occur
anywhere, at any time, and with anyone. A key factor in determining which
situations to target for intervention is based on motivation. A child is likely to
have the greatest success when targeted situations are ones in which the child is
motivated to communicate. Utilizing these situations is not only crucial to the
empowerment of the child as a communicator, it also deters passivity that may
result from unsuccessful attempts (MacDonald, 1989; Prizant, 1994).
3. Match the pragmatic level and the situation. Once the pragmatic level is
determined, the functions within it should be matched to situations within
which they can occur. For example, if the child is at the level of using communi-
cation for the purposes of behavioral regulation (e.g., requesting), this function
must be taught in a situation where he or she is able to regulate another's
behavior (e.g., the child must want something).
4. Structure the situation. Each situation should be shaped to teach the
pragmatic function in the context of it. Make the activity concrete via the use of
behavioral techniques, such as a modified discrete trial format, which maxi-
mizes naturalistic proced,ures, contingencies, and reinforcement (Twachtman,
1995; Williams et ai., 1981).
5. Consider the communicative means. This should be continually reas-
sessed when addressing as many targeted situations as possible to ensure that it
is (1) the optimal method of initiation for the child, and (2) appropriate to the
context created by the interaction of pragmatic and situational variables.
Even when these steps are followed, the "final product," as a whole, must
be examined to ensure that it appropriately serves the child (i.e., that it
"works" for him or her). Layton and Watson (1995) have outlined five behav-
iors that are mandatory for an individual to be a communicator: (1) something
to communicate about; (2) understanding of cause and effect; (3) a desire to
communicate; (4) a communication partner; and (5) a means of communica-
tion. These provide the professional or caregiver with a simple way to evaluate,
at a basic level, the utility of the system.
Because the system must be functional and reliable, frequent adaptation of
it and flexibility on the part of the caregiver may be required. In addition,
communication training does not stop once the child "learns" a defined com-
munication skill. He or she must be continually encouraged to use the acquired
system, especially in new settings, with new people, and new items. Attention
to these parameters can help to promote functional use of the system and
ensure generalization of skills.
OTHER CONSIDERATIONS
Transitioning between Systems

As noted earlier, an emphasis on initiation does not preclude the child's
progression to more sophisticated symbolic systems. Such progression is en-
couraged given two conditions. First, it must proceed at the child's pace. This
refers to the notion of gradual replacement of the current system. For example,
a child who begins to use a few words should not have his or her communica-
tion book or other augmentative system taken away until speech has developed
into a more reliable communication system. He or she should not even have the
individual pictures removed because he or she now "knows" them, a mistake
commonly made by well-intentioned caregivers and professionals. The replace-
ment of one system by another is largely child-determined-based on the
system he or she uses to initiate-although specific strategies may be employed
to facilitate a smooth transition. Second, the child's ability to initiate must
remain the primary focus of intervention. The following procedure is recom-
mended to ensure a transition that preserves initiation:
1. Allow the child to initiate through his or her current means.
2. Acknowledge the initiation, but do not provide natural reinforcement
(e.g., for a request, let the child know that you got the message, but do
not immediately meet the request).
3. Provide the necessary support to encourage use of the more sophisti-
cated means. A variety of strategies may be used here, including time-
delay (Berkowitz, 1990; Halle, Marshall, & Spradlin, 1979) and
prompt-fading procedures (Billingsly & Romer, 1983).
4. Provide natural, pragmatically appropriate reinforcement following use
of the more sophisticated means.
A word of caution is in order. If the child does not use the new means after
two or three attempts to elicit the response, provide the natural reinforcement
to preserve initiation. Finally, it is extremely important to consistently monitor

the child's use of initiation when he or she is transitioning between systems.
Encouraging Speech
Through informal clinical observations, there appears to be a significant
percentage of individuals with autism who exhibit some form of motor speech
disorder. Although it has been argued that speech should not always be the first
system to be considered, some children may be held back from using it by
purely motoric factors. For these individuals, it is appropriate to work toward
speech as a communicative means, given the proper combination of communi-
cation training and speech therapy.
It must be again emphasized that speech should not be considered as a
means to communicate unless the following factors are present: (1) the child is
using another symbolic system (e.g., sign or pictures) to reliably communicate
needs, as defined above; (2) the child understands that he or she can use his or
her voice to communicate (Wetherby, 1986); and (3) the proper oral-motor
prerequisite skills are present for the formulation of words. All of these factors
may be assessed through formal assessment procedures and observation of the
child's use of vocalizations. The protocol presented above for transitioning
between systems, coupled with the "Effectiveness of Communicative Means"
data sheet (Fig. 12.1), can also be used to encourage the development of verbal
language. A particular advantage of the data sheet is that the child's ability to
use individual vocabulary words may be assessed. This is of particular impor-
tance when the presence of a motor speech disorder is questioned, as certain
sounds may be more difficult for the child to produce independently (Love,
1992).
Addressing Nondesirable Verbal Behavior

When a child with autism develops speech, understandably many parents
and clinicians are most concerned with encouraging any attempt at verbaliza-
tion. They may be unprepared for what that child might choose to say, if
nondesirable verbal behaviors develop such as swearing, whispering, "nag-
ging," or "talking too much."
Two potential difficulties arise from the development of nondesirable ver-
bal behaviors. First, because the battle for speech was so "hard-fought," many
fear that if they intervene, the child will stop talking. Second, given our knowl-
edge of the power of words, there is the potential for faulty intentions to be
attributed to the child's speech. The reasons for this stem from (1) the potential
difficulties humans may have with conceptualizing autism, exemplified above,
and (2) our assumptions about speech. Most of us feel that we know what we
are saying. Thus, we are held accountable if our words, or the way in which
they are rendered, upset another in any way. Speech appears to be assumed by
many to be the "magic door to normality" in that individuals with autism are
often expected to "know the rules" of conversation and communication just as

we know them. This expectation is evidenced by common sentiments that, for
example, "X knows the answer to that question, he or she is just trying to get
me to change my mind." In this sense, many individuals appear to lose their
sense of the pragmatic difficulties of autism once the child begins to talk.
Although the importance of attributing respectful motives to the behavior
of individuals with autism has been stated by some (Groden & LeVasseur,
1995; Twachtman, 1995), a comprehensive package of alternate attributions is
not always given. There are many reasons why a child may produce a non desir-
able verbal behavior, aside from the intention to upset another. These reasons,
along with optional strategies to address them, have been organized in a hand-
out series (Twachtman, 1994). Each handout in the series addresses one behav-
ior. Depending on the behavior addressed, five or six attribution categories are
given. These include auditory processing difficulties/cognitive style; pragmatic
deficits; insistence on sameness; time perception deficits; sensory/perceptual
difficulties; and other neurological difficulties. A sample portion of the handout
that addresses "nagging" is presented in Table 12.1.
SUMMARY AND CONCLUSIONS
Autism presents a unique "variation on the theme" of the human condi-

tion. While many of the universal themes that characterize human nature in
general apply to autism, some specific developmental patterns give autism its
uniqueness. An intervention program must consider the child's entire perspec-
Table 12.1. Behavior: "Nagging"-Why Does X Ask a Question Over and Over
Again?
Possible reasons
Auditory processing • Client may not process the answer given

difficulties • If the client was not given a concrete answer to the question,
he/she may need to ask again
Pragmatic deficits • Difficulty using language (i.e., the child may not know how to con-
ventionally tell you that they do not understand your response)
Insistence on same- • Need for conversational closure (i.e., if the child is not given a
ness concrete answer, he/she may feel a need to continue asking, even if
he/she knows that the request cannot be met at that time
Time perception • A child may not know how long he/she should wait to ask the
deficits question again
Other neurological • Autism may co-occur with other neurological difficulties (e.g., at-
deficits tention deficit disorder; obsessive-compulsive disorder)
• Children may perseverate (i.e., get "stuck" on making a particular
response-this is a neurological problem)
tive-as it both conforms to and differs from ours. An active appreciation for
this will enable the caregiver or clinician to make more accurate attributions
about the behavior of children with autism.
This orientation forms the basis of the framework of respect, the compo-
nents of which have been presented as essential building blocks to effective
communicative intervention. The clinical priority of giving the child a commu-
nication system that can be used immediately, easily, and independently to
initiate defines the intervention approach presented. This approach requires a
shift in focus from communicative means to the individual's ability to initiate
effectively and appropriately.
It has been proposed that such a shift may reduce stress, increase indepen-
dence, reduce nondesirable behavior, and decrease prompt-dependency during
communicative interactions. Individuals who learn to effectively initiate will
develop an understanding of how to use communication to affect many aspects
of their lives; they will become more active participants in the human experi-
ence.
This chapter provides several directions for both clinical practice and re-
search:
• This writer feels that the clinical emphasis on and orientation to the
construct of respect and its components should not be assumed. Rather,
it must systematically be defined and its importance emphasized to those
who serve individuals with autism.
• In keeping with the above, a shift in clinical priority from the sophistica-
tion of the communication system used to its functional utility is recom-
mended.
• More research is needed on the relationship between symbolic level and
initiation. This will further define effective methods for transitioning
between systems as the child's communicative and cognitive skills in-
crease.
• The relationship between initiation and prompt-dependency warrants
systematic investigation.
• The use of respectful means for reducing nondesirable verbal behaviors
without discouraging speech production should be explored empirically.
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IV
Social Issues
13
The Social Relevance

of Applied Behavior Analysis
and Psychological
Intervention Strategies
Waris Ishaq
This current volume of issues in behavior therapy is a response to the crises of

our times. Some of the problems we face endanger our planet and the survival
of all living organisms-humans, animals, plants. At the very least, these prob-
lems place our well-being at risk:
• The threat of a nuclear holocaust and an eternal winter. This will remain
until we stop making, testing, and buying and selling nuclear weapons.
• Pollution. Shrinking rain forests. Holes in the ozone layer. Even sunbath-
ing has become a health hazard. Too much exposure to the sun's ultraviolet
rays, which are getting through the ozone layer, can cause skin cancer.
• Substance abuse and dependency.
• The law-and-order crisis. Drug-related killings and the rate of crime in
general that keeps going up, up, all the time. Small wonder that Ameri-
cans, calling TV stations and writing to newspapers, overwhelmingly
have supported Singapore's public caning of an American teenager for
vandalism and theft.
Waris Ishaq • Department of Anthropology, University of Oregon, Eugene, Oregon, 97403, and
Mental Health Paraprofessionals Training Division, Pacific Behavior Sciences Center, 2581 Will-
akenzie Road, Eugene, Oregon 97401.
235
236 IV • SOCIAL ISSUES
• Poverty and homelessness. The United States, a nation among the richest
in the world and the only superpower, has more homeless people than
anywhere in the industrialized West.
• The decline of educational standards, the dropout epidemic; broken
homes, juvenile delinquency, and teenage pregnancies. And now ac-
quired immunodeficiency syndrome (AIDS), the most merciless killer we
have known.
Most of the problems are behavioral. But they involve emotional suffering, too:
hurt feelings, despair, and worst of all, apathy when one sees no light at the end
of the tunnel. "Problems can be solved, even the big ones, if those who are
familiar with the details will also adopt a workable conception of human
behavior" (Skinner, 1974, pp. 250-251).
THE "GOOD" AND THE "BAD"

In everyday language, one might say, "Let's keep the good, get rid of the
bad." But, in this chapter, I stay away from the terms "bad" and "good." I do
this to avoid sticking people with possibly unwarranted labels. Far too often,
from parents, teachers, and self-appointed arbiters of what is right and what is
wrong, one hears the phrases, "bad boy," "bad girl." A behavior may be
thoroughly undesirable; it may be obnoxious. But there's no such thing as a
"bad" person. Indeed, a behavior described as bad by someone may be some-
thing done at the wrong time in the wrong place. For this reason, we use the
nonjudgmental terms, appropriate and inappropriate.
We use these terms as adjectives for behaviors, not for persons engaging in
such behaviors. In simple English, "appropriate" behaviors are "OK," and
"inappropriate" behaviors are "not OK" behaviors. To these terms, we add two
subclassifications: (1) behavioral deficits (too little or none at all of some
appropriate behavior); and (2) behavioral excesses (too much of some behavior).
In this second category, the behavior may be appropriate (OK) when it
happens within limits, but it may be inappropriate (not OK at all) when it
happens too often. Or, it may be a behavior that already is inappropriate and
becomes more bothersome when it occurs too often.
The preference for being nonjudgmental-labeling behaviors rather than
labeling persons engaging in specific behaviors-is not intended to lessen the
gravity of antisocial behaviors. Acts of violence, such as murder, rape, child
molestation, and spouse abuse, are "inappropriate" only in a generic sense and
are far more reprehensible in real life. Indeed, even in the clinical setting, the
cover of "confidentiality" is not available to clients who are child molesters. In
most states, mental health professionals are legally required to report child
abuse cases to the appropriate authorities. For their own protection, mental
health professionals inform their clients about their rights to confidentiality as
well as the limitations of confidentiality.
13 • SOCIAL RELEVANCE OF ANALYSIS 237
CULTURAL DETERMINANTS OF BEHAVIOR
We need also to allow for individual differences and for cultural (and
often, religious) differences. What is appropriate in one culture may not be so in
another culture. For example, animal sacrifice is a sacred ritual for the fol-
lowers of some religions; others consider it to be barbaric.
Jews and Muslims believe, as is written in their scriptures, that God, to test
the faith of his prophet Abraham, commanded Abraham to sacrifice his son
Isaac. Abraham proceeded to obey. Just before Abraham brought down his ax,
God replaced Isaac with a lamb on the altar. In commemoration of Abraham's
intended sacrifice of his son Isaac, Muslims all over the world celebrate the
Feast of Abraham. They sacrifice lambs, goats, camels, or cows and distribute
the meat to the needy in their communities. Indeed, the Muslim Hajj pil-
grimage to Mecca, one of the Five Pillars of Islam-required behaviors for all
Muslims-coincides with the anniversary of Abraham's intended sacrifice of
his son. But in India the slaughtering of cows by Muslims during the Hajj
season leads to riots in which hundreds of thousands of Muslims and Hindus
have been killed. The cow is sacred for Hindus.
NEED FOR PARAPROFESSSIONALS
Sociologists and psychologists, regardless of their orientation, agree that

we do not have-and are not likely to have, in the foreseeable future-a
sufficient number of qualified professionals to deal with the problems that
confront us. The remedy lies in (1) developing teams of paraprofessionals to
take on the challenge and (2) retraining of members of target groups such as
parents, teachers, and teenagers. Many leading research organizations (e.g., the
Oregon Social Learning Group in Eugene) and faculty members at universities
have been training undergraduates in techniques of behavior management.
Results have been encouraging: paraprofessionals at the undergraduate level,
after being trained, have performed on par with PhD-level clinicians.
Strange as it may seem, it is possible for a person to be certified as a
teacher without her or his taking any courses dealing with the management of
classroom behaviors. "Teacher education" programs typically do not include
courses dealing with the application of psychological and/or behavior manage-
ment procedures to real life. The reason for this shortcoming in teacher educa-
tion curricula, stated by Dr. Glenn Latham, a Utah State University professor in
the Department of Special Education, is that most education departments at
universities do not have faculty members qualified to teach behavior manage-
ment courses (G. Latham, personal communication, 1994).
Special education departments do offer courses dealing with behavior
management principles and procedures, but only at the graduate level. Thus,
many, or most, school teachers as well as care providers in nursery schools
and/or day-care centers function with no knowledge of the principles and
procedures in behaviorology and/or cogmtlve psychology. Some exceptions

include nursery schools and day-care centers in Utah where the Family Services
Division provides inservice seminars for staff members as well as parents. (Dur-
ing 1981-82, as a member of the adjunct faculty in the Department of Psychol-
ogy at Utah State University, and under contract with Utah's Family Services
Division, this author taught a series of seminars dealing with principles and
procedures in behaviorology, social learning, and cognitive psychology. Partici-
pants in these seminars included Utah State University graduate and under-
graduate students, staff members of nursery schools and day-care centers, and
parents of toddlers.)
Programs of training teachers and members of communities in techniques
of behavior management currently are being offered through a federally funded
research project. The Mountain Plains Regional Resource Center, headed by
Dr. Glenn Latham, provides technical assistance in serving hard-to-teach and
hard-to-manage students in Utah, Colorado, Montana, Wyoming, North and
South Dakota, Kansas, Nebraska, Missouri, Iowa, and the Bureau of Indian
Affairs. The project's training packages consist of modules for training teachers
and students, as well as members of communities (see also Chapter 19, this
volume).
Mental health professionals during recent years have been leaning increas-
ingly in favor of education or training-oriented intervention and favoring pre-
ventive programs rather than "after-the-calamity" treatment models. Dr. Rob
Hawkins, professor of psychology and head of the child clinical doctoral pro-
gram at West Virginia University, advocates for the training of teenagers long
before they become parents. Two other authors of chapters in this volumes, Dr.
Carl D. Cheney and Dr. Grace Baron are involved in school-and community-
based training programs for teachers, parents, and children, aimed at spreading
awareness of the ways in which AIDS strikes and the ways in which it can be
prevented (see Chapters 2 and 6). Parents and teachers in Arkansas report a
significant decline in the school dropout rate associated with a program that
was instituted with the backing of Hillary Rodham Clinton (when she was the
First Lady of Arkansas). In that program, mothers sit in classrooms to become
active participants with their children in the learning process. The magazine
Woman's Day hailed the program in an article, "My Mom, My Teacher."
Behavior analysts as well as cognitive psychologists are increasingly becoming
active in putting psychology to work in real life.
REMAKING THE WORLD
Scientific procedures in applied behavior analysis and in the cogmtlve

approach are available to us for reprogramming the social environment. In
applied behavior analysis, we help people to unlearn inappropriate behaviors
and to learn appropriate behaviors. In the cognitive approach, we target behav-
iors as well as feelings. These strategies, both behavioral and cognitive, are
being used widely in dealing with problems in the social environment. In both
approaches, the interest is in exploring ways of bringing about changes in
behaviors when such changes are for the good of the individual and for the
good of society. Their interest is also in bringing about changes in feelings when
such changes become necessary. A therapist with a behavioralogical orienta-
tion at a community mental health center cannot insist on focusing exclusively
on a client's behaviors when the client insists that he or she is "bleeding
inside," and is assailed by "negative feelings and self-deprecation," and so on.
Nor can a therapist with a cognitive orientation focus exclusively on a client's
"inner feelings," ignoring the client's obvious behavioral problems.
During a typical workday, a mental health professional, regardless of his or
her orientation, is likely to be working with clients on a wide array of problems
in the home, in school, at the workplace. These problems, during recent years,
have become more widespread. A related factor may be what is stated as, "It's
the economy, stupid!" And indeed, that has added to the problems that con-
front us. The following excerpts from records of my cognitive-behavioral thera-
py sessions from 1975 to 1992 suburban and inner-city areas are presented as
samples of referrals (lshaq, 1992).
Joan, 17, is an unwed mother. Like her baby, she herself is the daughter of
an unwed mother. Her father was one of her mother's many transient lovers,
and was never identified to her as her father. "Maybe, my mother didn't know
either," Joan said. Before she became pregnant (after an involvement with one
of her schoolmates), she had been a victim of sexual molestation by one of her
mother's many boyfriends. As she said in her intake interview, "My pregnancy
brought me escape from becoming a sex-slave of my mother's lovers." She
wants her baby to have the kind of home she herself never had-a home with a
mother and a father. But welfare regulations do not permit this normalcy. She
has been warned, "If the baby's father lives with you, you'l1 be off welfare."
However, her baby's father does live in her apartment. He sneaks in at night,
slips away early in the morning. They have been having some problems in their
relationship: "a lot of arguing, quarreling, blaming each other." She yearns to
marry her baby's father and to give her baby what she herself never had: a
father. But she would be dumped from the public assistance program that is
exclusively for unwed mothers. She might also lose the medical insurance
provided by Medicaid for her baby. Her social worker notes on Joan's file,
"Prevailing public policies and public assistance regulations work against tradi-
tional family values in this and similar cases."
Irene, 55, is a widow who seeks help for her obesity, the result of her
overeating behavior, and her increasing state of depression. She has one child, a
teenage son who is a motorcycle buff. His life pattern of coming home late at
night is "driving her up the wall." She sits at the window, staring at the
driveway, seeing mental pictures of his mangled body lying on the roadside
after a crash. Every now and then, she leaves her chair facing the window and
raids the refrigerator for snacks. She eats and eats, waits and waits, and eats.
During a cognitive therapy session, we work with her to help her learn coping
skills, and during the radical behavior therapy session, we focus on altering the
prevailing stimulus control to help her break the link between her anxiety and
her snacking behavior. In keeping with the theory that depression may also be
the product of a person not engaging often enough, or at all, in "pleasing
activities," she is encouraged to set up a "pleasing activities schedule." She has
rejoined her canasta group at the senior citizen's center and also has resumed
her weekend visits with her friends to the community swimming pool (Lewin-
sohn, 1986).
After intensive retraining in stimulus control, now when she takes a break
from her vigil beside the window, she turns on the TV instead of raiding the
refrigerator for snacks. She is steadily losing weight. A remarkable improve-
ment in her condition has been her going to bed on three consecutive nights
instead of sitting by the window to wait for her son's return.
John, 63, is a homeless person. His wife left him 20 years ago, taking their
children with her. Two years short of being eligible for Medicare, he belongs to
that vast segment of our population for whom President Clinton and Hillary
Rodham Clinton and some lawmakers in the Congress have been trying to put
together a health-care package that would extend coverage to the currently
uninsured populace.
John became homeless after he lost his job as a janitor. His work involved
strenuous manual labor that he was unable to do after sustaining a back injury
in a car crash. It was an off-the-job injury, uncovered by his employer's insur-
ance. He himself carried no insurance. After a futile job search, he joined the
homeless. He seeks help with his drug addiction and also his depression associ-
ated with his recently identified HIV-positive (human immunodeficiency virus)
condition. His treatment consists of stimulus control training (Thomas, 1991;
Hickis & Thomas, 1991), coping skills training, and involving him in "pleasing
activities" as part of the cognitive-behavioral program for controlling his de-
pression (Lewinsohn, 1986). As part of the treatment, he is placed as an instruc-
tor in a carpentry workshop at a local high school.
Frank, 44, a truck driver, and his wife Dianne, 38, a clerk in a grocery
store, with their daughter Iris, 17, and their sons, Henry, 15, and Mike, 14,
attend weekly sessions for marriage and family counseling. Frank and Dianne
admit to having frequent quarrels, mostly over their different approaches to
child rearing. All three children have spent brief periods in juvenile detention:
the boys for shop-lifting, the girl for driving without a license and while under
the influence of liquor; all three have also been arrested for being in possession
of a "controlled substance" (marijuana). By general agreement, we focus on
parent training and take the parents through procedures of behavior manage-
ment. They also involve the family in exercises aimed at improving communica-
tion between Frank and Dianne and between the parents and their children. A
drug rehabilitation counselor, working with the children, gives them intensive
training in covert aversive conditioning procedures aimed at making the inges-
tion of marijuana or any drug, including alcohol, a nauseous and unpleasant
experience (Cautela, 1971; Cautela & Kearney, 1986).
13 • SOCIAL RElEVANCE Of ANALYSIS 241
Scientific procedures for reprogramming the social environment that are

being used to grapple with the problems confronting us, as briefly stated ear-
lier, include (1) cognitive-behavior modification, coping skills training, and
internal restructuring; and (2) applied behavior analysis, also known as behav-
ior modification.
THE SAME PRODUCT, DIFFERENT LABELS
Some behavior analysts argue that behavior modification is not the same
as applied behavior analysis, but others consider that the product is the same;
only the labels are different. As a matter of convenience, not because of any
preference, we use the term applied behavior analysis in this chapter. A survey
of published research in applied behavior analysis shows studies covering
virtually the full range of socially significant human behavior, including
academic skills, language acquisition and use, work productivity and per-
formance, marital interactions, child-rearing skills, consumption of elec-
tricity, public littering, clothing selection, self-help skills, highway speeding,
seat belt usage, exercise, elevator use, and sport and leisure skills. The
important criterion here is that the behavior is important to the subject or
to society. (Cooper, Heron, & Heward, 1987, p. 5, italics added)
In keeping with the credo stated by Cooper and his associates, behaviorlogists
concern themselves with "socially significant" behaviors, not with just any
behaviors. The goal is to help produce meaningful changes in the social envi-
ronment, changes that are important to the subject or to society, that are for the
good of the individual, for the good of the community; not for the good of just
one person, one social group, one nation.
FROM THE LAB TO THE REAL WORLD
Procedures in applied behavior analysis are drawn from operant condi-

tioning, which has its roots in the pioneering work by B. F. Skinner and his
students and associates, in their experimental work with animals in laborato-
ries. The procedures are also drawn from the classical conditioning model
developed by Pavlov. Pavlovian classical conditioning principles have led to the
development of many treatment strategies used with considerable success in
behaviorist as well as cognitive programs for solving behavioral and emotional
problems (e.g., phobias, panic attacks, anxiety, depression, overeating, alcohol
and drug abuse, smoking).
The creation of procedures for shaping new behaviors and making appro-
priate changes in existing behaviors began with the work with animals in
laboratories. The work in the laboratory has provided, and continues to pro-
vide, cues for developing procedures suited to our own human environment.
Scholars have taken, from the findings in the laboratories, what was adaptable
for use with human clients. In the adaptation process, these procedures inevita-
bly have undergone drastic changes. So much so that they are not faithful
facsimiles of procedures used in the animal laboratories: "Testing of operant
conditioning principles began with animals pressing levers under highly con-
trolled conditions. Current applications of the general principles bear very little
resemblance to these experimental beginnings" (Kazdin, 1989, pp. 10-11). Be
that as it may, much of what we know-and the techniques we use in applied
behavior analysis-might not have been possible without our experience with
animal subjects. Without the controlled conditions that are available only in a
laboratory, it would not have been possible to develop, test, and fine-tune many
of these procedures. However, many of the procedures we currently use are the
direct product of experience with human clients.
Classical Conditioning
Using the Pavlovian principle, it has been possible to condition human
subjects, to establish cues for eliciting appropriate behavioral as well as emo-
tional responses. Frequently, treatment effects are produced by an interaction
between classical and operant conditioning.
Operant Conditioning
In operant conditioning, procedures exist for producing new appropriate
behaviors and for strengthening and maintaining existing appropriate behav-
iors. Procedures also exist for weakening or completely doing away with un-
wanted behaviors. For this procedure, the technical term is "extinction." Just
as we snuff out a candle and extinguish the flame, we snuff out a behavior
targeted for extinction. These procedures are so powerful that scholars empha-
size the need for guarding against accidental extinction of appropriate behav-
iors, just as much as guarding against accidental strengthening of inappropriate
behaviors.
Some General Assumptions

Behaviorist scholars and practitioners base their theories and procedures
in operant conditioning on some general assumptions validated during studies
in naturalistic settings as well as controlled conditions:
1. Most behaviors (overt and covert) are learned. Overt behaviors are the
observable things we do. Covert behaviors are the things we think, feel, or
imagine. Except for some survival behaviors, "such as breathing and the beat-
ing of the heart, it is difficult to think of many behaviors that are not obviously
dependent on prior learning." That is, most of the things we do are what we
somehow, somewhere, have learned already (Mazur, 1986, p. 2).
2. Behaviors do not occur in a vacuum. They occur in orderly, integrated,
sequential patterns: an antecedent event (something that happens before) then
the behavior, and then, its consequence, which is what happens after the behav-
ior: For example:
Antecedent: The teacher enters the classroom.
Behavior: The students crowd around the teacher's desk, hand in their
homework assignments.
Consequence: The teacher smiles, and announces, "Good work! You got
your assignments in on time. You deserve a treat. It's a sunny day; we'll have
our class out in the garden."
3. Most behaviors are under the control of their consequences.
We do not have to go much farther in this volume to predict that, in the
example above, the consequence for the students' behavior-being taken
outdoors for their class meeting-will strengthen their behavior of having their
homework assignments ready for the teacher in the future. When a behavior
occurs again, and this repeat occurrence is related to the consequence and to no
other event in the environment, we can say, with confidence, that the conse-
quence strengthened the behavior.
Positive Reinforcement
When a behavior becomes strengthened after whatever happens after the
occurrence of the behavior, we refer to this consequence as a positive reinforcer
of the behavior. Once a positive reinforcer has proved itself, we can use it for
exercising control over the behavior. We exercise this control through a process
known as management of contingencies of reinforcement. This is an "if this!
then that" equation that is at the heart of most behavior-conditioning pro-
grams. The following excerpt from my own self-administered contingency-
based behavior management protocol is offered as an example: "If and only if I
complete my quota of writing X words for this volume, Contemporary Issues
in Behavior Therapy, then and only then I will treat myself to watching C-Span
and CNN on my television." Note: According to this protocol, I would not
view CNN or C-Span unless I've first completed my quota of work on this
book. If I did, that would be "noncontingent" reinforcement-and that is an
absolute "no-no."
Thus, the delivery of a positive reinforcer-in my case, watching C-Span,
CNN news programs, Larry King Live, or Sonya Live-is made contingent on
my having completed my quota of work on this book. (The host on CNN's
"Sonya Live" is Dr. Sonya Friedman, PhD, a clinical psychologist.) According
to the "if this!then that" equation, the positive reinforcer is not available if the
behavior that we wish to strengthen does not occur.
Behaviorologists caution that when a behavior targeted for strengthening
does occur and we fail to deliver the positive reinforcer, we run the risk of
triggering the extinction process. Unreinforced, the behavior may weaken and
ultimately stop occurring. We need to watch out: we do not want to extinguish
an appropriate behavior; we would do that if we let an appropriate behavior go

by without its being given positive reinforcement.
Noncontingent reinforcement and unsystematic or haphazard manage-
ment of contingencies of reinforcement are at the root of many behavioral
problems in the home, in school, and in the work environment:
• A husband comes home from work with a bouquet of flowers for his
wife. She is busy in the kitchen. Barely looking at the flowers, she tells
one of the kids to put the bouquet in a vase; not a word, or a hug, for the
husband.
• A child walks in from the garage and announces, "Dad, I washed your
car. Come, take a look. It's like new." Dad withdraws for a moment
from his newspaper and his bottle of beer. He'll look, he says, when he
goes to the garage to get the car out to go to work in the morning.
Do we have to wonder whether the dad in this family will often (or at all) bring
flowers home for his wife or whether the son will wash the car for his dad often
in the future?
Reinforcement Schedule: Las Vegas Style

It is not practical, in nonlaboratory conditions, to deliver a positive rein-
forcer every time a person engages in an appropriate behavior targeted for
strengthening. We get over this problem by using an intermittent schedule of
reinforcement. Under the intermittent schedule, we operate very much in the
way that slot machines do in Las Vegas or Atlantic City gambling casinos,
where pressing or pulling the bar in the machine is the behavior that is rein-
forced by the pouring of coins or tokens into the money box. All bar-pressing
actions do not fill up the money box. Some do, but on a random basis. And the
gambler remains glued to the slot machine, continuously pressing the bar,
waiting for the jingling of coins in the money box.
Thus, after a particular behavior has been strengthened, preferably
through continuous reinforcement (that is, delivering a reinforcer every time
the targeted behavior occurs), we shift gears to deliver the reinforcer on a
random basis, some of the time. Behaviors strengthened under the intermittent
schedule are highly resistant to extinction (Crossman, 1991; Malott, Whaley,
& Malott, 1993).
The antecedent-the event that occurs before the behavior-is also a
necessary part of the equation. After we have studied a pattern, the antecedent
event helps us predict both the behavior and its consequence. A behavior may
also come under the control of its antecedent. Then, we call this antecedent a
discriminative stimulus. In our example above, the teacher herself becomes a
discriminative stimulus. Her entry signals the gathering around her desk of her
students with their completed homework asignments, and her taking her class
outdoors or handing out any other goodie. "A stimulus that is present when a
response is reinforced acquires some control over the response. If a behavior is
reinforced only when a particular stimulus is present, this stimulus acquires

exclusive control through a process called discrimination" (Skinner, 1974,
pp. 73-74).
THE HOW, WHEN, WHY, AND WHERE OF HUMAN BEHAVIOR
What a person learns to do, and not to do, and what the person actually
does are the product of the person's interaction with the environment. The
environment includes the person's own and others' behaviors; other events in
his or her surroundings; the person's genetic and cultural endowment; and her
or his "individuality." The learning-and doing-of a behavior, as well as
its being changed or unlearned, occur in the context of (1) prior learning;
(2) cultural factors-customs, traditions and taboos, religious beliefs, myths,
superstitions, legends, folklore, and the way of life in a person's family or social
group; (3) the person's heritage or genetic endowment; and (4) individual
differences. No two persons, even if they share a common culture, are likely to
react in the same manner to the same situation. If they belong to separate
cultures, they are even less likely to react in the same manner.
Social Learning: Imitative Behavior

We also learn behaviors through observation, a process described by Ban-
dura (1969, 1977) as observational or imitative learning. In this process, if the
observed consequence of the behavior is aversive, unpleasant, or punitive, we
are less likely to imitate it than if the observed behavior is followed by a
pleasing consequence.
For example, Oklahoma law professor Anita Hill's charge of sexual ha-
rassment against Clarence Thomas became a major issue in the US Senate
hearings on his nominations as Associate Justice of the Supreme Court. At
times, during the televised Senate hearings, the language was so explicit that
one might have been watching an X-rated movie. The hearings provided an
abundance of painful and humiliating consequences for both Clarence Thomas
and Anita Hill. Women who observed the punishment taken by her may be less
likely to imitate her behavior, less likely to go public with genuine or fabricated
complaints. Men, and women, who observed the punishment taken by
Clarence Thomas may be less likely to imitate his behavior, less likely to accept
a nomination for high public office, a process that involves close scrutiny,
public hearings, and possible embarrassment.
The status of a person is a major factor in determining whether his or her
observed behavior will be imitated. We are less likely to imitate the behavior of
a nobody and more likely if the behavior is modeled by a person we re-
spect and admire. For people who are devoted to the cause of world peace
and clean air, the ideal models may be environmental and peace activists, such
as Barbra Streisand, Joan Baez, Robert Redford, and Gregory Peck. They could
also be Nobel Peace Prize winners, like Gorbachev, Mandela, and DeKlerk. For
some, the ideal model may be an Olympic champion. Advertising agencies,
aware of the power of observational learning, also known as imitative learning,
pay high prices for endorsement of their clients' products by persons of high
stature.
Bandura and Walters (1963) offer the observational learning phenomenon
as a part of their social learning theory. By social learning, according to Mazur
(1986), they meant "a combination of (1) the traditional principles of operant
and classical conditioning, plus (2) the principles of observational learning or
imitation" (p. 258). Behavior change procedures in operant conditioning typ-
ically involve the use of positive reinforcement, negative reinforcement, or pun-
ishment.
Positive Reinforcement
By definition, a positive reinforcer is a consequence that strengthens a
behavior that precedes it. Alberto and Troutman (1986) argue that a conse-
quence must be "pleasant" for it to function as a positive reinforcer: "To put it
very simply, behavior ... followed by pleasant consequences tends to be re-
peated and thus learned. Behavior ... followed by unpleasant consequences
tends not to be repeated and thus not learned" (p. 21). But, some words of
caution from Rob Hawkins: "If the behavior preceding the consequence is
repeated and strengthened, the consequence qualifies as a positive reinforcer.
This consequence may not always be pleasing. Indeed, it may be the opposite,
and still exercise control over a behavior for it to be repeated" (personal
communication, 1994). Kazdin (1989), in support of Rob Hawkins' definition,
cites a study of the effect of scolding by a teacher on children's "standing up"
behavior in a classroom. The teacher's shouted "sit down" reprimand was a far
from pleasant consequence. Its effect was the opposite of what the teacher
intended: "Interestingly, the reprimands increased the frequency of standing,
serving as a positive reinforcer for the behavior they were designed to suppress"
(p. 145).
Accidental Reinforcement
Frequently, behaviors come under the control of accidental reinforcement.
Or, as stated earlier, they are strengthened or extinguished as a function of
misplaced, unsystematic, haphazard reinforcement. Thus, appropriate behav-
iors become extinct and inappropriate behaviors become strengthened. This
happens all to often in homes, in classrooms, at the workplace, in prisons, and
in mental hospitals:
• A nurse pounces upon schizophrenic patients when they engage in bi-
zarre talk, but ignores them when the same patients engage in some
appropriate activity. Without meaning to do so, she reinforces her pa-
tients' bizarre talk behaviors and extinguishes or weakens their appro-

priate behaviors.
• In a home situation, a parent appeases a child who is having a temper
tantrum by giving in to the little tyrant's demand. By doing so, the
parent reinforces the child's tantrum behavior. As Becker (1971) states,
the parent and the child train each other. The parent trains the child to
throw a temper tantrum to get what he demands. The child trains the
parent to comply, to give in, when the child throws a temper tantrum.
As stated earlier, whatever is learned can be unlearned. It becomes a

matter of reprogramming the environment, a matter of rearranging the conse-
quences so that inappropriate behaviors are unlearned through nonreinforce-
ment leading to extinction. We are more likely to get results with an extinction
or unlearning process if we dovetail it with procedures for the strengthening of
alternative appropriate behaviors that are incompatible with the behavior tar-
geted for extinction.
A behaviorlogical or psychological intervention program is likely to be
more effective when we look at and study the client's total environment. The
term environment includes the client's behaviors and feelings, and the behav-
iors and feelings of others in the client's surroundings. When a teacher succeeds
in changing a student's behavior or a therapist succeeds in producing a change
in a client's behavior, the interaction is also likely to produce changes in the
behaviors of the teacher and the therapist. This applies across the board-in
families, in the workplace, in school, in all situations involving human interac-
tion.
Punishment and Negative Reinforcement

For many scholars-B. F. Skinner, Murray Sidman, and Joseph Cautela,
among them-the strategy of choice is positive reinforcement. (Note: Covert
positive reinforcement is an important ingredient in Cautela's covert condition-
ing model.) However, in spite of the many studies exposing the harmful side
effects of punishment, some, if not many, behavior analysts use and defend the
use of punishment and negative reinforcement.
By definition, an aversive consequence qualifies as "punishment" only if it
stops future occurrences of a behavior. If it fails to achieve that result, its
continued use is nothing but wanton and unwarranted cruelty. Thus, the death
penalty is not "punishment." It does not do away with the punished behavior;
instead, it does away with the behavior. At best, it is an act of vengeance, "a life
for a life," in keeping with the Mosaic Law: "an eye for an eye, a tooth for a
tooth." Opponents of the death penalty claim that statistics fail to support its
value as a deterrent.
Negative reinforcement refers to an increase in the frequency of a response
by removing an aversive event immediately after the response has occurred.
Removal of an aversive stimulus or a negative reinforcer is contingent upon a
response. An event is a negative reinforcer only if its removal after a response

increases performance of that response (Kazdin, 1989; Skinner, 1953).
We equate punishment with negative reinforcement partly because the
presence of some aversive stimulus is essential for negative reinforcement to
occur. Behaviors that remove aversive conditions become negatively reinforced.
If aversive conditions were not present, there would be no occasion for behav-
iors that remove aversive conditions. Skinner (1989) and Sidman (1989) de-
scribe punishment and negative reinforcement as being the same.
What I called negative conditioning should of course have been called
punishment .... If we define positive reinforcement as a stimulus that
strengthens behavior when presented, and a negative reinforcer as one that
strengthens (behavior) when removed, then punishment consists of present-
ing a negative reinforcer ... or removing a positive one. (Skinner, 19H9,
p.127)
We can make shocks go away-negative reinforcement; or we can get
shocked-punishment. (Sidman, 1989, p. 82)
Many scholars question whether the use of punishment is justifiable as a

treatment measure, even if it stops an undesired behavior. They express concern
about the desired side effects of punishment, even when it seems to work.
Among these side effects is escape-avoidance behavior. The punished person
may learn not to engage in the punished behavior in the presence of the pun-
isher. This avoidance behavior may escalate to the point that the person who
administers punishment acquires the attributes of punishment, and the pun-
ished person stays away from this dispenser of punishment as one stays away
from punishment. The punished person may also learn to engage in the pun-
ished behavior more discreetly and avoid being detected (see Sidman, 1989;
Cautela & Kearney, 1986).
Sometimes, during the process of reprogramming the environment, we
need to make changes in feelings as well as behaviors. Feelings may not be
accepted as the cause of a particular behavior, but a linkage cannot be denied.
Skinner (1989) has been cited earlier for saying that "feelings are most easily
changed by changing the settings responsible for what is felt" (p. 10). The same
is true for behaviors. If we get our behavioral setting mixed up, we need to
change the setting or the behavior. If we do not, we are in trouble. Some
behaviors, all right in one setting, are not all right in another setting.
We can yell all we want during a ball game. We can cheer, jump up and
down, rattle the bleachers, stamp our feet on the floor. But not in class; not at
work. We can sing all we want in the shower. But not in public, unless singing-
or the playing of a musical instrument-fits the occasion: a Native American
pow-wow, an office party, the Metropolitan Opera, the Barbershop Quartet,
the Woodstock Music Festival. Senator Byrd has played his violin at the Grand
Ole Opry, but not during a session of the US Senate. President Bill Clinton,
during his election campaign, played his saxophone on the Arsenio Hall
show-and later, at many of the Inaugural Balls on January 20, 1993-but he

is not likely to do so in the Oval Office.
TOWARD A MEETING OF THE MINDS AND JOINING

OF FORCES-RADICAL BEHAVIORIST AND COGNITIVE
Behaviorlogists and cognitive psychologists are engaged in grappling with

the problems that we face. Although their approaches are different, they share a
common goal: "improving the human condition." A relevant question of inter-
est is: How different are the radical behaviorist and cognitive approaches? Are
they mutually exclusive?
We talk in this chapter about the how and the why, and the when and
where, and also the why not, for the things that people do or do not do. We talk
about human behavior, and about the feelings we feel, why we feel them, and
when and where we feel them. And about the ways in which we can make
socially significant changes in behaviors and in feelings, to improve the quality
of life for ourselves and for others who share this planet with us.
In including public as well as private events in their survey, cognitive
psychologists remain within the parameters of radical behaviorism. Taking
feelings into account when targeting changes in the social environment is not
heresy (see Cooper et aI., 1987; Catania, 1984; Ishaq, 1991; Sidman and
Ishaq, 1991): "How people feel is often as important as what they do ...
Feeling is a kind of sensory action, like seeing or hearing" (Skinner, 1989, p. 3).
Cooper et al. (1987) emphasize that the principles and procedures of applied
behavior analysis presented in their classic and broad-based text "apply equally
to public and private events ... And the philosophical position underlying the
content presented here (in the authors' text) is radical behaviorism, which is the
philosophy of the science of behavior" (p. 12). What Cooper and his associates
say about their text (with its radical behaviorist orientation) is in keeping with
the position taken by Catania (1984). It is also in keeping with the position
taken by Skinner, as stated by Cooper and his associates (1987) in their com-
prehensive analysis.
Cooper and his associates tell us that, contrary to popular opinion, Skin-
ner does not object to the philosophy of cognitive psychology in its concern
with events taking place "inside the skin." Skinner (1953, 1974) clearly indi-
cates that it is a mistake to rule out events that influence our behavior because
they are not accessible to others. Radical behaviorism does not restrict the
science of behavior to phenomena that can be detected by more than one
person. In the context of radical behaviorism, the term observe implies "com-
ing into contact with" (Moore, 1984, pp. 73-97).
Radical behaviorists consider private events such as thinking or sensing
the stimuli produced by a damaged tooth to be no different from public events
such as oral reading or sensing the sounds produced by a musical instrument.
According to Skinner (1974, pp. 10-19), "What is felt or introspectively

observed is not some nonphysical world of consciousness, mind, or mental life
but the observer's own body."
Catania (1984) surveys the major areas in the psychology of learning from
a "consistent behavioral point of view." But he adds the proviso:
I will only note that to take a behavioral position one need not exclude
from consideration aspects of human behaving sometimes called mental,
such as thinking and imagining. Thus, topics, often regarded as the exclu-
sive province of contemporary cognitive psychology will be treated along
with those more traditionally regarded as behavioral. (p. vii)
In admitting observable public events as well as feelings and beliefs-private

events-one remains within the bounds of radical behaviorism. Admitting the
existence of feelings is not only appropriate, it is also essential in our problem-
solving work with individuals and groups.
Sidman (1989) points out that private behaviors, not accessible to others,
such as "thinking, talking to oneself, paying attention, feeling happy or sad,
worrying, enjoying, imagining" -despite problems in observing or measuring
them-nevertheless "remain within the province of behavior analysis" (p. 28).
Moore (1980), paraphrasing Skinner (1953), says that "for radical behaviorism
... one's responses to private stimuli are equally lawful and alike in kind to
one's responses ... to public stimuli" (p. 460).
Cognitive psychologists have argued that findings based on experimental
work with animals cannot be generalized across the board. This now is becom-
ing less of a divisive issue. Many radical behaviorists, including William Buskist
and his associates at Auburn University in Mobile, Alabama, are active in
promoting experimental analysis of human behavior.
A MATTER OF LANGUAGE
Under Catania's (1984, pp. 6-7) microscopic analysis, we see the points of
agreement and disagreement between the radical behaviorist and cognitive
approaches. Both rely on the "experimental method," and anchor their con-
cepts to experimental manipulations. Both agree that the subject matter,
whether it is behavior or feelings, is "orderly and not capricious." For what we
do, for what we feel, there are reasons for which there is an explanation. The
debate between them, to some extent, is about" appropriate ways" of talking
about psychology.
Differences do exist between the radical behaviorist and cognitive a p-
proaches. These are, Catania says, "a matter of language":
The difficulties persist not because behaviorists and cognitive psychologists
cannot understand each other, and not because there are psychological
problems that either can resolve that the other cannot, but rather because
the two kinds of psychologists are interested in different types of questions.
The behaviorist tends to be interested in questions of function, and the

cognitive in questions of structure. (1984, p. 8)
In a functional approach our interest is in the interaction between behavior and

the environment. We study the effect of consequences on behavior. In a struc-
tural approach our interest is in how behavior and the environment are orga-
nized.
As an example, take the teaching of a child to read and write. As behavior-
ists, we want to find out which particular consequence improves the child's
learning. As cognitive psychologists, we want to know which particular order
of presentation of teaching material gives better results. Will a child be more
attentive if we present the material in single letters, or syllables, or whole
words? Or if we add pictures to our presentation of words or use moving
images?
Both structure and function are important, Catania maintains. If we ig-
nore either of them, "any attempt to affect how children read will be deficient."
It is important to distinguish between structure and function. But there is "little
value in arguing the priority of one or the other approach if both are indispens-
able to our understanding" (1984, p. 9). Contingencies of reinforcement are
important. So is the way in which teaching materials are presented to a child.
Minimizing the gulf between the two approaches, Catania (1984, pp. 8-9)
explains that because functional problems involve behavior and consequences,
they are better stated in the behaviorists' "language of stimuli and responses,"
and that because structural problems involve the properties of particular capac-
ities or abilities, they are more aptly stated in the "language of knowledge and
mind." It remains a matter of acquiring the ability to understand each other's
languages. Efforts to integrate behaviorist and cognitive approaches have be-
gun. See the summary below for more details.
Catania's analysis clearly states that the functional (behaviorist) and struc-
tural (cognitive) approaches are "indispensable." Indeed, we may infer that the
two psychologies can work together. It is a matter of crossing a language
barrier.
Radical behaviorists focus on behaviors, and accept the existence of feel-
ings, albeit as a form of "covert behavior." They do not list changes in feelings
as a treatment goal. But it is doubtful if any of them will deny that they expect
that the improving of socially significant behaviors will make a person "feel
good." And if a behaviorist clinician's client does not "feel good" after a couple
of sessions, she or he is not likely to come back. That much for real life.
Cognitive psychologists focus on feelings. They target a client's overt as
well as covert behaviors. They work on the altering of thought patterns, beliefs,
attitudes, and opinions----'and behaviors, too. Cognitive psychologists take
what they consider to be a realistic view. It may not be possible entirely to blot
out a negative emotion. Therefore, their emphasis is more on coping with
problem-causing emotions than on eliminating them (Martin & Pear, 1988,
pp. 396-397, 400-401). Coping is the same as learning to live with an un-
avoidable situation. Relaxation training is frequently included in cognitive be-

havior modification.
SYSTEMATIC DESENSITIZATION
Behaviorists as well as cognitive psychologists use Wolpe's (1958) system-
atic desensitization model, and its variations, in the treatment of anxiety reac-
tions, panic attacks, and phobias. Anxiety typically begins as a reaction to a
particular object or situation, and then spreads to other situations. Phobias are
learned fears about objects, situations, or persons. Some common phobias are
fear of being in crowds, open spaces, or elevators, or fear of flying. Mostly,
these are fears that have come about by becoming linked to other anxiety
situations (Ishaq, 1992).
Using the principles of classical conditioning as a base, Wolpe developed
his systematic desensitization model in 1958. He describes it as reciprocal
inhibition or counterconditioning. Deep relaxation and guided imagery are the
essential ingredients of this model. Relaxation and anxiety are incompatible: a
person cannot be relaxed and anxious at the same time. The client is trained to
imagine pleasant scenes, to actually see him- or herself engaging in a pleasing
activity: watching a sunset, walking on a beach, listening to the sound of the
waves and the singing of the seagulls, tasting the salt water as a wave breaks
nearby. In between the imagined pleasant scenes, the client is asked to imagine
a series of anxiety-evoking scenes and then relax, and again see the pleasant
Images.
Gradually, relaxation overpowers anxiety reactions. When the client is
able to go through the imagery of the entire series of anxiety scenes with no
onset of anxiety, he or she generally is able to face the actual anxiety situation
in real life without feeling any distress. Wolpe used Jacobson's (1938) progres-
sive relaxation model in which the client learns to relax muscle groups. Wolpe
combined hypnotic induction procedures with the standard instructions for
progressive relaxation. Wolpe's model has generated a number of variants. In
Richard Suinn's anxiety management program, the client is trained to practice
seeing images as if she or he is viewing them on a TV screen. The client is
prompted to see an anxiety image and then, to counter anxiety, to switch to the
already-practiced "happy" images and "success" scenes.
A more recent addition is Cautela's "anxiety meter" (AM). Its use "is
taught to clients to reduce anxiety. At first, the AM is used as part of the self-
control triad. It is then used alone to reduce anxiety.... The AM is a self-
control strategy for use in treating agoraphobia and panic reaction" (Cautela,
1994, p. 307).
The client is trained to see, with the eyes of the mind, a "meter" that
measures the anxiety level; then, to visualize an anxiety scene, and to determine
where the anxiety is on the AM. The self-administered treatment proceeds as
follows:
13 • SOCIAL RElEVANCE OF ANALYSIS 253
After determining where your anxiety is on the AM, you imagine

yourself in a situation that would usually produce anxiety. You then imag-
ine you are really there and can see and hear everything around you.
Then the self-control triad (SeT) is used in the following manner:
1. Visualize the anxiety meter.
2. Say, "Stop" (in your head, not out loud) as loudly as you can.
3. Take a deep breath.
4. Exhale. While exhaling, say, "Relax" ... and feel a wave of relax-
ation, starting from your head, going all the way down to your toes. While
exhaling, visualize the AM and the amount of anxiety you have shaded in.
Imagine ... pushing down the anxiety control lever (ACL). As you imagine
pushing down the lever, visualize and experience the anxiety reducing to a
lower level. Watch the numbers becoming smaller and smaller.... Imagine
a pleasant scene that is easy to visualize-clear, pleasant, and enjoyable.
(p.314).
IN ACCORD WITH CULTURAL ANTHROPOLOGY
During my affiliation with the University of Oregon as a member of the

Department of Anthropology faculty, I have been engaged in an ongoing re-
search project aimed at blending data collection and assessment techniques in
anthropology with those in experimental, clinical, and counseling psychology.
The goal is to inject into cultural anthropology the rigor in the design of
assessment plans in psychology, and to inject into psychology some of the
procedures used in cultural anthropology, especially the use of "participant
observers." Through this synthesis, cultural anthropologists would be able to
add to the validity of their own research and mental health professionals (be-
haviorists and cognitivists) would be able to look at the person and the social
group, at the entire cultural pattern: religious beliefs, family hierarchical sys-
tems, taboos, values, and such other factors as may seem to have a bearing on
the problem-factors such as customs and traditions.
If the study of customs is to be scientific, there should be no "preferential
weighting" of one or another of the items selected for consideration, writes
Ruth Benedict (1989; republication of 1934 original, preface by Margaret
Mead and foreword by Mary Catherine Bateson). By taking note of all possible
variants in the" less controversial fields," Benedict tells us, we have learned all
that we know of the laws of astronomy, or of the habits of the social insects. It is
only in the study of man himself that the major social sciences have substituted
the study of one local variation, that of Western civilization:
The fact of first-rate importance is the predominant role that custom plays
in experience and in belief, and the very great varieties that it may mani-
fest .... The life-history of the individual is first and foremost an accom-
modation to the patterns and standards traditionally handed down in his
community. from the moment of his birth the customs into which he is
born shape his experience and behavior. By the time he can talk, he is the
little creature of his culture, and by the time he is grown and able to take
part in its activities, its habits are his habits, its beliefs his beliefs, its
impossibilities his impossibilities. Every child that is born into his group
will share them with him, and no child born into one on the opposite side
of the globe can ever achieve the thousandth part. There is no social prob-
lem it is more incumbent upon us to understand then this of the role of
custom. Until we are intelligent as to its laws and varieties, the main com-
plicating facts of human life must remain unintelligible. (Benedict, 1989,
pp.2-3)
This joint psychological-cum-cultural anthropological probe would take us out

of the "encapsulation" trap. We would look at persons and groups for what
they are. We would not measure the client in relation to our own mold, our
values, our standards. We would be able to tailor "treatment plans" for them to
be synchronous with the culture of the client and her or his social group, in
harmony even with the client's idiosyncrasies that might seem alien to us.
Research scholars as well as faculty members at universities have been
showing increasing interest in adopting a cross-cultural approach in psycholo-
gy. Many of them have taught and have been engaged in research overseas as
Fullbright scholars (e.g., Norman Sundberg who has lived and taught in India,
Australia, and Europe). 1 Less credence is being paid now to the myth of the
"American mold." More than ever before, we are likely to find acceptance for
the proposition that investigators in cross-cultural psychology or behavior
analysis across cultures, in their search for determinants of human behavior,
must lean on history, political science, sociology, cultural anthropology, reli-
gion, folklore, literature, and even mythology (Ishag, 1991, pp. 257-278).
Earlier, we introduced the terms appropriate and inappropriate behaviors
and behavioral deficits and behavioral excesses as subclassifications of in-
appropriate behaviors. We now examine these labels within a cross-cultural
framework. What is appropriate in one culture may be inappropriate in anoth-
er. What is inappropriate in one culture may be appropriate, and even expected,
in another. It is important to take account of cultural variances, especially with
the continuing massive influx of many cultures to the United States. More so
than anywhere in the world, we in the United States are becoming a multi-
cultural society. Who would have believed, a few years ago, that Chinese Amer-
icans would be in the majority in a city council in the Greater Los Angeles area!
Educators, psychologists, clinical social workers, and other mental health
professionals, as well as paraprofessionals, whatever their orientation, will do
well to obtain information about the client's lifestyle, beliefs, values, and the
customs and traditions that prevail in her or his culture. For example, parents
in almost all Asian cultures retain their protective hold over their children well
beyond the children's teen years. Living in one of those cultures as a participant
observer, one will find that, to varying degrees, children like it this way. Some
children may rebel. But cultural pressures and massive reinforcement for stay-
'Norman D. Sundberg, Emeritus Professor of Psychology and former head of the Community and
Clinicall'sychology program at the University of Oregon, introduced cross-cultural psychology to
the doctoral curriculum in 1977.
ing within the family fold usually bring them around to conformity. Parents
certainly like it this way. And, unknown is the problem of the "empty-nest"-
parents left alone after the children have gone away.
In the West, parents start as early as they can to give independence training
to their children. They prepare their children for facing the world outside the
home; and they prepare themselves, too, for being in the inevitable empty nest.
Obviously, this is the way in Western society. But what do parents in the West
feel when, one by one, the children go away? If it did not cause heartaches, the
term "empty nest" would not be applied to human parents. Which one of us,
among parents in the West, has not wiped a tear and felt heartbroken when the
youngest and the last to go has departed. We seek comfort by telling ourselves,
"She'll be a great lawyer, maybe a Supreme Court Judge." Or, for another one
of them, "she'll have her album soon, we'll see her on MTY." But the tears do
not stop. The videotapes and albums provide little comfort.
We need to tailor culture-relevant programs for strengthening and main-
taining appropriate behaviors, for weakening or extinguishing inappropriate
behaviors, for increasing the frequency of behavioral deficits and decreasing or
doing away with undesired behavioral excesses. When we refer to different
cultures, we usually refer to cultures that have their roots in countries other
than our own. But we have cultures within cultures, too. For example, the
culture of poverty. Indubitably, the inhabitants of inner-city slums and suburbia
are as alien to one another as are Londoners to inhabitants of Bombay.
OUR DEBT TO OUR YOUTH CULTURE
Our young adults have their own culture, too. Our failure to admit its
existence as an entity in its own right, with a history of its own, has created and
nurtured a communication gap. Sometimes, when adults and members of our
youth culture talk to one another, it seems as if they arc speaking two different
languages.
The gap between adults and members of the youth culture may be at the
root of many of the problems that we face: juvenile delinquency, even teenage
pregnancy. To some considerable extent, we have frowned on what our teenage
children do. The way they dress. The music to which they listen. Sometimes,
even the way they listen to it-jogging, a Walkman strapped to the belt, head-
phones plastered over the cars. While we have done a lot of frowning and
scowling, even scolding, for their doing the things of which we disapprove,
many of us have neglected to show our appreciation for their doing the many
things of which we should be proud. This is not to speak only of their report
cards with good grades, which so many parents do not have the time to read
and share with their children, or the PTA meetings and "Parent's Day" get-
togethers at school, which so many parents do not have the time to attend.
During the past 30 years, the "peace," "ecology," "democracy," and "hu-
man rights" platforms, adopted and popularized by members of our youth
culture, have become universally accepted ideals. They are stated as "goals" in
the campaigns of candidates for public office. In 1988, George Bush described
himself as an "environmental" president. Now, Vice-President Al Gore heads
the environmental lobby.
In the United States and worldwide-in the former Soviet empire and even
in China-members of the youth culture have led the fight to focus on these
ideals. But for the passion of our young adults, Mikhail Gorbachev's per-
estroika and glasnost might not have become a reality. In our dealings with our
youth, we often have done what the principles in applied behavior analysis tell
us never to do: We have zapped them for doing things of which we disapprove.
We have ignored their actions that merit our praise and our gratitude. Who can
ever forget the televised picture of the young Chinese student, a human barri-
cade, blocking a convoy of tanks during the historic demonstrations in Beijing's
Tienenmen Square in 1990-a movement begun by China's youth that raged
like an avalanche through the entire nation.
Carl D. Cheney, who has been deeply involved in the war against AIDS,
stresses the importance and "social relevance" of school-, home-, and commu-
nity-based AIDS education (personal communication, 1994). Citing projec-
tions made by the World Heath Organization (published in Newsweek, August
22, 1994, p. 37) that the number of persons infected worldwide by AIDS,
currently 17 million, will be 40 million by the year 2000, and that no cure for
AIDS is in sight, Cheney offers the conclusion that prevention-and the teach-
ing of preventive behaviors-are the only remedy:
In most cases, the transmission of AIDS is related to some willful action

such as performing of unsafe sex or the sharing of intravenous drug needles.
Why do people engage in "risky" behaviors that can result in death? The
answer lies in the laws of behavior. The immediate consequence of many
"risky" behaviors is pleasant while some delayed and uncertain conse-
quences may be fatal. Unsafe sex, smoking, and the use of credit cards are
examples of behaviors in this category. The immediate consequences are
positive, and the harmful consequences are not only delayed but also uncer-
tain. Not every act of unprotected sex is fatal; not every cigarette that one
smokes leads to infection or cancer; not every case of credit card use leads
to economic disaster. If we knew for certain that smoking would lead to
cancer and that it would be fatal to share an IV needle or to engage in
unprotected sex, no one would do it.
The social relevance of AIDS education in schools is at least twofold.
First, it provides direct instruction about the disease and how it is transmit-
ted by active participation. The disease is not contagious by contact; one
has to make an active, deliberate effort to become infected. Second, such
education provides a meaningful forum by which the characteristics of
contingency traps can be developed and discussed with regard to many
behaviors. When a behavior is followed by immediate reinforcement, it will
be strengthened, regardless of subsequent events. Therefore, it is useful for a
person to be able to specify what the results will be of falling into such a
trap. This is not to say that by being able to describe the controlling
contingencies, one will be immune to them. The power and operation of
13 • SOCIAL RElEVANCE OF ANALYSIS 257
reinforcement is not a theory, it is the way behaviors are shaped and main-
tained. Knowing that "compulsive" gamblinss is due to the randomness of
the payoff schedule does not mean that people can immunize themselves
from such schedule effects. AIDS transmission is due to willful misconduct,
not in the sense of a "weak will," but because of the voluntary nature of the
operant response involved in exposure. Being knowledgeable of the power
and presence of reinforcement schedules can help minimize the probability
of making the first response that may ultimately lead to increased risk-
taking. It is the learning of the science of behavior as it applies to all self-
help and health promoting behaviors that will indicate the relevance of
AIDS education everywhere. (Carl D. Cheney, personal communication,
1994)
SUMMARY
Funds for social services-including the prevention and treatment of

AIDS, the prevention of teenage pregnancies, the prevention and treatment of
substance abuse and dependency, the provision of shelter and food for the
homeless-have survived the budget cuts written into the several budget-bal-
ancing bills sent by Congress to the president during 1995 and early 1996.
These reprieves, however, have a limited lifespan. The final decision awaits the
results of the presidential and congressional elections in November, 1996.
Complete Republican control of the government, with Republican candidates
capturing Congress as well as the White House, will undoubtedly ensure the
passage of the Republicans' legislative measures and the elimination of many, if
not all, social service programs.
Educational and psychological services are important components of al-
most all social service programs. As stated earlier in this chapter, a concern for
many of us-clients as well as mental health professionals-has been the rifts
between professionals aligned with the various schools, particularly between
radical behaviorists and cognitive psychologists. The differences between these
two major approaches have been explained by Catania (1984, pp. 2-29) as
being a matter of "language." Catania considers both to be indispensable to
each other, with radical behaviorists focusing on behaviors and cognitive psy-
chologists focusing on feelings, beliefs, and thought processes.
As this book goes to press, there are signs of a rapprochement between
these two major approaches to cognitive-behavioral problems-a giant leap in
the entire history of radical behaviorism. The annual convention of the Asso-
ciation for Behavior Analysis (ABA), held in San Francisco in late May, 1996,
opened with a workshop titled "Behavioral Psychotherapy: A Radical Ap-
proach," led by Dr. Steven Zlutnick of the University of San francisco.
In his description and narration of objectives of this workshop, Dr. Zlut-
nick says:
Only a few practitioners have applied the radical behavioral approach to
more traditional psychotherapy. [There] has been a paucity of attempts to
address issues that traditional, nonbehavioral clinicians rightly deem criti-

cal to the therapeutic process. These include: therapist variables, such as
maturity, self disclosure, common sense; developmental issues, such as di-
vorce, separation, individuation, etc.; values clarification and conflict; car-
ing and concern. Attempts to translate, incorporate, or integrate rather
than discount such controversial topics as transference, countertransfer-
ence, insight, resistance, the need for long-term therapy, etc., are rare.
The goals of this workshop include: (1) a chance for the participant in
clinical practice to integrate the seemingly disparate views of radical behav-
iorism and traditional clinical psychology; (2) the opportunity for clini-
cians teaching applied courses in behavior therapy to develop coherent,
reasonable explanations to students who are attempting to reconcile these
issues during their training; and (3) an opportunity to address and discuss
issues and concepts historically avoided and discounted in "traditional"
behavior therapy training environments. The workshop will attempt ... to
facilitate discussion and integration of traditional clinical issues with a
radical behavioral approach (Zlutnick, 1996).
REFERENCES
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student performance. Columbus, OH: Merrill.
Bandura, A. (1969). Principles of behavior modification. New York: Holt, Rinehart & Winston.
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.
Bandura, A. & Walters, R. H. (1963). Social learning and personality development. New York:
Holt, Rinehart & Winston.
Becker, W. C. (1971). Parents are teachers. Champaign, IL: Research Press.
Benedict, Ruth (1989). Patterns of culture. Boston, MA: Houghton Mifflin. (Original publication
1934)
Catania, A. C. (1984). Learning (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall.
Cautela, J. R. (1971). Behavior analysis forms, vols. 1,2. Champaign, IL: Research Press.
Cautela, J. R. (1994). The use of the anxiety meter to reduce anxiety. Behavior Modification,
18(3),307-319.
Cautela, J. R. & Kearney, A. J. (1993). The covert-conditioning casebook. Belmont, CA:
Brookes/Cole.
Cooper, J. 0., Heron, T. E., & Heward, W. L (1987). Applied behallior analysis. Columbus, OH:
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Crossman, E. K. (1991). Schedules of reinforcement. In W. Ishaq (Ed.), Human behavior in today's
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Jacobson, E. (1938). Progressillc relaxation. Chicago: University of Chicago Press.
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Lewinsohn, P. (l n6). Control your depression. Englewood Cliffs, NJ: Prentice-Hall.
MaHot, R. W., Whaley, D. L, & Malott, M. E. (1993). Elementary principles of behavior. En-
glewood Cliffs, NJ: Prentice-Hall.
Martin G., & Pear, J. (1988). Behavior modification: What it is and holU to do it. Englewood Cliffs,
NJ: Prentice-Hall.
Mazur, J. E. (1986). Learning and behavior. Englewood Cliffs, NJ: Prentice-Hall.
Moore, J. (1980). On behaviorism and private events. Psychological Record, 30, 459-475.
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73-97.
Sidman, M. (1989). Coercion and its fall-out. Boston, MA: Authors' Cooperative.
Sidman, M., & Ishaq, W. (1991). Beware of coercion. In W. Ishaq (Ed.), Human behavior in today's
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behavior in today's world (pp. 191-204). New York: Praeger.
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14
From Aircrib to Walden Two

B. F. Skinner and Cultural Design
Julie S. Vargas
INTRODUCTION
Many textbooks and articles about B. F. Skinner's work assert that operant
conditioning procedures work with rats and pigeons or with drill and practice
in human beings, but not with complex behaviors such as problem solving or
creativity. The impression these secondary sources give is that Skinner was not
much concerned with larger issues, nor with behavior more sophisticated than
giving the answer to questions like "What is 2 + 2?" While it is true that
Skinner's first book reported work on the behavior of rats (Skinner, 1938), and
that one other book was a compendium of work using pigeons (Ferster &
Skinner, 1957), the rest of Skinner's books could not possibly give the impres-
sion that his main concern was the behavior of laboratory animals. Take, for
example, Skinner's (1953) textbook, Science and Human Behavior. Of the 449
pages, half are devoted to general principles about the analysis of behavior. The
remaining 222 pages discuss larger issues, including chapters labeled "Self-
control," "Thinking," "The Self," "Social Behavior," and" Designing a Cul-
ture." The breadth of Skinner's concern for human welfare always surprises
those who know Skinner only through secondary sources.
1 For a summary of misconceptions, see Cooke (1984) and Todd and Morris (1992).
Julie S. Vargas • Department of Educationall'sychology and Foundations, West Virginia Univer-

sity, Morgantown, West Virginia 26506.
261
Even when reporting work with nonhuman animals, Skinner was no more
interested in the rats and pigeons themselves than the geneticist is in fruit flies.
The organisms in both cases are simply convenient species for research on
general processes applicable to all living creatures. 2 In his first book, Skinner
ends by saying, "The importance of a science of behavior derives largely from
the possibility of an eventual extension to human affairs" (Skinner, 1938,
p. 441). He himself would devote much of his life to making this extension. To
understand Skinner's approach to improving the human condition, it will help
to look at his own background.
SKINNER'S EARLY LIFE
Skinner grew up in the small town of Susquehanna, Pennsylvania, in an

age of optimism. For most American families in the early twentieth century,
progress was tangible. Most people were better off than their parents had been.
Skinner's family was a case in point. His grandparents were working class: One
grandfather worked for the railroad repair shops that dominated the small
town, and the other grandfather was a housepainter. In the next generation,
Skinner's father was a lawyer. Home life for most of the inhabitants of Sus-
quehanna improved year by year from the technological inventions of the early
1900s. Like them, Skinner was aware of changes that substantially improved
daily life. During his childhood he witnessed the transition from outhouses to
indoor plumbing, from gas lamps to electricity, from horse and buggy to auto-
mobile. New inventions such as the radio and silent movies continually ap-
peared. The young Skinner saw the first plane that flew from one coast to the
other, hopping short distances between farmers' fields. Life became tangibly
better and better as the years went by. At the beginning of this century, Ameri-
cans had little information about global overpopulation, pollution, environ-
mental degradation, and the extinction of species. The threat of a nuclear
holocaust did not exist. Apart from the occasional tragedy of a smallpox
outbreak or a local flooding (and, of course, the World War, named, opti-
mistically, as though another would never occur), life seemed on a course of
constant improvement. Problems were not threats, but challenges.
The young Fred Skinner inherited the optimistic problem-solving outlook
of his day. He was a tinkerer in the tradition of American inventors. In his
autobiography he describes some of the gadgets he designed. Here is a charac-
teristic example, from around his tenth year: Skinner often forgot to hang up
his pajamas before coming downstairs to breakfast. His mother would make
him "stop eating, go upstairs, and hang them up" (Skinner, 1976a, p. 121). To
remind himself, Fred rigged up one of his first mechanical solutions to a behav-
ioral problem:
2A point more fully elaborated by E. A. Vargas (1988, 1993).

14 • FROM AIRCRIB TO WALDEN TWO 263
The clothes closet in my room was near the door, and in it I fastened a hook
on the end of a string which passed over a nail and along the wall to a nail
above the center of the door. A sign reading, "Hang up your pajamas,"
hung at the other end. When the pajamas were in place, the sign was up out
of the way, but when I took them off the hook at night, the sign dropped to
the middle of the door where I would bump into it on my way out.
Another gadget separated the green from the ripe elderberries he and a friend
picked to sell to neighbors. The boys built a trough-and-garden hose system
that carried off the green berries, leaving only the ripe ones to gather in a pail.
Later, when selling shoes during his high school years, part of Skinner's job was
to sweep the floor, first sprinkling a green dust and water over the planks.
Rather than do this by hand, he constructed a machine to mix the water and
granules and scatter them across the floor when he cranked a handle. Whatever
practical problems the young Fred Skinner encountered, he turned first to the
invention of a gadget.
Skinner was not modest in his ambitions. He tried designing a perpetual
motion machine, and at one point considered designing a nuclear-powered
submarine. Needless to say, these projects never got much beyond the design
stage, but the very fact that he considered such problems reflects the kind of
confidence that the early twentieth century had in the power of technology to
solve problems.
Skinner lived in Susquehanna until he went away to Hamilton College.
After graduating from college, encouraged by a letter from Robert Frost, whom
he had met at a summer writing institute at Breadloaf, Skinner returned home
to become a writer. Then came his first real failure. Not only did he not
successfully publish articles or books, he did not even produce manuscripts to
send out. He wrote a column for the local newspaper and many notes, but
clearly "being a writer" was not the profession for him. As he puts it in his
autobiography, "I had nothing to say," (Skinner, 1976a, p. 264). During his
2 years of floundering about, Skinner had read, and liked, the behaviorism
described by Bertrand Russell and by Watson. When a writing project his
father had given him provided funds to go to graduate school, Skinner applied
to Harvard University on the strength of recommendations from his Hamilton
College professors. He enrolled in the department of psychology, and had
found a career at which he would succeed.
Skinner's gadget-making proclivities served him well in his graduate pro-
gram where students were expected to construct their own apparatus. He
received his doctorate in 3 years, and was awarded two prestigious fellowships
that enabled him to continue experimenting as a postgraduate student from the
fall of 1931 to the spring of 1936. Looking for order in data, he made one piece
of apparatus after another, culminating in the apparatus for which he is known
(see Skinner, 1956). Skinner called his experimental space "the operant condi-
tioning chamber," but Clark Hull, the foremost learning theorist of those days,
dubbed it the "Skinner Box," and the latter name stuck. Unlike the mazes and
puzzle boxes of the time, Skinner's operant chamber contained an operandum
(originally a bar that the experimental animal could repeatedly press) that
enabled the experimenter to measure rate of responding. Rate turned out to
be a very sensitive measure of behavior, revealing small moment-to-moment
changes, and thus readily revealing relationships between experimental manip-
ulations and the resulting behavior. The simplicity of the act of bar pressing
(compared to the trials of mazes or puzzle box research), and the lack of
interference with the rat during experimental sessions, made clear what was
causing what. 3 Results also came faster with bar presses than with trials. In the
time it would take an animal to run a maze or escape from a puzzle box, a rat
could press a bar dozens of times. (Geneticists use fruit flies for a similar
reason-discoveries would be fewer and farther between were they to use
elephants). Without the operant conditioning apparatus and its companion,
the cumulative record, none of the work showing how schedules of reinforce-
ment and stimulus control affect behavior would have been possible. Inter-
estingly, the cumulative record, like the operant chamber, was a serendipitous
discovery. Skinner had not bothered to cut off a round protuberance on a scrap
of wood that he had used in building a piece of apparatus. He saw that, with
the cylinder, he could make a graph that showed each bar press as it occurred.
The slope of the line at any point would indicate momentary rate of respond-
ing. Rate of responding and cumulative records become synonymous with
operant research. The tinkering and gadget making in Skinner's postgraduate
Harvard years thus spawned an entire field of research on operant behavior,
that is, behavior selected and maintained by its effect on the environment. The
research included, of course, not only the relationship between actions and
postcedent events (as in schedules of reinforcement) but also the effect of pre-
ceding events (stimulus control) and prior conditioning history. The precision
of control was to prove useful not only in studying behavioral processes, but
also in other fields, such as behavioral psychopharmacology, which required a
consistent stable baseline against which to assess the effects of drugs.
After 5 postgraduate years at Harvard, in the fall of 1936, Skinner moved
to Minnesota. He had a book about to be published, a job, and soon, a wife.
Life was on an upward course. Busy with his job and family, Skinner attracted
little notice in the field of human behavior until, at the end of his Minnesota
stay, he again turned to gadgetry to solve a problem, this time in infant
care.
THE BABY-TENDER
The year of the invention of the baby tender was 1943. Skinner, then 39
years old, had been teaching at the University of Minnesota for 8 years. His
book, The Behavior of Organisms (1938), had been out 5 years and had sold
lSkinner had run rats in mazes and had been bothered by the lack of control over factors that
occurred between trials: The handling of the rat (whether rough or gentle) and the orientation of
the rat when the experimenter opened the door to the maze (whether it was facing the door or not)
made a great difference in one of the main measures, namely time to run the maze.
modestly, hardly enough to make him a celebrity, but enough so that, among
psychologists, his name was known. He had been married for 8 years and had
one daughter, 5 years old. Now his wife, Eve, was pregnant for the second time.
Eve had not originally wanted children, but the birth of her first daughter
had uncovered a maternal streak that had surprised her (E. B. Skinner, 1994).
From a sophisticated, somewhat aloof young intellectual, she had become a
concerned, even anxious, mother. Like many first-time mothers, she worried
about blankets suffocating her baby. Many evenings, she tiptoed into her
daughter's room to make sure that she was still breathing. The prospect of
another child pleased her, but she did not look forward to the first year with its
worries about suffocation and the piles of laundry involved in those days before
disposable diapers. Since her husband readily fixed things around the house, I
can imagine her saying, "Fred, can't you DO something?"
And, of course, he did-with another invention. He constructed an en-
closed and heated crib (see Figure 14.1). The new baby would sleep on a canvas
stretched between two rollers. As the surface became dirty or wet, the parent
would roll the dirty section on the used roller, pulling a fresh portion into the
bed from the clean roll. A window in the front doors would let the baby look
out (and parents look in), except when a shade was pulled down. The length
and width were the same as a traditional crib, but the surface on which the
baby would sleep was much higher, at a level that made it easy for parents to
interact with their child when putting her to bed for a nap or at bedtime.
In August 1944, the new baby girl, Deborah, was brought home. Enthusi-
Figure 14.1. The original baby-tender.

astic about his new invention, Skinner wrote an article about the baby-tender
and sent it off to a popular magazine, the Ladies Home Journal (Skinner,
1945). The magazine was interested. In due course, photographers came to the
Skinner household to take pictures to accompany the article. Skinner's title did
not have the word "box" in it, but the magazine-perhaps to attract more
interest-changed the title to "Baby in a Box." The article appeared in Octo-
ber 1945, and brought Skinner into the public eye.
Reactions to the Baby-Tender

Of all of Skinner's inventions, the one most often misrepresented is the
baby-tender. An AP wirephoto, taken from the original article along with a
caption added by the editors, helped the misconceptions. It showed a pleasant
picture of the parents looking at a smiling Deborah in the baby-tender, but
included the following text:
Prof. B. F. Skinner ... and Mrs. Skinner watch their 13-months-old daugh-
ter, Derby [sic], through the open window of the mechanical baby tender in
which the girl has lived since birth. The compartment, free from almost all
sound and dirt, has solved the Skinner's nursery problems. (Italics added)
(unpublished family scrapbook, 1945)
This certainly gave the impression that the baby never left her bed and that she
could not be heard when in it. In fact, the baby-tender was not soundproof, and
the Skinners used it like a regular crib. Like other babies, Deborah had a
playpen, a feeding table, and spent a normal amount of time out of her crib
(E. B. Skinner, 1994; Skinner, 1987).
With press like the above, however, many reactions to the new invention
were vehemently antagonistic, protesting Skinner's "caging this baby up like an
animal just to relieve the Mother of a little more work" (Skinner, 1979, p. 305).
Even years later, articles appeared. In 1965, the National Enquirer had a two-
page centerfold with pleasant photographs of the babies and beds, but a less
pleasant title: "1,000 Babies Raised in Glass Cases" (Woodruff & Warner,
1967). An insert box announced in large type, "Inventor Called Monster" with
text that started, "Would you raise your baby in a glass case, like a hothouse
plant?" In 1968, the New York Times Magazine published a cover story called
"Bringing Up Baby in a Glass Box." One of the photographs of a mother
holding a child had a caption that read, in part, "third child she's raised in
Skinner Box." By calling the baby-tender the name by which Skinner's experi-
mental apparatus was known, this photo caption raised the specter of experi-
mentation on infants along the lines of Skinner's work with rats and pigeons.
Of course, none of the aircrib parents, including Skinner, did any such thing.
In spite of misleading press releases, many people reacted positively to the
new invention. Best of all, Deborah, the Skinner's baby, thrived. Deborah was
an unusual baby. Unlike the Skinner's first child, she did not have a cold for
years and she almost never cried. Naturally enough, Skinner attributed these
remarkable results to his invention, and he spent considerable time in investi-
gating commercial production. But between established companies' fear of

potential lawsuits and Skinner's extraordinary trust and naivete about business,
nothing came of his efforts. Much later, John Gray, a machinist in the psychology
shop at Harvard University, did market an "Aircrib" made, ten at a time, at the
machinist's home. Many of the 1000 babies mentioned in the National Enquirer
article had slept their first couple of years in John Gray's Aircrib model. While
these babies did not duplicate Deborah's lack of colds and crying, parents and
babies were happy with the beds. When Skinner's first daughter had children,4
he purchased one of the commercial Aircribs for his grandchildren.
Most of the negative reactions both to the original baby-tender and to
succeeding models were from people who had only heard about the crib that
Skinner designed. Skinner had not helped misconceptions with the description
of the "cubicles" in Walden Two, in which he describes them as soundproofed,
and he talks of the babies "spending most of the first year in an air-conditioned
cubicle," though "visited by parents who take the baby out for some sunshine,
or play with it in a play room" (Skinner, 1948b, pp. 89, 91, 109). In the 1940s,
"air-conditioned" meant filtered air, not cold air. "Soundproofed" was likewise
misleading. Some soundproofing material was added to the real cribs to muffle
sounds, but none of them were soundproof. Had Skinner described the cubicles
as "beds providing warmed, clean air and protecting the child from overly
harsh noises," he would have given a very different impression. To make mat-
ters worse, misconceptions were aided by the language of actual Aircrib users.
Most of them talked about "raising their children in an Aircrib," rather than
saying, more accurately, "using an Aircrib as a bed" for their children. Even the
maker of the Aircrib showed a lack of sensitivity to the public. His brochure
showed a baby in an Aircrib drinking from a bottle held with his feet. Not only
did this imply that the mother did not hold the baby during feeding, but it
caught the infant in a pose more commonly associated with a chimpanzee than
with a human being.
Although the aircrib never became a commercial success, Skinner re-
mained convinced of the value of the warmed, protective crib. To the end of his
life, when colleagues or students made aircribs of their own, he would answer
their letters, and when invited, would accept invitations to go over and see and
hold the babies, to which he was always partial. He also took the time to read a
preliminary version of a do-it-yourself manual that two behaviorologists wrote,
and he corresponded with the designers to offer suggestions (Cheney &
Ledoux, 1991). However, after his own efforts at commercial production of a
baby-tender came to nought, Skinner went on to other things.
WALDEN TWO
Deborah was born just before the Skinners moved to Indiana, at the end of
8 years at the University of Minnesota. Skinner was finishing 3 exhausting years
4Julie (the author), not Deborah. Deborah married but did not have children.
of wartime research on Project Pigeon, during which pigeons were taught to

guide missiles. Dozens of experiments with the birds alternated with frustrating
waits for resources and feedback from Washington. In his autobiography, Skin-
ner mentions the effect on him wrought by the lack of support from Washing-
ton, in spite of very impressive demonstrations of effectiveness: "My co-work-
ers told me after it was all over that toward the end of the project I was not
finishing my sentences" (Skinner, 1979, p. 274). Project Pigeon had demanded
the production of behavior meeting precise standards. While Washington may
not have provided encouraging feedback, Skinner was receiving daily feedback
from his birds, and they were showing him how powerful operant conditioning
was. "The research that I described in The Behavior of Organisms appeared in
a new light. It was no longer merely an experimental analysis. It had given rise
to a technology" (Skinner, 1979, p. 274).
The realization of the power of operant conditioning for a technology of
behavior no doubt started Skinner thinking about its use to improve living
conditions. The end of the war, with the return of servicemen and discussions
of what they would do, must have lent strength to thinking about the design of
society as a whole. In the summer of 1944, with the project ended, Skinner
took a sabbatical to "finish" his book on verbal behavior.s (It took another
sabbatical, this one in 1955, to actually finish the book!) In spending his days
writing about what people say and why, Skinner was concentrating on the
behavior of human beings. During this period, Skinner also started an informal
discussion group of graduate students, faculty, and friends that met monthly at
the Skinner house (Skinner, 1976b, p. vi). The topics ranged widely, including
ways to establish contingencies of reinforcement for people. Then, at a dinner
party soon after the armistice, when Skinner exclaimed how it was too bad that
soldiers would return to "the old lock step of American life," a friend asked
him what they should do instead. Skinner suggested experimenting with new
ways of living, and the friend "asked for details" (Skinner, 1979, p. 292). The
release from the worries of war and wartime research, the lack of daily demands
of teaching, and the concentration on human verbal behavior together set up
conditions for Skinner to seriously consider cultural design. Closer to home, he
had a wife who was unhappy about his incipient move to Indiana and a
daughter whose first grade teacher was a strict disciplinarian. In an ideal
society these problems would not arise.
The day after sending off a prior writing commitment, Skinner started
writing Walden Two (June 2, 1945). The strength of his convictions is revealed
in the speed with which he completed the book. He typed directly rather than
first handwriting the drafts, which was how he had written his thesis and The
Behavior of Organisms. He finished the book in just 7 weeks. (In contrast, he
calculated that he had spent 2 minutes a word for his doctoral thesis and about
5Years earlier, in 1934, another challenge, this one by Professor Alfred North Whitehead, to
explain "No black scorpion is falling upon this table," started Skinner thinking about verbal
behavior (Skinner, 1957, pp. 456-457).
the same for The Behavior of Organisms.) Parts of Walden 'livo he wrote with
great emotion. He describes working out one section while walking near his
house and coming back to type it in "white heat" (Skinner, 1979, p. 298). This
section describes Burris's visit to Frazier's messy room, where Frazier dashes a
glass against his fireplace in exasperation, saying, "But, Damn it, Burris, Can't
you see? I'm not-a-product-of-Walden- Two." Skinner must have been reflecting
on his own behavior.
In the book, Burris, the visitor to the community, and Frazier, the origina-
tor of the community, both bear characteristics of Skinner, as he himself
pointed out (Skinner, 1967, p. 403). Burris is the cautious side. He is frustrated
with university life and disappointed with the ultimate effect he has on his
students. Burris is the Skinner who wrote his friend and lifelong colleague, fred
Keller, about problems with a senior faculty member at the University of Min-
nesota, saying, "I have to keep my 'system' and systematic point of view
completely undercover so far as he and his students are concerned" (Skinner,
1940). frazier, on the other hand, is cocky and egoistic, and mentions suffering
from feelings "of superiority or contempt." This side comes out in letters to
Keller, too. In one, after saying that what he's writing is "pretty good stuff" he
adds in parentheses, "Skinner's getting a swelled head, now he has a book out."
"What d'ya mean GETTING?" In another letter, Skinner tells of a convention
session in which he essentially embarrassed the venerable Clark Hull, observ-
ing his own behavior with the comment, "It was unfair, but fun" (Skinner,
1942). Struggling to control his own behavior and having seen the power of
environmental control, it was natural to think of an improved society in which
people would behave better.
It is interesting that among behaviorists and learning theorists, only Skin-
ner wrote a utopia. 6 Did only he realize the potential of his work for improving
daily life in society in general? Clearly his day-in, day-out experimentation had
given him a confidence in the power of contingencies. He could see their effect.
Such precise control was not evident in the mainstream psychology of the day,
as is illustrated by a story about Hilgard (Skinner, 1984, p. 332), author of a
popular book called Conditioning and Learning. Hilgard had heard about
Skinner's demonstration of shaping and asked Skinner for directions on how to
do it. After experiencing success, he wrote Skinner, saying, "You can actually
see learning taking place." This came from a man who had written a whole
book on learning. Skinner had spent thousands of hours in the lab. He had not
only seen behavior change, he had repeatedly seen the effect of schedules of
reinforcement and the ease with which operants could be brought under stimu-
lus control. He had witnessed, in other words, a powerful science of behavior.
He had no doubts about the relationship between contingencies and behavior.
Why not use this new science to improve the human condition, just as physics
and chemistry had been used to produce all of the improvements he had experi-
enced as a child? Walden 71uo showed how such an application might work and
"A point mentioned hy Skinner ( 1994, p. 3(7) and hrought to my attention by E. A. Vargas.
might provide a mechanism for continually improving through experimenta-

tion. It was partly a dream, but also a blueprint.
Most utopian novels are set far away from current society in space or time;
on an island, for example, or in another time period. Walden Two, in contrast,
was set right in the middle of America, in the Midwest (where Skinner was
living at the time), and in the present. As Frazier puts it,
The one fact that I would cry from every housetop is this: the Good Life is
waiting for us-here and now! ... At this very moment we have the
necessary techniques, both material and psychological, to create a full and
satisfying life for everyone. (Skinner, 1948b, p. ]83)
The idea of Walden Two as a call to action was not lost on readers of the book.
Starting a Real "Walden Two"

Even before the book was on the market, several people who had read
drafts or participated in discussion groups had considered starting a real com-
munity. In a letter to Fred Keller, dated April 12, 1948, Skinner wrote,
Walden Two is now scheduled for June 8. A group of our people in Min-
neapolis have prepared a brochure to enlist others who like themselves are
are [sic] planning to set up such a community some time this year. Maybe I
won't get to Harvard after all! (Skinner, 1948)
The last sentence was not serious, though it reveals that Skinner had toyed with
the idea of joining a real community. Skinner himself was not part of any start-
up groups. For one thing, his wife did not like the idea of living in a planned
community. Then, too, his appointment as full professor at Harvard University
must have seemed utopian enough. In any case, the group designing the bro-
chure evidently did not get beyond the discussion stage. After the book came
out, however, a few groups, claiming Walden Two as a model, or at least as an
inspiration, did form communities.7 Skinner corresponded with individuals in
these groups, though never as a potential member.
Reactions to Walden Two

Walden Two was published in the spring of 1948. Although major publica-
tions such as the New York Times and the Chicago Sunday Tribune reviewed
the work, the public responded slowly. Walden Two sold only 1271 copies
through December 1948. But each year sales increased, until by 1972 the book
had reached total sales of over a million copies.
Most readers react strongly to Walden Two. The fact that some readers of
this fictional book were willing to devote financial resources and their own
7Twin Oaks, in Louisa, Virginia, was partly inspired by the book, though members do not consider
it modeled on Walden Two. Los Horcones, in Hermosillo, Mexico, explicitly states its debt to the
book, but has a very different economic structure.
lives to carry out its ideas attests to the strength of some of the positive reac-
tions. But there were negative reactions, too. These, like reactions to behavior-
ism in general, centered around the notion of control (Newman, 1992).
The idea of planning a society to produce happy, productive people chal-
lenges the notion that people, unlike other animals, have "free will." Darwin
encountered a similar vehemence of opposition when he proposed a mecha-
nism to explain the evolution of new species. If man has evolved by natural
processes, then we, too, are biologically "just animals." Skinner challenged our
special status in a similar way. If our behavior is controlled, each of us, as
Skinner was to point out repeatedly, is merely a locus in which genetic and
behavioral evolution come together to produce the behaviors in which we
engage. We are no more free of genetic and environmental determinants over
our behavior than are other animal species. For the critics, Walden Two seemed
to rob us of our "free will" and our "humanity."
Interestingly, the word "humanity" has among its definitions, "kind or
generous behavior or disposition" (Webster's Third New International Dictio-
ary, 1963), and "kindness as shown in courteous or friendly acts" (Oxford
English Dictionary, 1971). That description certainly fits Walden Two, where
concern for others in the group is encouraged and behavior one would call
"selfish" rarely appears. In the community, all resources are shared and the
economic structure is built upon cooperation rather than competition. No
individual can benefit from his or her ideas or efforts at the expense of others,
nor can any member accrue capital in any form other than work credits. Each
member must do some of the physical labor required to keep the community
going. Moreover, each member has an equal opportunity to design the contin-
gencies under which all members live. Skinner's notion of "humanity" thus
requires more equality than is found in America, where, despite rhetoric to the
contrary, many individuals have gained wealth or power through the exploita-
tion of others.
To induce the individual to act in ways that benefit the group requires
socializing, and it is here that "control" enters the picture. It is difficult to
imagine that anyone really believes that people are free in the sense of acting
completely independently of their previous experience and events around them.
Even the most staunch defenders of "free will" will take a stand on TV vio-
lence, or point out the detrimental impact on children from the breakup of the
family, or dispute the impact of educational practices, showing that they realize
that what happens to people does affect their behavior. But they avoid the word
"control." The development of the child is said to be "guided." Techniques are
given to "enhance," "support," "influence," or "affect" behavior. In the field
of education, "self-control" is encouraged. But self-control is a misleading
term, as Frazier points out (Skinner, 1948b, p. 98). Certainly, in America, no
one condones self-control that enables a student to become more adept at
lying, cheating, or getting away with violent acts. Self-control means conform-
ing to socially approved norms without an authority conspicuously present. We
want control, but we do not want to see it.
In Walden Two, the controls over behavior are described in naked clarity.
Readers who realize that behavior is "affected" by advertisements, laws, daily
events, reactions of family and friends, and so on may still wish to clothe those
factors in words that hide their nature and power. In our society, self-control is
learned, to the degree it is learned, by chance. In Walden Two, the steps are
spelled out as a sequence of temptations the children are taught to resist. They
learn not to lick a lollipop they are given, nor to eat even when hungry until a
signal is given, and so on. Interestingly, Castle, the book's skeptical visitor, calls
this training "sadistic tyranny," but would himself, at a banquet, hold back
from eating until it was socially appropriate to begin. In our society the self-
control training most children receive comes as punishment for mistakes rather
than a gradual shaping where each progressive step is taken successfully. In
Walden Two, contingencies are set up in order to reduce aversive controls as
much as possible.
There is one loss, however, from abandoning aversive controls: If people
do not experience cruelty, extreme deprivation, intolerable work conditions,
and threat of financial ruin, they are deprived of the relief or elation from
escape and avoidance. Similarly, pain and despair are part of romantic notions
of the poverty-stricken artist creating a great work of art, of the despairing lover
overcoming tremendous odds to gain his amour, and the hero saving the world
from destruction. Danger, despair, and potential disaster are reduced to a
minimum in Walden Two, thus removing negative reinforcement as motivation
for behavior.
Walden Two was published when Skinner was just moving to Cambridge.
His first years at Harvard were busy. Skinner asked for a large undergraduate
course (for which he eventually wrote Science and Human Behavior), and
between teaching, research, and other university demands, he wrote few notes
on planned communities. As soon as he had time for reflection, however, he
once more sketched out his ideas.
Seven years after joining the faculty at Harvard University, Skinner went
on sabbatical to finish (finally!) the book Verbal Behavior (1957). In January
1955, at the age of 51, he took a small room in a tiny inn in Vermont, on the
grounds of the Putney School, where his older daughter was a high school
junior. He took his younger daughter, Deborah, now 11 years old, with him. H
(His wife Eve, who loved to travel, took the opportunity to take a trip
around the world.) It was on a similar sabbatical-to "finish" Verbal Behav-
ior-that Skinner had written Walden Two originally. The similarity of his
situation, living essentially by himself in a rural setting, to a life in Walden
Two was not lost on Skinner. On his first day at the little inn, he wrote a note
beginning, "If not Walden Two, at least a reasonable Walden One" (Skinner,
1955a).
During the months that he spent in Vermont, Skinner again reflected on
larger issues. About half of the notes that he wrote during this period concern
8Deborah stayed with the family who ran the inn.

practical problems in starting a community. Table 14.1 shows the topics of the
notes. The originals are not grouped by topic and many are not titled.
To give an idea of the notes, here is one in its entirety:
Other Ideas
It should be understood that one experiment doesn't try everything.
This one is based upon certain principles and cannot succeed if too many
others are brought in. Thus if a member (of Walden Two) feels that some-
thing should be tried, he has the right to advocate it. But if it is turned
down, it is up to him to accept that or leave. There are undoubtedly many
ideas to be tried out in a similar way but they cannot all be tried out here.
Whether something is to be tried depends upon all of the following:
1)There must be a reasonable chance of results which would justify

time and effort.
2) The experiment must not interfere with others already in progress.
This would mean whether the resources of the community can support
it now. (Skinner, 1955b)
For a writer so often accused of being against freedom, Skinner shows

extraordinary concern with the "freedoms" allowed by the contingencies of
Walden Two. For example, in a note titled, "What the Community Guarantees
the Individual," he includes the freedom of members to leave the community
without financial penalty. No member should stay in the community from lack
of finances necessary to leave. But how to do this effectively? Skinner's notes
outline a system where members earn shares in the "stock" of a Walden Two
corporation according to the work credits they have contributed. He contrasts
the resulting freedom with the so-called "freedom" to choose a job in Ameri-
can society, which, he notes, is no freedom at all if a person cannot quit because
of financial obligations and a lack of alternative job possibilities.
A concern with freedom also appeared in the notes on codes of conduct
and in musings about reinforcers that Skinner saw as undesirable, for example,
TV and comics. Where traditional society relies on aversive control to prevent
indulgence in nonproductive activities, Walden Two would substitute positive
controls. Since, Skinner reasoned, many time-wasting activities provide escape
from aversive activities, they would not be as attractive in a Walden Two com-
munity. In addition, the community would provide opportunity for participa-
tion rather than mere observation. Skinner's view of the attractiveness of partic-
ipating reflects his own reinforcers. In one note, he says that TV and comics
are cheap substitutes for other sides of life which will be abundantly pro-
vided for. Kids will not watch "super-circus" of a Saturday morning if they
can hang around the dairy barn watching a new-born calf. The sadistic
kind of humor of most comics grows pointless and boring for a contented
productive reinforced person. (Skinner, 1955a)
Here, Skinner is promoting what in our society we would call the freedom to
choose what to do. As he was to clarify later (Skinner, 1971), most discussions
Table 14.1. Walden Two Topics in the Notes Made by B. F. Skinner

while on Sabbatical in Putney, Vermont in 1955
First steps in starting a community

Proposal for a beginning group
Starting steps
Names for a community
Spirit in which one selects a site
Design of buildings
Basic plan for initial group-primarily builders, machine workers
Lack of representativeness of initial members of a community
Attitudes of neighbors, local town
Financial structure: Shares. What to do about people who wish to join and who have a private
income but also financial obligations, e.g., supporting a mother
Financial sanctions (shares in community)
Other use of "plant" (camp? health institute,)
Rights and obligations of members
Entrance requirements
What the community guarantees the individual
What the individual agrees to do for the community-responsibilities of members
Statements of principles: general formulation, statement of political principles, internal problems
Possible principles (no alcohol, no smoking)
Guaranteeing personal freedom to try new ideas; right of members to advocate trying something
Temporary leave from community
Three prospectuses
1. for planners
2. for prospective members
3. for shareholders
Practical problems
Schooling in the community
Holding outside jobs as a member
Size of group needed to justify full time dentist, doctor, barber, druggist, etc., to make profitable
chicken-raising and so forth
Need for planning for long-term reinforcement-"getting trapped by quick reinforcement"
Nonpolitical action philosophy to avoid later persecution
Problem of productive use of time
Using "natural" leaders to help in training children
The problem of cleanliness
Rainy day "nothing to do" situation
New members
Trial period in the community for people considering joining
Feelings of new members during transition
Enjoyments (e.g., the joy after anxiety) that would be lost in community life
Receiving a new child in the community
Transition for new members into community-how to ease it
Philosophical issues
Walden Two: Is it communism? [Skinner's answer, was, of course, "no"]
Parallels between Walden Two and "man against nature" feats
The largest social unit-answer to objection that Walden Two sponges on society
Special tolerance in the family for offensive behavior (e.g., nagging) versus in workplace
of freedom involve freedom from, that is, the removal of aversive controls.
Concern with freedom from aversive controls appears throughout Skinner's
notes, as indeed it does throughout his published works.
What Skinner saw as desirable behavior differed little from his life in the
small town of Susquehanna. A country setting like that in which he grew up
figures prominently in both the book and in later notes. The activities that
Skinner most enjoyed as a boy involved active participation-exploring nature,
building gadgets, creating miniature theaters and putting on plays, painting,
sculpting, and playing music.
At Putney, Skinner again lived near nature, and he responded to elements
in his current situation. He made notes on cows and horses but not on sheep or
pigs: Putney School had cows and horses, but not sheep or pigs. The fact that
the notes correspond so closely with his daily life leads one to suspect that the
notes entitled, "Feelings of new members during transition (to Walden Two),"
were actually Skinner's own feelings. Here he was, living in a beautiful setting,
close to his children and free to do whatever he wanted all day long. Did he
miss negative reinforcement-the exhilaration of finally finishing a paper or
book with a tight deadline or the joy of release when some onerous meeting or
trip was canceled? The notes about adjustment problems, I suspect, reflect
Skinner's own reactions to life at a Walden Two-like pace:
New members should expect to experience a period of transition. Rest,
dietary change, new routine of acquiring substitution for aversive control.
May be difficult. May find there is nothing you want to do. May feel
lazy. This is release of aversive control. Begin with ... 9 work-wait for
interests to develop, skills to be acquired.
Project: a study of problems of new members. What would be an
improved program of transition? (Skinner, 1955b)
Clearly, laziness did not interfere too much with Skinner's sabbatical project.
He finished Verbal Behavior during the time he was at Putney.
Skinner's musings about cultural design do not end with his 1955 notes,
though he did not write many notes on starting a community in later years. lO
To apply his science for the greater good, he turned to education in the 1960s
and addressed the culture at large in the 1970s with the publication of Beyond
Freedom and Dignity (Skinner, 1971). He argued that the main problems con-
fronting the human race are behavioral problems. True, we have to deal with
natural disasters, but the main threat to us as a species involves controlling our
own destructive behaviors of overpopulating the earth and thus depleting re-
sources, of annihilating other species, and of polluting our environment. 11
Behavioral problems, Skinner knew, can be solved. If you change the contin-
gencies under which people live, their behavior will change.
'IThe written word at " ... " is unintelligible.

I"With one exception in 1961, where there is a brief burst of notes again about starting a commu-
nity.
lIThe same themes appear currently in books such as Wilson's (1992) The Diversity of Life.
What Skinner offered is as valid today as it was when he first wrote Walden
Two. The basics of a good life as enumerated by the character, Frazier, can
scarcely be contested: good health, a chance to exercise talents and abilities,
intimate and satisfying personal relationships, a schedule that allows relaxation
and rest as well as work at jobs one enjoys, and a minimum of unpleasant labor.
The book also anticipated "problems of an entirely new order of magnitude-
the exhaustion of resources, the pollution of the environment, overpopulation,
and the possibility of a nuclear holocaust" (Skinner, 1976b, p. vii). Walden Two
emphasized minimal consumption and minimal pollution. Although the origi-
nal Walden Two advocated early childbearing, which would normally increase
population (and which Skinner said he would change ifhe were to write the book
over), in a preface to a new printing, Skinner pointed out that contingencies in
Walden Two would make it "easy to change the birth rate" (Skinner, 1976b,
p. xi). Members would not need to bear children to ensure economic security,
and they could relate to the young in a parental role without conceiving chil-
dren themselves. The topic of war is clearly more difficult to address. In the
1976 preface, Skinner addressed violence at a local level, citing face-to-face
social sanctions as more effective than "delegating censure to a police force and
the law courts" (1976b, p. xi). Ultimately, Skinner suggests, worldwide change
might come about, not through political action, but through a cultural revolu-
tion arising at the local level. The revolution Skinner recommends is the design
of a culture based on an understanding of human behavior.
SUMMARY AND CONCLUSION

Skinner's small town upbringing at the beginning of the twentieth century
gave him a set of democratic values and an optimism that never left him. He set
about every aspect of his life with a remarkable energy. His approach to any-
thing that was not working just right was to fix it. His first foray into improving
daily life was more an extension of tinkering than of science. The baby-tender
helped solve the dangers and inconveniences of the standard crib, but it could
have been built without the years of research Skinner had conducted by then.
But as Skinner increasingly saw the power of selection by consequences, of
schedules of reinforcement, and of precise stimulus control, he extended prob-
lem solving to larger issues. Walden Two was Skinner's first real foray into
human behavior. It was a deliberate application of the principles researched in
the lab to the design of a culture. Skinner's approach was pragmatic: replace the
haphazard and unplanned controls over people's lives that end up being mostly
punitive by a planned system that reinforces activities that benefit all. And, in
the true spirit of scientific experimentation, the Walden Two community would
evaluate and alter its own cultural practices according to data gathered in a
continual endeavor to produce an ever better world.
Walden Two was fictional, but the science on which it was based is carried
on today by behaviorologists and by many behavior analysts and behavioral
psychologists. If we can take from Skinner not only the science that explains
how and why behavior changes over the lifetime of the individual but also his
optimism and his energy, we can have a real impact on the future. For it is only
by continuing to explore how human behavior is controlled that we can begin
to systematically change practices that lead to conflict and misery and to adopt
cultural practices that will improve the human condition.
REFERENCES
Cheney, C. D. & Ledoux, S. (1991). Crandpa fred's baby tender, or why and how we built our
aircribs.
Cooke, N. L. (1984). Misrepresentations of the behavioral model in prescrvice teacher education
textbooks. In W. L. Heward, T. E. Heron, D. S. Hill, & J. Trap-Porter (Eds.), Focus on Behavior
Analysis in Fducation (pp. 197-217). Columbus, OH: Merrill.
Family scrapbook (no date). Unpublished scrapbook kept by Grace Burrhus Skinner (B. F. Skin-
ner's mother). B. F. Skinner Foundation Archives, Cambridge, MA.
Fcrster, C. B., & Skinner, B. F. (1957). Schedules of reinforcement. (New York: Appleton-Century-
Crofts.
Newman, B. (1992). Brave New World revisited: Huxley's evolving view of behaviorism. The
Behavior Analyst, 15( I), 61-69.
()xjiJrd English Dictionary (compact cd.). (1971). Glasgow: Oxford University Press.
Skinner, B. F. (1938). The /}(!havior of organisms. New York: Appleton-Century-Crofts. (Now
available through the B. F. Skinner Foundation, Box 380825, Cambridge, MA 02238.)
Skinner, B. F. (1940). Unpublished letter to F. S. Keller. B. F. Skinner Foundation Archives, Cam-
bridge, MA.
Skinner, B. F. (1942). Unpublished letter to F. S. Keller. B. F. Skinner Foundation Archives, Cam-
bridge, MA.
Skinner, B. F. (1945). Baby in a box: The mechanical baby-tender. I.adies' Home Journal, pp. 30-
31, 135-136, 138. [Also in Skinner, B. F. (1972), Cumulative record (3rd ed., pp. 567-573).
New York: Appleton-Century-Crofts. [
Skinner, B. F. (1948a). Unpublished letter to F. S. Keller. B. F. Skinner Foundation Archives,
Cambndge, MA.
Skinner, B. F. (1948b). Walden Two. New York: Macmillan.
Skinner, B. F. (1953). Science and human hehavior. New York: Macmillan.
Skinner, n. F. (1955a). Unpublished notes 30(2) 40(4) 50-55. B. F. Skinner Foundation Archives,
Cambridge, ,\1A.
Skinner, B. F. (1955b). Unpublished notes 55-56. B. F. Skinner Foundation Archives, Cambridge,
MA.
Skinner, B. F. (1956). A case history in scientific method. American Psychologist, J J, 221-233.
[Also in Skinner, B. F. (1972). Cumulative record (3rd ed., pp. 101-124). New York: Appleton-
Century-Crofts.]
Skinner, B. F. (1957). Verbal behavior. New York: Appletoo-Century-Crofts. (Now available
through the B. F. Skinner Foundation, Box 380825, Cambridge, MA 02238.)
Skinner, B. F. (1967). B. F. Skinner. In E. G. Boring & G. Lindzey (Eds.), A history of psychology in
autobiograph), (Vol. V, pp. 385-4 U). New York: Appleton-Century-Crofts.
Skinner, B. F. (1976a). Particulars of m)' life (part 1 of an autobiography). New York: Knopf.
Skinner, B. F. (1976b). Walden Two revisited (preface to a new printing of Walden Two). New York:
Macmillan.
Skinner, B. F. (1979). The shaping ot d behaviorist (part 2 of an autobiography). New York: Knopf.
Skinner, B. F. (1987). The first baby-tender. Unpublished manuscript. B. F. Skinner Foundation
Archives, Cambridge, MA.
Skinner, E. B. (1994). Tlpe-recorded interview of Eve Skinner abollt the baby-tender. Personal
collection, Julie S. Vargas.
Todd,.J. T., & Morris, E. K. (1992). Case histories in the great power of steady misrepresentation.
Americ(m Psychologist, 47(11),1441-1463.
Vargas, E. A. (1988). Verbally governed and event-governed behavior. The Analysis of Verbal
Behavior, 6, 11-22.
Vargas, E. A. (1993, October). From behaviorism to selectionism. Educational Technology, pp. 46-
51.
Webster's Third New International Dictionary. (1963). Springfield, MA: G&C Merriam.
Wilson, E. O. (1992). The diversity of life. Cambridge, MA: Harvard University Press.
Woodruff, M., & Warner, R. (1967, January 15). 1,000 babies raised in glass cages. National
Enquirer, pp. 16-17.
15
Perspectives on the Problem

of Poverty
Jerome D. Ulman
In today's world, on a massive scale, we witness poverty of appalling magni-

tude. We associate absolute poverty with underdeveloped regions of the world
stricken with disasters such as war, droughts, crop failures, pestilence, and
starvation. Televised scenes of horribly emaciated bodies of young children in
impoverished countries are only too vivid. And what television brings us from
afar, we can see easily at home in a so-called first-world country. As we walk
through the streets of our major cities in the United States, we cannot avoid the
distressing sights of homeless people, often within view of conditions of wealth
and luxury. We write checks to charitable organizations to aid the poor or vote
for politicians who promise to support a government initiative to help alleviate
poverty. However, seeing no apparent effects of our efforts or contributions,
sooner or later we may find ourselves become increasingly frustrated and dis-
couraged. Still the question remains: what to do about the problem of poverty?
As behavioral scientists we know that to have any measure of success, the
solution must be appropriate to the problem. At the onset, then, we must
clearly delineate what we mean by "the problem of poverty" -not an easy task.
In contemporary political discourse, poverty is a chronically misused and hotly
contested term, one that generates and perpetuates unbounded confusion (see
Burton, 1992). Even how it is defined has contentious political implications.
Adding to the confusion, sometimes poverty is discussed in absolute terms, as a
Jerome D. Ulmdn • Department of Special Education, Ball State University, Muncie, Indiana
47306-0615.
279
lack in the means of subsistence, and at other times in relative terms, as a lack of
the usual or socially acceptable amount of money or material possessions.
Further, poverty is often conflated with a number of other thematically related
terms such as need, deprivation, and destitution, all of which are similarly iII-
defined and problematic.
Presumably, then, if we are to have a significant impact on the problem of
poverty, we should begin by analyzing how we go about conceptualizing it. In
other words, what is needed is an appropriate frame of reference for consider-
ing the problem. To this end, the present chapter will first examine the problem
in the United States, then survey how it is considered from a variety of disciplinary
viewpoints, and finally suggest at least the beginning of a behaviorologically
based conceptual framework for analyzing the problem of poverty.
POVERTY IN THE UNITED STATES
Some Facts and Figures

Let's begin with some facts and figures on poverty and employment in the
United States. If we use the official poverty line based on what the Social
Security Administration considers the minimal amount of money to maintain a
subsistence level of life, "in 1991, 14 percent of the population ... 35.7 million
persons ... were defined as living in poverty" (Eitzen & Zinn, 1994, p. 161).
As reported in a recent news article (Ver Meulen, 1994),
The Commerce Department set the official poverty level in 1993 at $7357
for an individual and $14,764 for a family of four. Yet, according to the
Census Bureau's latest figures, one in six full-time employees earns less than
the poverty level. This is a shocking 35% rise in America's "working poor"
since 1979.
The economy is robustly recovering from recession, but that recovery has
been led by increased productivity, not by an increasing number of jobs.
Instead, workers are putting in more overtime .... And many of the jobs
that were created this year were lower-paying service or part-time positions.
(pp.4-5)
When more carefully defined economic measures are applied, we find that in
the last two decades "poverty not only increased, it became more chronic and
less transitory in nature" (Rogers & Rogers, 1993, p. 25). Looking at the long-
term economic trends in the United States, the future of the employment picture
for working people in this country does not look good. How many more
Americans will become the "working poor" or out of work altogether?
Being poor in the United States means particular hardships in the country-
side, where access to housing and health care is especially limited. Goodno
(1992) reports that
rural poverty occurs virtually as frequently as inner-city poverty. In 1987,
rural poverty stood at 17'10, and one in four poor Americans lived outside
15 • PERSPECTIVES ON POVERTY 281
metropolitan areas. Almost a fourth of rural children lived in poverty, as did

45% of rural female-headed households. Of the rural poor, 25% were
black, 71 % white. (p. 7)
No economic issue is more disheartening than that of child poverty. Today

more than 13 million children in the United States are poor, making them one
of the largest impoverished groups in this country-contrasted with 9.8 million
poor blacks, 3.7 million poor elderly, and 3.7 million female householders
(Jensen, Eggebeen, & Lichter, 1993).
Trends in Poverty
In their analysis of US Census Bureau data from 1970, 1980, and 1990,
Jensen et al. (1993) report
(1) a marked increase since 1970 in the percentage of poor children receiv-
ing public assistance; (2) a sharp rise in poor children's reliance on public
assistance vis-ii-vis parental earnings; and (3) stagnation or even deteriora-
tion in the ameliorative effects of public assistance on child poverty during
the 1980s. (p. 542)
During the last decade the politically conservative view has persuaded
some public opinion that welfare is not only a waste, it is actually making the
poverty problem worse; allegedly, it "fosters dependency, creates disincentives
to work, encourages the formation of single-headed families, and ultimately
reinforces poverty from parental to filial generation (d. Murray, 1984; Jencks,
1991)" (Jensen et aI., 1993, p. 543). Skepticism about the beneficial effects of
welfare programs in the United States has been growing and new "workfare"
legislation has been enacted, such as requiring recipients of Aid to Families with
Dependent Children (AFDC) to seek employment or job training to remain
eligible for assistance. In the current political climate, elimination of welfare
programs altogether at the federal level is becoming less and less of a remote
possibility.
Paradoxically, at the same time that welfare dependence is increasing
among children, both black and white, the ameliorative effects of welfare are
decreasing. The rise in child poverty during the 1980s "implies that welfare
receipt was not especially effective in ameliorating poverty among children. The
poverty rate among unemployed single mothers is almost 90 percent," while
"only 45 percent of all female-headed families with children received AFDC in
1988, ... down from 63 percent in 1972 (Jencks, 1991). Moreover, since the
mid-1970s the real value of AFDC ... has declined by 30 percent" (Jensen et
aI., 1993, p. 545). This decline, in part, reflects conservative efforts to tighten
eligibility guidelines and reduce welfare benefits (see Levitan, 1990).
The perverse implication is that the effectiveness with which welfare ame-
liorates poverty may have declined in effectiveness in the 1980s, while at the
same time welfare dependence among poor children may have increased,
largely because they increasingly live in mother-headed families. (Jensen et

aI., 1993, p. 545)
The terrible consequences of these two trends in the actual living conditions of
its victims are presented in graphic detail in Johnathan Kozol's (1988) book
Rachel and Her Children. Jensen et al. (1993) conclude: "Our results under-
score the need for new policy initiatives that will improve employment oppor-
tunities for the parents of poor children, reduce the barriers to employment
they face, and make work pay a living wage" (p. 558).
WHAT IS THE PURPOSE OF WELFARE IN THE UNITED STATES

Marmor, Mashaw, and Harvey (1990) argue that the gloom and doom
that surrounds so much of the public discussion about welfare in the United
States stem from a multitude of popular but false ideas about social welfare
programs in this country and how they supposedly work. The authors begin
setting the record straight by describing four fundamental conceptions of the
purpose of welfare that coexist, often uneasily, in the design of welfare pro-
grams in the United States.
Malthusian Behaviorist View

Not to be confused with the behavioral scientist view, the Malthusian
behaviorist view grew out of the English Poor Laws system that preceded the
modern welfare state. The purpose of social welfare is to induce the poor to
behave in a more socially acceptable manner and thereby become more self-
reliant. Social welfare programs based on this view would be limited to charita-
ble relief for victims of genuinely exceptional circumstances. The underlying
premise of the Malthusian behaviorist is that "the poor are poor-and suffer
from a lack of medical care, food, housing, and security-because they do not
live as they should: (Marmor et aI., 1990, pp. 23-24). Although human suffer-
ing should be partially relieved, more generous assistance would reinforce the
very behavior patterns responsible for the suffering in the first place.
Residualist View
Based on the metaphor of the "safety net," the residualist holds that social
welfare programs are intended to rescue the victims of the market economy and
provide subsistence level relief to those unable to provide for their own needs.
Like the Malthusian behaviorist view, it originated from the English Poor Laws
tradition but "more nearly reflects the legacy of philanthropic humanitaria-
nism in that tradition than the influence of the workhouse disciplinarian"
(Marmor et aI., 1990, p. 25).
In the United States, the residualist is representative of the mainstream
position that the administration of welfare should be highly decentralized,
limited to temporary assistance, and closely supervised so the recipients are

only the "deserving" poor. In the United States, public assistance programs
such as the federal-state AFDC exemplify this model. Following from the
safety net metaphor,
the net is close to the ground and the benefits are accordingly modest-a
subsistence that might well vary widely in connection with community
standards of adequacy.... Minimal adequacy, selectivity [only the "truly
needy" qualify], localism [under the control of state and local govern-
ments], and tests of need [i.e., means-tested]-these constitute the residual-
ist's standard bases for evaluating the welfare state. (Marmor et aI., 1990,
p.26)
Social Insurance View

The basic purpose of welfare, according to the social insurance view, is "to
provide economic security, to prevent people from falling into destitution rath-
er than rescuing them after they have already fallen" (Marmor et al., 1990,
pp. 26-27). Held among the major threats to financial security are involuntary
unemployment, death of the primary breadwinner, extended sickness or injury,
retirement, and in some cases a large family. "The central image of social
insurance is the earned entitlement [italics added], publicly administered bene-
fits for which all similarly situated persons are eligible by virtue of their finan-
cial contributions to the system and the taxes they pay" (Marmor et al., 1990,
p. 27). The aim of welfare is insured equitable treatment, not equalized in-
comes, an aim not unlike the type of financial security presumed in the fringe
benefits of civil servants. Although social insurance advocates differ in some
details, particularly about how much redistribution of income and power
should be allowed, they all reject the Malthusian behaviorist and residualist
views of welfare.
Egalitarian Populist View

"The aim of the egalitarian populist theorist is social change, not guaran-
teeing insurance payments or providing a safety net for the poor, and certainly
not correcting the alleged misbehavior of the poor" (Marmor et al., 1990,
p. 28). In fact, "the goals of behavior modification, charity, and insurance
compensation are viewed as either repressive or inadequate" (p. 28), merely
minor adjustments to the harsh realities of capitalist society, not a substantive
means for transforming it. The most advanced form of the egalitarian populist
program (but not discussed in Marmor et al., 1990) is found in revolutionary
Cuba (see Ulman, 1989). As Frank (1993) documents,
Cuban works enjoy a series of basic rights and benefits superior to those of
workers in the rest of the region [i.e., the Americas], including the United
States and Canada. Cubans have won the right to work or an income, the
right to organize and participate in company management; equal pay for
equal work; and no job discrimination .... benefits include a one month
paid vacation for all, unlimited sick pay, paid maternity leave, full health
coverage and guaranteed social security without paying into a fund. Chil-
dren of both blue-collar workers and the highest paid executives have equal
access to quality health care and education. (pp. 73-74)
Plainly, the egalitarian populist view has not had much influence in the
design of welfare programs in the United States, but it has not been totally
absent either. As one example, Marmor et al. (1990) mention that part of the
antipoverty strategy of the 1960s involved "efforts to organize the poor to
shape the economic and social development of their own communities" (p. 29)
such as the establishment of community development corporations and free
legal services for the poor.
In sum, solutions implemented to ameliorate the problem of poverty range
from "benign" neglect to the radical transformation of society. For Malthusian
behaviorists, the powerful correct the faults of the weak; for the residualists, the
powerful take care of the weak; for the social insurance advocates, government
provides some measure of economic security for all, but does not attempt
directly to transform society's power structure; and for egalitarian populists,
nothing short of social change and the redistribution of wealth will do. The
latter fall into two camps, those who favor reform but only within the confines
of the capitalist economic structure and those who call for the replacement
capitalism with socialism by revolutionary means. However, the current ap-
proach to welfare reform in the United States is best characterized as a stew of
residualist and social insurance programs seasoned with just a dash of the
mildest form of egalitarian populism.
HOW NOT TO THINK ABOUT WELFARE IN THE UNITED STATES
If we were to accept as factual the relentless negativism in public debates

on welfare policies in the United States, we might think that the course was
being set by Malthusian behaviorists. Marmor et al. (1990) provide a cogent
counterargument to this "War on Welfare" (a war that continues, now threat-
ening AFDC recipients with a 2-year limit; see Amott, 1993). They point out
that the United States is indeed a welfare state, as are the other major indus-
trialized countries, but of a peculiar kind. Unlike other welfare states that-
owing to the political power of labor parties and social democratic parties-
provide a broad spectrum of social welfare programs, the United States is more
accurately characterized as an opportunity-insurance state. Social welfare ex-
penditures in the United States consist overwhelmingly of social insurance
payments, the principal beneficiaries of which are the elderly. "Social Security
old-age pensions alone account for almost 40 percent of all social insurance
payments, and Medicare benefits for predominantly the same population ac-
count for another 22 percent" (Marmor et aI., 1990, p. 33).
A second but significantly smaller component of the US welfare state
consists of means-tested programs, those that deliver mainly in-kind assistance

(e.g., medical care, subsidies for food and housing expenditures, college tuition
assistance) to persons who qualify for it on the basis of need. The United States
provides more than twice as much social insurance as it does means-tested
assistance, and little of the latter (26%) is provided in the form of cash pay-
ments. Moreover, the amount of cash assistance provided through the two
programs we most commonly associate with "welfare"-AFDC and general
assistance-account for less than half this total (i.e., 10% of all means-tested
aid). If this data-based picture of welfare programs in the United States does not
comport with our preconceptions, we can credit our misunderstandings to the
effects of the popular media.
The incessant pandering of misconceptions about welfare programs have
made them become part of the conventional wisdom. In their effort to shine
some light on the subject, Marmor et a!. (1990) offer four useful rules on "how
not to think about the American welfare state" (italics quoted from Chapter 7):
(1) projections are not forecasts (or, a constant growth rate to age 4 does not
mean that a person will be 10 feet tall at age 22); (2) incentives are not
behaviors (other cultural factors may dwarf the effects of economic incentives);
(3) purposes are never unitary (being compromises, all welfare programs con-
tain contradictions); and (4) comprehensive reform is usually not on the agen-
da (or, beware of the hyperinflation of reform rhetoric). Given the nature of the
criticisms of welfare portrayed in popular books such as Charles Murray's
(1984) influential Losing Ground, rule 2 deserves our special attention.
Murray's (1984) thesis, echoed so frequently in the mass media, is that
welfare generates rather than reduces dependency. A serious charge indeed! He
argues that the more we spend on welfare, the more dependents we continue to
create; hence, the only solution is to stop welfare payments. Murray builds his
case with a wealth of statistics (prompting my recollection of the title of a
marvelous little book, How to Lie with Statistics) and persuasive but fictional
anecdotes about welfare dependency. Murray's major statistical error is one of
enormous overgeneralization. He lumps all income transfers and other sup-
portive programs together, while confining his target to means-tested welfare,
principally AFDC payments-less than 30% of all welfare expenditures. (For
scholarly rebuttals to Murray, see the references cited in Chapter 4 of Marmor
et a!., 1990.)
Virtually all of the changes in poverty rates in the United States between
the beginning of President Johnson's War on Poverty and the publication of
Murray's Losing Ground can be accounted for by three of factors: raising
average unemployment rates, an increased percentage of the population in
high-risk groups, and the long-term trend toward inequality in income distri-
bution (Marmor et a!., 1990). While these trends pose an increasingly serious
challenge to the well-being of the masses of people in the United States, there is
no evidence to support the notion that efforts to relieve poverty have been
causing the growth in poverty, illegitimacy, and nonparticipation in the work-
force.
POVERTY CONSIDERED FROM VARIOUS

DISCIPLINARY VIEWPOINTS
Let us next survey how various academic disciplines view the problem of
poverty. We will look at the problem from the standpoint of the behaviorolo-
gist, the sociologist, the cultural materialist, the neoclassical economist, and
the institutional economist.
Behaviorological Considerations
There are countless proposals for dealing with poverty, but few derived
from the perspective of the natural science of behavior. For behaviorologists,
insofar as poverty is a social problem, it is also a behavior problem, that is, a
problem with the past and present arrangements of behavior-environment
contingency relations. The most straightforward line of attack on the problem
would focus on the possible applications of behavior-change technology (ap-
plied behavior analysis). With regard to behavior-change programs dealing
with relative poverty in the United States, Opulente and Mattaini (1993) pro-
vide a useful, comprehensive overview. After reviewing some current facts and
policy initiatives concerning welfare, along with the an overview of programs
focused on the problem of poverty (which I recommend reading), they find that
(1) that the most effective approaches will be those that are based primarily
on offering adequate supports and incentives, and (2) indiscriminate cuts
and sanction-based programs are often based on myth, and are likely to be
ineffective and produce undesirable side effects. (p. 17)
They conclude, "American society cannot afford further delay in address-
ing these [welfare reform 1issues if we value social stability, competitiveness on
the world market, and a minimally acceptable quality of life for millions of
poor women and children" (p. 32).
We can agree with Opulente and Mattaini's (1993) assessment of the
behavioral research literature on welfare interventions, but certain ethical as-
sumptions they make bear closer scrutiny. Specifically, why should we value
competitiveness on the open market? As a counterpoint, Sidman (1989) argues
that
the inherent coerciveness of competition is clear enough. One outcome of
unbridled competitiveness is our two-tiered world of haves and have-nots, a
structure that is now proving unsteady. Institutionalized and private charity,
and government "safety nets, " try to provide minimal levels of support for
the most severely deprived, but they have neither prevented the economic gap
from widening nor reduced the threat of social instability. (pp. 202-203)
As for alleviating poverty, Sidman is most concerned with what we should
not do. With noncontingent charity, including government welfarism, the end
result would be just as devastating as maintaining the current unequal access to
resources, "turning givers into self-righteous hypocrites, and receivers into
vegetables" (Sidman, 1989, p. 205). Ultimately, such a policy would produce a

recomposed two-tier welfare society: "one tier ... will contain producers, the
other, parasites" (Sidman, 1989, p. 204). Sidman would take issue with Opu-
lente and Mattaini's (1993) apologia favoring market competition but would
concur with their suggestion for welfare reform, one based on positive rein-
forcement and contingency management.
Among Skinnerians, there are of course other ideas about what should be
done above poverty. They range from Malthusian behaviorists who would
advocate doing nothing at all-such as Herrnstein's (1973) view that society
inevitably sorts itself into various socioeconomic levels according to differences
among individuals in native ability-to egalitarian populists (see Ulman,
1989).
Sociological Considerations
The sociologist, Herbert Gans (1971), offers a functionalist account 1 of
poverty, based on the assumption that if it persists, it must be serving some
useful purposes for society (or at least the dominant sector). According to
Gans, the poor provide a low-wage labor pool to perform society's "dirty
work"; create jobs for a number of occupations and professions (e.g., social
workers, police, liquor store owners, drug-dealers, prison guards); subsidize
merchants by purchasing products that others do not want (dilapidated hous-
ing, second-hand goods, quick-sale produce, etc.); serve as negative models to
demonstrate the "correctness" of conventional, middle-class values; guarantee
the status of the nonpoor by occupying the bottom rungs of the status hier-
archy; assist in the upward mobility of others; and, being powerless, absorb the
cost of change in society (as refugees from urban "renewal," being the "last
hired, first fired," etc.).
From the sociological perspective, what can be done about the problem of
poverty? In their textbook, Social Problems, Eitzen and Zinn (1994) refer to
Harrington's (1963) forceful argument for the elimination of poverty in the
United States: "In a nation with a technology that could provide every citizen
with a decent life, it is an outrage and a scandal that there should be such social
misery" (Harrington, 1962, p. 24). Toward the goal of uprooting poverty, the
authors go on to enumerate nine basic assumptions: Poverty (1) can be elimi-
nated in the United States; (2) is caused by a lack of resources, not a deviant
'It should be made dear that a functional analysis is not the same thing as a functionalist account
or explanation (e.g., Gans, 1'171). In sociology, a functional account explains the existence or
form of a given phenomenon by virtue of its beneficial effects on something else. Thus, for
example, poverty exists because it benefits the functioning of society as a whole. This functionalist
account presumes that "society" is a equilibrating, integral whole. We could just as well apply the
framework outlined above to a functional analysis of class struggle where, for example, I have
defined class struggle as "agonistic behavior (cultural practices) among people organized by
macrocontingencies into conflicting institutions selected by antagonistic relations of production
... within a class-divided society" (Ulman, 1'195). A functional analysis describes behavioral
relations and the variables of which they are a function.
value system; (3) is not simply a matter of deficient income, it results from
other inequities in society as well; (4) cannot be eliminated by the efforts of the
poor themselves; (5) cannot be eliminated by the private sector of the economy;
(6) will not be eliminated by a rising economy; (7) will not be eliminated by
volunteer help from well-meaning individuals, groups, and organization; (8)
will not be eliminated by the efforts of state and local governments; and (9) is a
national problem and must be attacked with massive, nationwide programs
financed largely and organized by the federal government (quoted from Eitzen
& Zinn, 1994, pp. 177-182). These assumptions obviously express the egali-
tarian populist view. Undoubtedly, there are sociologists of even the Malthu-
sian behaviorist persuasion, but their ideas will not be discussed here. Perhaps
Harris (1988) said it best when he commented that the Malthusian behavior-
ist's view reveals
a streak of prurient yahooism such as one might find in Roman spectators
defending the sport of throwing people to the lions. Every once in a while
someone manages to avoid getting eaten. Ergo, the reason people get eaten
is partly that the lion is hungry and partly that the victims don't try hard
enough. (p. 88)
Anthropological Considerations
As behavioral scientist and practitioners, we tend to concentrate on chang-
ing the behavior of individuals or small groups (children in a classroom, resi-
dents of a sheltered home, etc.), and as a result suffer from a peculiar kind of
conceptual myopia called methodological individualism. Within the last few
years, however, several Skinnerians (Bigland, Glasgow, & Singer, 1990; Glenn,
1988; Lamal, 1991; Lloyd, 1985; Malagodi & Jackson, 1989; Malott, 1988;
Vargas, 1985) have come to recognize this shortsightedness and prescribe as the
remedy for understanding the larger social context the cultural materialist
perspective of the cultural anthropologist Marvin Harris (1979).
In analyzing social problems such as poverty, rather than starting from the
top or "superstructure" of a culture, that is, from changes in moral and spiritu-
al values ("hearts and minds"), Harris (1981) starts from the base or "infra-
structure"; as he puts it, "from changes in the way people conduct practical
and mundane affairs of their everyday lives" (p. 11). Concerning the culture we
call America (a misnomer for the culture common to English-speaking US
citizens), among the important infrastructural changes Harris points out are:
(1) The majority of Americans now produce services and information rath-
er than goods .... (2) Married women who formerly worked exclusively in
the home now work outside the home almost as often as married men
do .... (3) Firms are much larger and more bureaucratic ... (4) [And] a
surprising number of Americans now work for government rather than for
private companies. (p. 11)
Harris adds that this set of changes "may provide the best framework for
understanding how the pieces of American culture fit together" (p. 11). How,
we must ask, does this cultural materialist framework apply to our achieving a
better understanding of poverty in the United States?
In America Now (subsequently entitled, Why Things Don't Work), Harris
(1981) writes about the shortcomings of contemporary mainstream economics
(as he calls it, "the new dismal science"):
Believers in unfettered capitalism profess to be concerned about improving

the well-being of the poor, but it quickly becomes apparent that they are far
more concerned about protecting the well-being of the rich. While the new
dismal scientists [economists 1 want to solve the problem of poverty by
abolishing everyone's material desires, the unfettered capitalist wants to
solve it by collvincing the poor that they have only themselves to blame for
not being rich. (p. 177)
What solution docs Harris offer? He proposes a strategy of radical decentraliza-

tion: "encouraging the development of small-scale private enterprises, manned
by hard-driving, profit-sharing work teams producing enough of a surplus to
pay for first-class educational and community services as well as for the com-
passionate care of the sick and the elderly" (p. 181). Beyond this quite non-
specific nostrum, he has nothing else to offer. In fact, Harris is specific on this
point, forewarning the reader that "this book does not contain a detailed set of
prescriptions as to how America can regain its momentum toward affluence,
democracy, and justice" (p. 16). Nonetheless, we can agree wholeheartedly
when he asks rhetorically, "Yet is not the struggle to understand a problem part
of its solution?" (p. 16).
Mainstream Economic Considerations

Neoclassical or mainstream economists study how humans allocate scarce
resources to meet unlimited wants. Thus, if people are to satisfy their presumed
unlimited wants, they must carefully economize their presumed scarce re-
sources. For mainstream economists, the core of modern welfare economics is
the concept of allocative efficiency (Pareto optimality): "Allocative efficiency
occurs when there is no possible reorganization of production that would make
everyone better off-the poor, the rich, the wheat and shoe producers, etc."
(Samuelson & Nordhaus, 1985, p. 483).
In recent years, mainstream economists (especially monetarists and "sup-
ply siders"; see Klein, 1994) have come more and more to stress the notion that
leaving economic allocation to the market without intervention is best. So we
must have faith that left on its own, under unrestricted market conditions, the
economy will reach an equilibrium that will be maximally efficient and there-
fore the best of all possible worlds for all concerned. The benefits will naturally
trickle down from the have to the have-nots. By deduction,
if fl.'sources are fixed, human poverty is unavoidable. [Therefore I Malthus

was right-schemes to aid the poor will only increase their misery in future
generations. So the common man must be inoculated against the schemes
of the utopians and the levelers, lest those schemes give rise to false hopes of
a decent life for all. (Dugger, 1989, p. 116)
The stock-in-trade of mainstream economists is a simple but persuasive

story. People behave rationally. If you increase or decrease the economic re-
wards of particular activities, you will get more or less of those activities,
unless, of course, something else happens simultaneously to alter behavior in a
different direction. (Recall the rule, incentives are not behaviors.) As Marmor et
al. (1990) point out, the problem with the economists' story is that it is too
persuasive. "People tend to forget both the 'useless' qualification ... and that
nothing yet has been said about how much more or less we should expect"
(p.219).
In the final analysis, we see very little trickling down. In fact, the flow
seems to be going in the opposite direction. As Klein (1994) observes, "today,
mainstream theory is too often justified merely for providing a precise and
rigorous method for solving elegant, challenging, complicated puzzles that
economists et out for themselves" (p. 205). So, they "continue to pursue their
Pareto optimizing ways, unconcerned by either real-world power concentra-
tions, performance failures, or institutionalist criticisms" (p. 197). This point
brings us to the next topic for consideration in trying to understand poverty:
institutional economics.
Institutional Economic Considerations

In her 1985 article, Glenn identifies a group of economists who appear to
have an evolutionary view of culture, and thus a close affinity to the Skinnerian
view of culture. Since then, however, behaviorists have given negligible recogni-
tion to the work of the institutional economists. Perhaps one reason for this
neglect is that Glenn discussed only one wing of this group, the conservative
wing of C. E. Ayers, an extreme technological determinist.
Following Glenn's (1985) advice that we learn something about institu-
tional economics, I was pleasantly surprised to discover that there is much
fertile terrain to explore in a discipline that seems as far removed from main-
stream economics as behaviorology is from mainstream psychology. Besides the
conservative Ayerian wing, there is another grouping of institutional econo-
mists who refer to themselves as radical institutionalists. According to Dugger's
(1989) definition, "radical institutionalism is the processual paradigm focused
on changing the direction of cultural evolution and the function of social
provisioning in order to promote the full participation of all" (p. 133). Elab-
orating, Dugger states:
By choosing to be institutionalists, we are choosing to try to improve the
flow of goods and services to better meet the needs of people. By choosing
to be radical institutionalists, we are choosing to improve the flow of goods
and services to poor people. We cast our lot with the wretched of the earth.
Not all institutionalists have chosen to do so ... (p. vii)
To illustrate the contrast in the way mainstream and institutional econo-

mists think about economic problems, consider the mainstream term jobless
recovery. "The very terminology suggests how insensitive to human needs cur-
rent economic thought has become. In other words, [mainstream] economists
look for signs of health and disease in the requirements of the system, not
people" (Plotkin & Scheuerman, 1994, p. 10). On the other hand, institutional
economists call attention to the human welfare implications of economic termi-
nology such as, for example, between the terms antipoverty versus public assis-
tance. As Northrop (1991) points out, antipoverty programs "are directed
toward moving people from poverty and helping people avoid poverty"
(p. 101 !l), whereas public assistance programs are "designed to ameliorate the
conditions of having a low income" (p. 101!l). A favorite ploy of the conserva-
tive commentators is to castigate the latter for not achieving the goals of the
former. [For further discussion of the difference between institutional and
mainstream economists, see Klein (1994). To gain a better appreciation of the
work of the institutional economists, see their primary publication outlet, the
journal of Economic Issues.]
Marxist Considerations
Neoclassical economics tends to treat economic inequality as due to differ-
ences in the skills, ability, and motivation of individuals that affect their earning
capacity. Marxist economics, its diametric opposite, treats economic inequality
as due to unequal distribution of wealth and access to skill-engendering social
resources such as education, both of which stem from the social division of
labor institutionalized within capitalist society. It is noteworthy that radical
institutional economists see themselves as allies with Marxist economists, "not
opponents, in the struggle against [mainstream economic 1 orthodoxy" (Dug-
ger, 19H9, p. 132).
Concerning the US economy, the so-called paradox of the existence of
poverty in the land of plenty is, for Marxists, better understood not as a
paradox but as an unavoidable outcome of the process of extracting surplus
labor from the wage workers. hom the Marxist perspective, the economy is
essentially a system of competing power relations, so poverty is compre-
hended in relation to the class struggle for power. The property of the owning
class is protected by the coercive force of state power (police, military, courts,
prisons, etc.). The power of the working class begins with their capability to
organize, starting with the formation of labor unions and culminating in the
coalescence of a workers' and farmers' government, the overthrow of the cap-
italist state, and the construction of socialism. Until then, in the class-divided
society under capitalist rule, poverty is inevitable and will rise and fall accord-
ing to the blind, uncontrolled forces the capitalist world economy. [For a
behaviorologically oriented exegesis of Marxist theory, see Ulman (1995) also
Ulman (1991)1
TOWARD A CONCEPTUAL FRAMEWORK
In Science and Human Behavior, Skinner (1953) writes,

The traditional procedure [in economics 1 has been to deduce the behavior
of the individual engaged in economic transactions from data derived from
the group. This procedure led to the Economic Man of nineteenth-century
economic theory, who was endowed with just the behavior needed to ac-
count for the overall facts of the larger group. (p. ,199)
Unfortunately, this kind of explanatory fiction-now termed rational choice
theory-continues to playa prominent role in economic theorizing, as is evi-
dent in the mainstream economic considerations of poverty we reviewed above.
Skinner's (1953) purpose in discussing economics is not to offer an alter-
native theory to economists, but to discuss the economic control of the behav-
ior of the individual. The problem of poverty, however, must also be addressed
at the sociocultural level. In recent years, a number of approaches have been
offered to investigate sociocultural phenomena from the operant point of view
(e.g., Lamal, 1991).
A natural science conceptual framework for approaching the problem of
poverty would be built on a behaviorological foundation. If we are to get
beyond the cul-de-sac of methodological individualism, we must take into
account not merely problems of the individual such as the lack of employment-
related skills and the like (i.e., as outlined in Opulente & Mattaini, 1993), but,
even more, the dysfunctional cultural milieu. At this juncture, of course, we
transcend the conventional disciplinary boundary of the science of behavior
relations and change our focus from the behavior of the individual to the
dynamic properties of the social environment made up of many reciprocally
interacting individuals. We thus enter the preserves of the social sciences (in
particular, political economics) but with a unique natural science perspective-
selection by consequences, the causal mode of all life forms (Skinner, 1981).
The following represents an initial attempt to construct a conceptual
framework, one capable of analyzing sociocultural phenomena such as poverty
in terms of a continuum of increasingly integrated and complex functional
relations. We will begin with the development of a unit of analysis involving the
contingent relations of many interacting individuals, the macrocontingency,
and then progress to the functional analysis of verbal (ethical) communities,
and finally to the analysis of social institutions.
Macrocontingencies
In 1978, I suggested that behaviorists begin to examine "those enormous
controlling variables that operate at the institutional level of analysis ...
[which] might be called "macrocontingencies" [italics added] (Ulman, 1978,
p. 62). I proposed the macrocontingency as a conceptual tool for analyzing all
kinds of sociocultural phenomena, but did not offer a functional definition of
the concept. Subsequently, Glenn (1986) provided a functional definition of
metacontingency: "the unit of analysis describing the functional relations be-

tween a class of operants, each operant having its own immediate, unique
consequence, and a long-term consequence common to all the operants in the
metacontingency" (p. 2).
For the present purpose, however, I find the concept of the metacontingen-
cy too constraining. First, it seems difficult if not impossible to identify unam-
biguously "the long-term consequence common to all the operants in a meta-
contingency" operating in the context of real, complex social phenomena
descriptive of the problem of poverty. Second, the term metacontingency itself
is problematic. The prefix meta implies something beyond or transcending,
whereas macro means long in extend or duration and contrasts with micro (as
in micro- and macroeconomics).
As a working definition, macro contingency is the verbally governed (see
Vargas, 1988) coordination of two or more operants among individuals, all of
which may have one more or common, identifiable environmental effects.
There may be more than one long-term consequence common to all the oper-
ants in a macrocontingency; the flexibility of the definition allows for descrip-
tions of real coordinated actions of any degree of complexity.
Ethical Communities
Examined within a behaviorological perspective, the problem of poverty is
fundamentally a problem of competing macrocontingency arrangements in a
particular social environment giving rise to opposing ethical communities. As
described by Vargas (1975), an ethical community consists of those people who
(1) make the same rights statements, and (2) are under control of the same
macrocontingencies when making them. According to Vargas, claiming
rights-that is, emitting verbal behavior in the form of rights statements-
concerns the use of oneselt, others, or things to obtain reinforcement or avoid
punishment. Invariably, claiming a right raises the question of who does or
does not have that right. There is no intrinsic merit to any right; claiming the
priority of one eventually ends in negating another. Anyone can emit a rights
statement, but whether others will abide by those statements is an entirely
different issue, one determined by the ethical community. And the ethical com-
munity, or a more powerful superordinate community, exercises total control of
an individual's behavior regarding rights.
An ethical community may be described as a group of people acting in
concert with respect to the rights they share in common, where "acting in
concert" is a function of the arrangement of macro contingencies compelling
its members and outsiders to respect those rights. A well-functioning com-
munity will attempt to maximize positive reinforcement for all of its mem-
bers.
What is important for understanding the problem of poverty in terms of
Vargas's (1975) rights analysis is that more than one ethical community may
exist and compete within the same social environment. He states
What shapes, mairuains, and changes ethical practices are the outcomes of
a given ethical community's struggles against the world and with other
ethical communities. The solutions to community problems ... are
bounded ... especially its institutional arrangements and codified prac-
tices. (p. 185)
Thus, poverty and its converse, wealth, reduce to a matter of (1) who
claims ownership rights over what resources, and (2) who is capable of exercis-
ing control over who does and does not have access to those resources-where
control is determined ultimately by the extant configuration of macrocon-
tingencies regulating the actions of the members of the ethical communities
involved in the rights struggle. In modern society, such property rights (who
owns or has access to what) are spelled out by the legal system-institutional
arrangements and codified practices-which, when analyzed functionally, con-
sist of a complex of macrocontingencies. Ethical practices (law-abiding actions)
are deemed "good" ("just") when they promote the interests of the given
community or "bad" ("unjust") when they act against that community's inter-
ests.
In general, when the macrocontingencies controlling the ethical behavior
of some members of a community compete with the macrocontingencies con-
trolling the ethical behavior of other members of that community, the commu-
nity may divide into two antagonistically related ethical communities. In such
conflict situations, institutions emerge to deal with those competing macrocon-
tingency arrangements. Institutions constitute the next level of analysis in our
examination of the problem of poverty.
Institutions
As suggested above, institutions emerge in verbal communities as a result
of a certain configuration of macrocontingencies. The macro contingencies of
accountability enforced within a group constitute what is seen conventionally
as an institution. Institutions are differentiated on the basis of the kinds of
reinforcers to be protected; for example, governmental and legal institutions
protect the property rights of the most powerful members of a society.
The first task in making a functional analysis at the institutional level,
obviously, is to define our unit of analysis. What exactly is an institution? Neale
(1987) provides a redefined definition. An institution is identified by three
characteristics: (1) people doing, people engaged in observable activities; (2)
rules, giving the activities repetition, stability, and predictable order; and (3)
folkviews, participants' statements explaining or justifying the activities and
the rules. According to Neale (1987),
rules are identified by ordering the doings into repetitive event sequences.
[One] observes and records what happens [so that one can,1 ... after a
number of observations, state that in such-and-such a kind of situation this
person will do this-and-such and another will do thus-and-so. (p. 1182)
Continuing with our proposed behaviorologically based conceptual

framework, in place of rules, we can substitute the term macrocontingency
without doing any harm to Neale's definition of institution. In this way, we do
not assume the existence of any new principles of behavior. Consequently, we
assume that "orderly event sequences" are due, not to rules, but to macrocon-
tingencies.
Folkviews, Neal (1987) relates, provide information needed to participate
intelligently in the activities of the community. They "justify the activities or
explain why they are going on, how they are related, what is thought important
and what unimportant in the patterns of regularity. Folkviews, like rules, can be
discovered by observation" (pp. 1182-1183). Folkviews are not presumed to
be inherently truthful. Rather, "what one wants to know is how the ideas of a
culture interpret events and explain the world around them" (Neale, 1987,
p. 1183). Neale's qualification here suggests an analogy: the folkview is to the
macrocontingency in an institutional analysis as the form of the verbal operant
is to contingency in a behaviorological analysis.
An essential feature of Neale's (1987) operational definition of the institu-
tion is that
the components of an institution may be observed, but an institution itself
cannot be observed as a whole. Rather, what one can observe are activities
of people in situations. A situation is the total relevant context in which a
participant in a society finds himself at any moment. It includes the social
rules and the cultural folkviews as well as the physical or natural environ-
ment and it is "structured" by the prior acts (verbal as well as physical) of
the participants and others (p. 1184)
In sum, "each constituent of an institution can be observed, or can be

stated as testable predictions of event sequences: (1) people doing; (2) the rules
[macrocontingenciesl, including the situations in which they are followed; and
(3) the folkviews explaining the rules" (Neale, 1987, p. 1185). However, we do
not assign any special ontological status to folkviews. They consist merely of
verbal behavior and as such are amenable to an operant analysis to determine
the variables of which they are a function. Just as a tact may vary from being
pure to distorted (see Skinner, 1992, Chapter 6), we must presume that a
folkview may vary in the accuracy with which it describes an institutional
situation, depending on the relevant macrocontingencies operating. The essen-
tial point is that the behavioral regularities reported by the participants de-
scribing the institutional situations in which they are involved-as well as the
controlling macrocontingencies-are potentially verifiable by direct observa-
tion.
SUMMARY AND CONCLUSION
We began the construction of this functionally defined conceptual frame-

work with contingency relations and ended with institutions. Applying this
framework to the problem of poverty, we might next, for example, functionally

analyze the concrete events reported in Plotkin and Scheuerman (1994) de-
scribing how the suburbs have become institutions (Fortress Suburbia) for
preventing property taxes from going to urban areas; how corporations extort
huge concessions from city governments on the threat of job loss and plant
closings (corporate flight); how the business community institutionalizes into a
powerful political lobbying group (e.g., the Business Council in New York
City); how city governments must cut back on public services or risk a low
credit rating from Wall Street, consequently no longer being able to raise
additional funds through bonds; or how state negotiators play one public
sector union against another, rewarding the winner with special benefits but
weakening the labor movement as an ethical community; and so on.
This politically conservative era-when serious consideration is given to
dismantling the federal welfare system while states and cities are embarked on
an aggressive budget-cutting campaign-is having increasingly devastating ef-
fects on the inner-city poor, the so-called underclass, along with the rural poor
and others who are trying to survive on the margins of society. Only through an
analysis of macro contingencies (especially social and economic) will we be able
to grasp why, despite rising wealth in a society, subsets of people continue to
suffer greater and greater levels of deprivation. However, the beginnings of such
a functional analysis (as distinct from functionalist; see footnote 1) would
require its own chapter. The ethical point is that we must begin to develop a
proper perspective on the problem of poverty, a scientific perspective, one that
leads to effective ameliorative action.
Acknowledgment. I thank Ernest Vargas for his comments on an earlier

draft of the manuscript.
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v
Clinical Applications
16
Behavior Therapy-Generated
Insight
Douglas H. Powell
For nearly 20 years, evidence has been accumulating that behavior therapy can
be integrated with psychotherapy to create a powerful treatment regimen for
troubled individuals (Goldfried & Castonguay, 1992; Beitman, Goldfried, &
Norcross, 1989; London & Palmer, 1988; Marmor & Woods, 1980). The past
decade has witnessed a growing eclectic orientation among mental health prac-
titioners and efforts toward theoretical integration by psychotherapy re-
searchers (Garfield & Bergin, 1986). During this period an interdisciplinary
group of mental health practitioners and clinical researchers formed an organi-
zation for eclectically oriented clinicians: the Society for the Exploration of
Psychotherapy Integration. Their Journal of Psychotherapy Integration is now
over 10 years old and serves as a forum for those using multimodal therapies.
One of the reasons that the integrative or eclectic therapy movement has
attracted the attention of so many diverse clinicians and researchers is because
multiple therapeutic modalities are often helpful when neither psychodynamic
nor behavioral therapies alone are effective. This young field is just beginning
to understand how and why certain blends of techniques work. Millon (1988)
has called these combinations "catalytic sequences" or "potentiating pairings."
These are, in his words, " ... therapeutic arrangements and timing series which
promote and effect changes that would not otherwise occur by the use of one
technique alone" (p. 217).
The idea that psychodynamic therapies can be combined with behavioral
Douglas H. Powell • Harvard University Health Services, Cambridge, Massachusetts 02138.
301
302 v • CLINICAL APPLICATIONS
treatment is not so new. Writing about the value of hypnosis in treating trau-
matic neuroses resulting from World War I, Jung (1921, pp. 129-138) pointed
out that this technique often brought about the abreaction of traumatically
dissociated memories. These then could be reintegrated into the psyche
through psychoanalysis.
Three decades ago, Cautela (1965) provided case evidence showing that
the process of desensitization produced spontaneous insight into the etiological
factors associated with the symptoms. These were not soldiers with "war neu-
roses," but rather ordinary individuals who sought behavioral treatment for
less dramatic problems: panic attacks while driving; intense anger at a spouse;
or social anxiety. In all three cases, the individuals became aware of the uncon-
scious reasons for symptoms though no direct efforts were reported by the
therapist to bring this knowledge to the surface. The insight followed behav-
ioral control of the symptoms through desensitization. In a more recent article,
Cautela (1993), presented four more cases in which insight occurred during the
process of behavior therapy.
Had these insights not occurred in the office of the skilled clinician who
could help the individual soothe the emotions that were evoked, the result
might have been an increase in anxiety as a result of the desensitization. Re-
searchers applying relaxation training with normal subjects discovered that
such procedures can arouse exactly the opposite emotions to those intended.
Heide and Borkovec (1983) documented anxiety reactions in over one third of
their subjects practicing relaxation training in their laboratory. Moreover, 31 %
of the men and women receiving progressive muscle relaxation and 54% of
those given relaxation training experienced increased tension. In an effort to
confirm these results by reproducing the experiment exactly, Braith, Mc-
Cullough, and Bush (1988) found 17% of the subjects reported increased
anxiety during the relaxation training.
Not being in a clinically defined therapeutic relationship, the researchers
in both studies rightly elected not to engage their subjects in an exploration of
reasons for the relaxation-induced anxiety. And, not being clearly defined as
patients with symptoms, the troubled subjects apparently did not see any rea-
son to discuss with the researchers why they had become anxious. The findings
of relaxation-induced anxiety led some to feel that behavior therapy leading to
spontaneous insight is not the correct model of a "catalytic sequence" or
"potentiating pairing." Birk (Birk, 1988; Birk & Brinkley-Birk, 1974) has
argued that insight into psychological factors associated with unconscious con-
flicts is necessary before behavioral approaches to the reduction of maladaptive
symptoms can be effective. In a similar vein, Wachtel (1977), in his influential
book, Psychoanalysis and Behavior Therapy, pointed to the value of psycho-
analytically generated insights in freeing patients from unconscious conflicts so
that behavior therapy could then enable them to reduce specific symptoms.
It is well established that behavior therapy can enhance the effects of
psychotherapy. For example, Borkovec and co-workers (1987) reported that
individuals with anxiety disorders given either a cognitive or nondirective psy-
16 • BEHAVIOR THERAPY-GENERATED INSIGHT 303
chotherapy along with progressive muscle relaxation showed substantial reduc-

tions in tension. Kutz, Borysenko, and Benson (1985) found that 10 weeks of
meditation was an effective complementary treatment for patients undergoing
long-term psychotherapy.
Just how behavior therapy acts to enhance psychotherapy has not been
widely discussed. Rhoades (1988) suggested that symptom relief might allow
the underlying conflicts associated with them to emerge because less energy is
invested in the symptom. Another possibility is that there may be something
else about the behavioral techniques themselves that has the potential to arouse
spontaneous insights and affects associated with the target symptoms (Powell,
1986). About 15% of patients treated behaviorally for physical or emotional
disorders in a university-based clinic showed evidence of behavior therapy-
generated insights (BGI). As these individuals became aware of the conflicts
related to the formation of their symptoms, some degree of improvement often
followed. When the psychodynamic material was then explored in accompany-
ing psychotherapy, remission continued and greater self-regulation of the symp-
toms occurred.
What is striking is that these individuals did not appear to be aware of
these connections between the symptoms and the psychic conflicts during the
diagnostic phase of their treatment nor during previous psychodynamically
oriented psychotherapy. As with Cautela's reports cited earlier, the insight
emerged spontaneously with no prodding by the clinician. What triggered the
breakthrough of the repressed material appeared to be the behavior therapy
itself.
Three patterns of BGI have been seen among these patients: (1) sponta-
neous recognition of conflicts associated with the symptom while practicing
behavior therapy by itself; (2) rapidly growing awareness of events keyed to
symptom formation while practicing behavior therapy, indirectly enhanced by
discussion with the psychotherapist; and (3) patients in ongoing psychotherapy
whose insights occurred only after beginning behavior therapy.
GROUP 1: SPONTANEOUS RECOGNITION
The first group is far more common in the author's experience. Linda is an
example. Linda was a 40-year-old personnel manager who suffered from
Raynaud's disease. She was referred for behavior therapy to treat this condi-
tion. She had to wear gloves in air-conditioned rooms even in the summer. Her
hands were blue and extremely painful. Beginning in adolescence the symp-
toms gradually worsened. She felt she had benefited from psychotherapy in the
past on two occasions, though nothing emerged that seemed associated with
the Raynaud's condition and the cold hands remained.
After one evaluation session, Linda was referred for autogenic training.
She was monitored by me at 2- to 3-week intervals after starting behavioral
treatment. Linda was seen a total of four times. While practicing handwarming
with autogenic training and thermal biofeedback, she found herself suddenly
very sad and wanting to cry. As Linda thought about it she recognized that she
was angry about her brother's nervous breakdown when she was 16. This
resulted in her parents focusing all of their attention on him, leaving Linda
feeling uncared for. She had previously been the star of the family and the
favorite. Though she was stoic at the time, repressing the anger and loss she
felt, Linda recognized that her cold hands began around that period.
After she vented these feelings, Linda reported she felt much better. Coin-
cidentally, her Raynaud's disease gradually abated. When it was suggested that
she might want to explore the relationship between the symptoms and her
feelings about her parents and brother, she declined. She showed no interest in
follow-up meetings. Chance contact with her 7 months later found her condi-
tion still improved. Again she had no interest in another meeting. A striking
aspect of Linda's improvement was that it was unassisted by psychotherapy.
The behavioral treatment appeared to allow her to recognize the conflict on her
own and work through the feelings.
GROUP 2: SPONTANEOUS AWARENESS ENHANCED

BY DISCUSSION WITH THERAPIST
The second group of patients rapidly became aware of conflicts associated

with their symptoms while practicing behavior therapy. These insights were
indirectly enhanced by discussions with the therapist. Katharine was a 32-year-
old associate director of the Harvard freshman writing program when first
seen. She was referred by a neurologist because of her "writer's cramp" of
about 4 months' duration. She described the symptom as an almost complete
inability to form letters and words. This created a massive problem for her
because her responsibilities including having to write comments on two sec-
tions of student compositions each week. As her handwriting deteriorated,
Katharine tried typing the remarks and suggestions for improvement on a
separate sheet of paper, but this did not work very well. What finally motivated
her to seek help was that she regularly was asked by the admissions committee
to comment on the writing potential of college applicants for the following
year. These comments were to consist of two or three paragraphs, handwritten,
in the admissions folder.
Extensive physical and neurological examinations revealed no significant
pathology. Psychotherapy was suggested but refused. As a "last resort" she
accepted a referral for behavior therapy. In the first meeting her history was
unremarkable except that Katharine's husband, Allen, a graduate student in
geology, had made little progress toward completing his thesis in the past 3
years. She described her marriage of 5 years as happy, though still childless. In
the course of this first interview, Katharine mentioned that she had been pro-
moted a few months ago over the heads of three more-senior faculty in the
freshman writing program. That promotion occurred shortly after she had
turned down a tenure-track position at a midwestern university. It was some-
time earlier in the year when she was considering this job offer that her symp-
toms made their first appearance.
A sample of her handwriting was obtained. These are shown in Figure
16.1. As can be seen in the sample dated October 13, her handwriting was
characterized by large, uncontrolled letters. When she tried to form words, she
J~JL(~
First meeting. October 13th:
J 141 Ykr- ~*- ~

JM~CYrY1
Second meeting, October 27th:
Third meeting. November 17th:
Figure 16.1. Writing Samples from Katharine, Meetings 1-6

pressed down very hard on the pencil, breaking the point off, and showed signs
of considerable frustration, including weeping.
A treatment plan was devised that consisted of teaching her a combination
of behavioral techniques, primarily progressive muscle relaxation and visualiz-
ation. While in a relaxed state, she was asked to visualize herself being able to
write smoothly and freely. After she demonstrated the ability to carry out these
procedures, a daily practice schedule was established for her to follow. Finally,
scheduled meetings spaced 2 to 3 weeks apart were held to evaluate the effec-
tiveness of the treatment and to talk about related matters. In all, we met six
times.
As Figure 16.1 shows, it was not long before Katharine began to improve.
A comparison of her writing on October 27, the second meeting, shows consid-
erably more control and freedom. This progress continued through January 12.
More importantly, she reported that she was able to write lengthy comments
on her student compositions and notes on admissions folders for as long as 12
consecutive hours.
In the third session, Katharine began to voice some of the frustrations she
experienced at work and at home. In her teaching, she recognized she was
leaning too far backward to accommodate demanding or difficult students.
After further encouragement to recognize her feelings and behavioral rehearsal
around handling some of these students, she began to be more realistic and
firm in her dealing with these undergraduates.
By the fourth meeting, Katharine's writing was nearly back to normal.
Between sessions, she and Allen had talked for long periods. As a result, she
recognized some of the stresses that had been upsetting her. One of these was
the hostile reaction of other members of the department when she was pro-
moted over them. During the summer after her appointment was announced,
they ignored her, were uncooperative, and made negative comments about her
work to other faculty members. Katharine said nothing to her husband or
anyone else about how much her colleagues had hurt her.
The second stressor she spontaneously became aware of had to do with
her husband. At 32, she was about ready to have children, but this was impossi-
ble until he finished his dissertation and found a job. Though Katharine had
been resolutely supportive and understanding of Allen, she was becoming im-
patient with his lack of reciprocal understanding.
Katharine called before the final meeting in January and wondered if she
and Allen could both come to the meeting. At the end of this session Katharine
said that she and Allen had also started talking about her impatience with his
thesis, and he had agreed to try to finish it during this calendar year. At this
point, she said, "Maybe this was a way of showing my husband he needed to
finish his thesis." But neither showed any interest in exploring the matter
further at that moment.
Six months later, Katharine called for a referral for couple's therapy. Fol-
low-up 12 months later found that the remission of the writer's cramp had been
maintained, but the marriage continued to be stormy.
GROUP 3: INSIGHT OCCURRING WHEN BEHAVIOR THERAPY IS

ADDED TO PSYCHOTHERAPY
The third group comprises patients in whom spontaneous insights are

aroused when behavior therapy is added to psychotherapy. Viktor was 58 years
old when first seen. He was a professor of history. He had experienced mi-
graines every week for nearly 40 years, except during World War II, when he
worked for the Polish underground. These were extremely painful and increas-
ingly disabling. Viktor also had encephalitis as a child, which seriously limited
the movement of his left side. He also had a noticeable palsy in his right hand
that various medications had not controlled. His intelligence, sensitivity, and
accomplishments were impressive.
He had been through 3 months of psychotherapy with a colleague who
used a psychodynamic approach based on the assumption that the migraines
were related to underlying hostility. In their work together they were able to
confirm the connection between repressed anger and subsequent migraine at-
tacks. This therapist also was able to help Viktor recollect that some of his
earlier frustrations were related to the sequelae of his encephalitis. He also
recalled a memory of having wanted to impress an attractive female cousin
when he was a child and not being able to do so because of his physical
disability. He recalled having his first migraine then. Although he acknowl-
edged the relationship between his physical disability, anger, frustration, and
headaches, he still had migraines regularly. He was not able to identify any
particular sources of stress in his present-day life.
At this point the psychotherapist decided to refer Viktor for coordinate
behavior therapy. After an evaluation, a course of behavior therapy was
planned, using a combination of hypnosis and meditative relaxation. Table
16.1 shows their frequency and severity before and after behavioral treatment.
As can be seen, this resulted in nearly instantaneous reduction of the migraines
from weekly to one every 6 weeks. They also became briefer in duration. There
rarely continued beyond 1 day.
While Viktor was seen at intervals to monitor his progress and help him
make minor adjustments in the behavior therapy, the parallel psychotherapy
continued, during which time more memories were recovered. One of these was
a younger brother taunting him just out of his reach when he was in early
adolescence. Shortly, Viktor recalled the taunting occurred at the very picnic he
had so wanted to attract the attention of the attractive cousin. As he recovered
this and associated memories, there was a good deal of catharsis and reex-
periencing of the hostility.
Over the period of the next 6 months, he had only two more migraine
attacks. As Table 16.1 shows, just four migraines occurred in the next 2 years.
Often he was able to reduce the pain of the migraines, though nausea and visual
problems would remain. Interestingly enough, each time he had a migraine, he
was able to link it to a present-day stress and then to control it by using
Table 16.1. Viktor: Headache Frequency

and Severity Level a
Date Headache level b
July 22 3
23 4
25 3
31 4
August 7 4
8 4
18 4
19 4
24 4
26 4
September 4 3
12 4
13 4
14 4
15 4
28 4
29 4
30 4
October 8 3
26 3
November 3 4
December 3 4
18 4
29 4
January
February 6 4
March
April
,'Highest headache level during day; only dates where

headache levels 3 and 4 are noted.
"Scale for headaches: 0, none; 1, background (doesn't
intrude or burden); 2, moderate (intrudes and bur-
dens); 3, severe (greatly restricts actions); 4, laid out.
relaxation and self-hypnosis. As he puts it, "Now when I get headaches, I can
see a reason."
DISCUSSION
Support for the thesis that behavior therapy has the power to stimulate
unanticipated thoughts and feelings can be found in accumulating evidence
over the past decade from the clinical practice of others and from the research
laboratory. Mental health practitioners write of patients whose insights are
facilitated by behavior therapy, and many fall into one of the groups described
above. Cautela's (1965, 1993) cases, for example, would be in either groups
1 or 2.
The group 1 patients, with BGI apparently unassisted by psychotherapy,
are reminiscent of a case reported by Kuhlman (1982). He tells of treating a
married business school student who failed four exams in a row due to "test-
taking anxiety." A careful history revealed that no psychological conflicts ap-
peared to be associated with the problem. During the process of constructing a
desensitization hierarchy, the young man visualized a scene between himself
and his wife prior to an imagined exam. Shortly after imagining his spouse
saying to him, "You'd better do well on this test or else," the patient began to
see that as a major reason why he was having trouble taking tests. He felt that
she was pressuring him to do well in school so that her parents, with whom
they lived, would be pleased. A week later, the young man said that he had
obtained a B in the last exam and was talking to his wife about their marital
problems. He declined an offer to pursue the matter further with the behavior
therapist.
Group 2 patients have also been described by others. Sedlacek (1979)
presents the history of a 42-year-old woman who, like Katharine, also had severe
Raynaud's disease. Sedlacek taught her to relax and to dilate her peripheral
blood vessels using a combination of electromyographic and thermal biofeed-
back to warm her hands. During this process she became aware of considerable
repressed anger and guilt in relation to her spouse. After talking it over with her
physician, she was referred for psychotherapy to explore these feelings. At 3-year
follow-up, she continued to be able to control her Raynaud's symptoms.
Finally, the group 3 clients whose spontaneous insights were triggered by
behavior therapy while in psychotherapy have been reported by others. Perhaps
the most compelling example has been Lazarus's (1981) 32-year-old male with
numerous problems, including anxiety attacks, somatoform disorders, and
overdependence on his mother. He had a long history of unsuccessful treatment
by therapists of various persuasions. During the course of a desensitization
treatment with Lazarus, the man was asked to imagine coping with anxiety
prompted by being alone in a strange city. During this behavioral treatment,
the patient recollected a crucial unconscious memory:
At this point, the client started hyperventilating, sobbing, wretching, heav-

ing, and panicking ... a "forgotten memory" ... evoked a full-blown
abreaction. When he finally calmed down, he recounted vivid memories of
an event that took place when he was seven years of age. He was in a
hospital after a tonsillectomy and was coming out of the anesthetic when he
could barely make out some people hovering around his bed. His mother
was talking to someone about his frail and sickly make-up. "I hope he lives
to see twenty-one," she declared. (1981, pp. 24-25)
Lazarus used this spontaneous insight to help the man to recognize that he had
internalized his mother's view of him and had become the fragile son his
mother assumed him to be. This memory was a turning point in the therapy.
Over the next 2 years, fears about his physical fragility, about death, and about
traveling alone were explored in the context of his mother's attitude. During
this period he also learned to apply a range of behavioral and cognitive tech-
niques to control his anxieties and to get on with the business of living. Follow-
up 4 years later found him living independently, in good health, playing racquet
sports, training for the marathon, and selling life insurance.
Unexpected effects are not always positive. Some patients have experienced
what have been called "negative" or "deterioration" effects when treated with
behavior therapy. Negative effects have for some time been the topic of hot
debate among mental health professionals. Until recently, behavior therapists
have argued that their treatments do not cause other distress or symptom
substitution (Walker, Hedberg, Clement, & Wright, 1981; Wolpe, 1973).
However, accumulating evidence from clinical practice indicates that a
minority of individuals respond to behavior therapy with distressing physical
and emotional symptoms. Jacobsen and Edinger (1982) noted two of their
patients developed severe anxiety following progressive muscular relaxation.
Others describe patients who exhibited signs of depression, depersonalization,
obsessive thinking, or impulsive fantasies following relaxation or desensitiza-
tion procedures (FitzPatrick, 1983; Marks, 1971).
Such symptoms would not surprise those practitioners who have cau-
tioned against the "negative" of "deterioration" effects of behavior therapy
(Everly & Rosenfeld, 1981; Bergin & Lambert, 1978). It is not yet clear wheth-
er, or to what extent, these side effects may be simply expressive of the variant
ways in which patients react to the behavioral techniques or, in fact, may be the
first step of a new positive direction in treatment.
On the basis of the clinical examples presented in this chapter, it seems
possible that, for a number of individuals, relaxation-induced anxiety and
other so-called "negative effects" may signal the presence of buried conflicts
and at the same time foreshadow a beginning awareness of them. The therapist
who is reasonably skilled in both behavioral and psychodynamic modalities
will have a sense of when to pursue these negative reactions in the search for
underlying connections and when to slow the pace or to choose an alternate
treatment plan so as not to overwhelm the client's defenses.
This can be a difficult task, however, because not everyone is interested in
exploring the dynamic issues underlying physical symptoms. Indeed, in our
experience some patients were unable or unwilling to work through these
sudden recognitions and have abandoned therapy. In most cases in which
follow-up was possible, symptoms reappeared after a short period of time.
Similarly, not all negative physical responses to behavioral treatment are
evidence of repressed conflicts coming into awareness. Sometimes they are signs
that the therapy should be abandoned or altered. A recent literature survey by
Lazarus and Mayne (1990) pointed to significant adverse side effects resulting
from behavioral approaches. In addition to paradoxical RIA noted earlier for a
minority of subjects, Lazarus and Mayne noted that some asthmatics with
small airway obstructions responded negatively to relaxation training. They
also found that autogenic training for individuals with gastrointestinal pain
can result in greater susceptibility to internal bleeding or "parasympathetic
rebound," leading to nausea and vomiting.
Why does behavior therapy arouse spontaneous insights and other affects
in a minority of patients treated for symptom reduction? And why do repressed
conflicts enter awareness in response to behavioral techniques when they did
not emerge in previous psychotherapies-the very approaches that actively
seek such latent material? Five explanations come to mind.
The first explanation is that the process of relaxation enables some pa-
tients to become unusually sensitive to neural messages from their musculature.
These individuals, like Linda, feel they can "read" their bodily state and recog-
nize those underlying feelings and thoughts that trigger increased physical
tensions. Until learning relaxation strategies, these patients were not suffi-
ciently aware of their physical state to recognize the presence of tension.
The second reason that behavior therapy may trigger insight has been
suggested by Rhoades (1988): When behavioral techniques successfully reduce
symptom distress, this frees the client to think about why the problems devel-
oped. It is difficult for a patient like Viktor to think about why he is getting
migraines when so much of his mental and physical energy is consumed by the
symptom and by orchestrating his life to accommodate these probable weekly
headaches.
The third way of understanding of phenomenon of BGI is that relaxation
and other behavioral techniques may lower psychological defenses just enough
to allow suppressed feelings to enter awareness. As Katharine's case demon-
strates, these new insights into present conflicts, which are not being con-
fronted, may liberate distressing affects. The experiencing of these affects asso-
ciated with the marital conflict allows the problem to be confronted.
The fourth reason has to do with the possible direct physiological effects
on the brain of relaxation, desensitization, and other forms of behavioral treat-
ments. The literature reviewed by Kutz et al. (1985) provides evidence that
meditation and relaxation techniques affect brain physiology and can influence
both mood and thought patterns. They conclude: "Not only may specific
moods and insights have specific neuroanatomical bases, but these moods and
insights may also be achieved by intentional manipulation of underlying psy-
chophysiology through specific mental practices such as meditation" (p. 3). It
is possible that Linda's spontaneous insights while practicing autogenic train-
ing may have been an example of this phenomenon.
A fifth explanation is that a considerable amount of psychotherapy occurs
in the process of carrying out behavior therapy. Practitioners of behavior thera-
py regularly respond to stress emerging out of their symptom-focused treat-
ments. For example, a comparison of the clinical work of behavior therapists
and psychotherapists found that they did not differ on the dimensions of
warmth, empathy, and positive regard for their patients. Indeed, behavior ther-
apists functioned at a higher level of intensity and intimacy with their patients.
It is not surprising, then, to find that little difference existed in the degree of
intrapsychic exploration. The patients of behavior therapists and psychothera-
pists alike discussed their problems at deeper rather than superficial levels and
were the recipients of interpretations (Sloane, Staples, Cristol, Yorkston, &
Whipple, 1975, pp. 147-149, 157-159).
This may be why, when one talks to one's colleagues practicing behavior
therapy, one is struck by their lack of surprise when the subject of BGI is
introduced. It may be that clinicians applying behavioral treatment have been
responding intuitively to this phenomenon for decades. Without formalizing
their perceptions, they have proceeded to deal with the manifestations of BGI in
a pragmatic way, by working toward the reduction of symptoms while at the
same time processing emergent insights.
It should be recognized that the experience of the author is limited and
that 85% of the patients seen for behavior therapy do not report BGI. The
reports of other clinicians are scattered and anecdotal. The research on relax-
ation-induced anxiety awaits confirmation from others. So far, little is known
about how the interactions among symptoms, client characteristics, therapist
temperament, and sequence of therapeutic modalities may work together to
promote spontaneous insight and enhance treatment outcome.
Yet there is something enormously intriguing about BGI. It seems to be a
"real" clinical event in the cases reported here and in the experience of others.
Anecdotal and infrequent as the phenomena may be, BGI illustrates the unique
power of a catalytic sequence in integrative psychotherapy. Perhaps those of us
who are interested in the integration of therapies in clinical practice can make
more systematic use of BGI to benefit our patients. Thus, when carrying out
symptom-focused treatment, we might be on the lookout for unexpected cogni-
tions and affects arising out of relaxation and other behavioral techniques. It
seems reasonable to tell patients about to undergo behavior therapy for specific
symptoms that a small probability exists that they may experience unexpected
thoughts, feelings, or insights during the process that might be upsetting. These
should be reported to the therapist immediately. Even for those patients who
do not report any unusual events, we might inquire whether they had experi-
enced any new thoughts or feelings during the process of behavioral treatment,
including negative or upsetting ones. If these occur, we can follow Messer's
(1986) suggestion that an effort be made to assist these patients in understand-
ing these unexpected thoughts and feelings if and when they occur. We should
encourage them to see relationships between symptoms and past conflicts in-
stead of viewing such symptoms as merely requiring relief.
By the same token, psychodynamically oriented clinicians might wish to
include a program of behavioral treatment in the course of insight-oriented
therapy. Not only does the practice of behavior therapy have a high probability
of relieving specific symptoms and enhancing a sense of efficacy, but it may
provide a catalytic sequence for a more powerful treatment program.
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17
Some Applications of
Behavioral Principles to Sport
and Exercise Enhancement
Albert J. Kearney
INTRODUCTION
There is a considerable overlap between behavioral medicine and the closely

related field of sport and exercise psychology. Both deal with the human body,
its interactions with the physical and social environment, and have as their
goals to help that body function as effectively as possible, whether achieving
and maintaining health or, at the other end of the continuum, performing at a
world class level in an athletic event. The emphasis of this chapter, however,
will be on sport and exercise applications of psychological principles, rather
than on the more clearly medical applications. The point of view taken will be
primarily from a behaviorological perspective.
Psychology has been called the science of behavior. Since behavior is sim-
ply anything anybody does, such as brushing one's teeth, reading a book,
hitting a golf ball, or dreaming about scoring a sudden-death touchdown in the
Super Bowl, psychology is a very broad field encompassing all aspects of hu-
man endeavor. Psychological principles have been applied to numerous human
activities in an attempt to improve the human condition. Some of the categories
of human behavior traditionally studied by psychologists include learning,
motivation, perception, development, psychopathology, and group processes.
Albprt J. Kparney • Action Therapies, 7 Carmen Circle, Medfield, Massachusetts 02052.
315
One of the less well-known but most rapidly growing areas studied by psychol-
ogists involves leisure, recreational, and more specifically, athletic activities.
That branch of psychology that deals with athletic behaviors is called sport
psychology.
Psychologists studying sport and exercise have made contributions to
many more aspects of the field than can be covered in this chapter. Certain
topics of recent interest that are not discussed here, however, are clearly related
to topics that are discussed. Some of those that are particularly compatible
include studies of methods of managing stress, anxiety, and attention (Kerr &
Leith, 1993), pain tolerance (Whitmarsh & Alderman, 1993), the relationship
between arousal and performance (Landers & Boutcher, 1986), and eating
disorders among athletes (Parker, Lambert, & Burlingame, 1994; Petrie, 1993).
The seriousness of this problem was sadly underscored in July 1994 by the
death of a 22-year-old world-class American gymnast as a result of eating
disorders. The problem reportedly was traced to her misperception of a com-
ment made to her by a judge about her weight in 1988. Clinical applications of
some of the behavioral procedures that will be discussed later have been helpful
with the treatment of eating disorders in athletes and nonathletes alike.
Sport and exercise are important human activities for both their invaluable
contributions to the physical, mental, and spiritual health that can result from
direct participation and for the entertainment value of spectator sports. With
the increasing awareness of factors contributing to health and the value placed
on personal fitness in Western culture, the importance of exercise has become
well known. In addition to the individual benefits of sport and exercise, team
sports help teach cooperation and the ability to put individual achievement
secondary to the well-being of the larger group. It is of course very useful for
societies to have members with this characteristic.
The importance of spectator sports in the twentieth century was recently
attested to by the estimated two billion fans who viewed the championship
match of the 1994 World Cup competition on television. In 1969, El Salvador
and Honduras fought a war in which 2000 people were killed over a soccer
game, and temporary truces have been called in other wars so the combatants
could watch the World Cup. It has also been pointed out that the flood of boat
people escaping Haiti slowed to a trickle during the month of the 1994 World
Cup so that the matches could be more closely followed.
Sport and exercise are clearly very important and highly valued human
activities. Enhancing performance on these activities can be seen as contribut-
ing to the improvement of the human condition for both the individual and the
culture.
BACKGROUND
Applications of psychological principles in mental health, education, and

military settings, to name a few, have been widely recognized for well over a
17 • SPORT AND EXERCISE ENHANCEMENT 317
century. Sport psychology has been well established in Europe for nearly as
long, tracing its roots to the 1890s. While much of the accumulated literature in
this field has dealt with motor learning and various forms of personality assess-
ment, there have also been numerous reported attempts to use psychological
principles to enhance athletic performance.
An early foray of psychology into sports dealt with how psychological
factors might affect motor performance. Early writings in the field showed
considerable interest in motor learning, reflecting the influence of physical
educators (Wiggins, 1984), and the social psychology of sports, attempting to
answer such questions as, "Why do people watch football games?" In 1920,
Carl Diem founded the world's first sport psychology laboratory in Berlin.
Soon after, in 1925, the first sport psychology laboratory was begun in the
Soviet Union.
Although Coleman Griffith, the father of American sport psychology, es-
tablished the first American sport psychology laboratory at the University of
Illinois the same year as the Soviets, sport psychology is not nearly as well
known in the United States and is generally considered to be a new field here.
Griffith was a pioneer in many ways, conducting research into personality
factors, learning, and the reaction time of athletes playing various sports. In
1938 the Chicago Cubs hired Griffith as the first sport psychologist for a major
league sport team in the United States. In the last few decades, sport psychol-
ogy has gained a great deal of public attention because of the great successes
achieved by the Eastern European and Cuban Olympic teams, all well known
for their scientific approach to athletics and extensive use of sport psychologists
and sport psychology principles. The formation of the American Psychological
Association's Division of Exercise and Sport Psychology (Division 47) in 1986
reflects this growth in interest.
In some ways the development of sport psychology in the United States has
paralleled the development of psychology as a whole. In the late nineteenth and
first half of the twentieth century, psychology was concerned with observing
behavior and developing competing theories to first explain and later predict
behavior. The psychological testing movement saw the development of many
tests such as the Minnesota Multiphasic Personality Inventory, Kuder Personal
Preference Schedule, Strong Vocational Interest Blank, General Aptitude Test
Battery, and Differential Aptitude Test. All these tests have been used, along
with many others, to try to predict the future performance of particular indi-
viduals on a variety of activities, including academic and job-related activities.
Similarly, many of the early applications of psychology to sports in the United
States also dealt with personnel selection. For example, the results of an intel-
ligence test might be used to predict whether or not a physically gifted individ-
ual was intelligent enough to learn the complex plays and tactical systems
needed to be a successful quarterback, or the results of personality tests might
be used to predict whether another physically talented individual was aggres-
sive enough to be an effective linebacker.
In more recent years, a number of testing and assessment instruments
specific to sport psychology have been developed. Personality factors are some-
times assessed in composite profiles of athletes who are highly successful in a
given area. The most widely recognized profile is measured by the Profile of
Mood States and referred to as the "Iceberg Profile'" (Morgan, 1980). It reflects
the self-ratings of successful athletes as being higher on vigor but lower on
tension, depression, anger, fatigue, and confusion than less successful athletes.
While the emphasis has been on personality assessment and selection,
there have clearly been applications of behavioral principles to the enhance-
ment of athletic performance. The 1970s saw an increase in the use of operant-
based behavioral techniques to improve performance in sports and physical
education. A detailed review of this work is contained in Donahue, Gillis, and
King (1980).
One such application has directly benefited probably millions of Ameri-
cans over the years. The swimming and lifesaving courses provided through the
American National Red Cross include a well-designed curriculum and instruc-
tional guidelines based on sound applications of shaping (positive reinforce-
ment of successive approximations of the final target behavior), modeling, and
other learning principles and include a discussion of the law of effect and other
laws of learning for the instructor (American National Red Cross, 1938).
During the 1970s and well into the 1980s, our country experienced a
running boom and general increase in interest in physical fitness and participa-
tory sports. Activities classified as aerobic (Cooper, 1968) exercise such as
running, swimming, and cycling (that is, activities that could be performed for
extended periods of time while raising the heart rate, but without going into
oxygen debt) became particularly popular. In addition to an increase in com-
petitive events such as road races and triathlons, which involve these activities,
there was considerable increase in fully recreational participation, with associ-
ated health benefits for the participants. Other areas of more recent interest
include methods of maximizing performance (Suinn, 1985), team cohesiveness
(Carron, 1988), and the effect of exercise on dysfunctional mood states such as
anxiety and depression (Raglin & Morgan, 1985).
A SPECIFIC APPLICATION: RUNNING
The field of behavioral medicine has experienced tremendous growth in

recent years. Due to the increasingly recognized health benefits of exercise both
in preventive and rehabilitative roles, there are clear areas of overlap between
behavioral medicine and sport psychology. These include motivational tech-
niques for complying with exercise regimens undertaken for health mainte-
nance considerations, such as weight loss or stress reduction, or for rehabilita-
tive reasons, such as cardiac recovery and stress management procedures.
In order to enhance performance on a particular activity, at least two
things need to happen. First, the behavior must be attempted frequently
enough so that sufficient opportunities to improve occur. Second, effective
methods to improve the athlete's performance of those behaviors must be

employed. After a review of a variety of behavioral motivational strategies, we
will examine some uses of imagery, with emphasis on two imagery-based be-
havior therapy procedures that have been adapted for the enhancement of
athletic performance.
The activity of running (which for the sake of this discussion will also
include jogging, the term that is sometimes used to distinguish running at
slower than an 8-minute/mile pace) is widely engaged in by millions of nor-
mally healthy individuals both for its exercise benefits and general enjoyment.
Running also has competitive applications, ranging from small-town road races
to the Olympic marathon. At the other end of the continuum, running is
increasingly used as a rehabilitative exercise in cardiac care and other medically
related programs. In addition, the act of running and the ability to run fast
come into play in many other athletic activities. Because of the widespread
interest and participation in this activity for one reason or another by such a
high portion of our population, our discussion and many of our examples will
focus on running. A more extensive discussion of self-regulation of athletic
activity with examples involving sports other than running can be found in
Kirschenbaum (1985).
Motivation
It has been well established that behavior is a function of its consequences.
for example, if we tell a joke and the consequence is that people laugh, we are
more likely to tell the joke again, and we say that the joke-telling behavior has
been reinforced. If we tell a joke and the consequence is that no one laughs, we
are probably less likely to tell the joke again, and we say that the joke-telling
behavior is being extinguished. If sometimes people laugh and sometimes they
do not, things can get very complicated. There are five contingent arrange-
ments of behavior and its consequences that influence the strength of behavior:
positive and negative reinforcement to strengthen behavior, and extinction,
punishment, and response cost to weaken it. Running, like most behavior, is
strongly influenced by its consequences.
It is often helpful to make a distinction between intrinsic and extrinsic
reinforcement, both of which are discussed below along with negative rein-
forcement, with regard to their usefulness in motivating running. Motivation to
perform a specific act often seems to stem from three sources:
1. The act itself may be enjoyable, or as we sometimes say, intrinsically
reinforcing. That is, it may feel good or we may have pleasant thoughts when
we perform the behavior. For example, many people feel good when they lie
on the beach in the sun or have pleasant thoughts about themselves when they
help an elderly person across the street. Some people feel great physically and
mentally after a good workout. Others occasionally experience a feeling
of exhilaration while actually working out. While this is sometimes attributed
to the influence of biochemical substances called endorphins (Cautela &
Kearney, 1984), the cause is less important than the fact that many people
continue to exercise simply because of its positively reinforcing natural conse-
quences.
2. Sometimes the act itself may not be particularly enjoyable, but there
may be a payoff or extrinsic reinforcer contingent upon performing a specific
behavior. For example, people often work at jobs they do not particularly like
because they do like their paycheck at the end of the week. In one case, contin-
gency contracting was used to motivate a normally healthy 33-year-old profes-
sional woman to adhere to a regular program of aerobic exercise with which
she asked for help. Two kinds of positive consequences were used. One payoff
was in the form of a work exchange with her husband. For every x minutes she
spent running, her husband would do an additional x minutes of house work.
This system, unfortunately, can tend to foster suspicion. Did it really take her a
full 30 minutes to run just 3 miles? Did it really take him a full half hour just to
vacuum the living room rug? So this system was replaced with a second one, in
which the woman earned money toward new clothes for each mile run in a
week's time. Extrinsic reinforcement is sometimes referred to as contrived rein-
forcement. The practical problem here is that once the reinforcers are removed,
the target behavior tends to weaken, unless other more natural reinforcers have
come into play.
3. The third kind of motivation involves the avoiding of or escaping from
a relatively unpleasant situation. This state of affairs is technically called nega-
tive reinforcement and is quite different from what is commonly known as
punishment. An example most adults are familiar with involves the aversive
sound given off by automobile seat belt buzzers before the belts are fastened. In
order to avoid the aversive stimulation, we fasten the belt before starting the
car. If we forget the belt and the buzzer goes off, we can escape from the
situation by fastening the seat belt then, thereby ending the obnoxious noise.
An example from the life of a man who later consulted with me for unrelated
reasons involved a homelife that had become rather unpleasant. To avoid
and/or escape from the unpleasant situation at home, this person began spend-
ing more and more time after work running until he was regularly running over
100 miles/week. Unfortunately this did not help the marriage, which ended in
divorce.
Motivation can be a particularly important problem for people who

should exercise for health reasons (e.g., strengthening their heart, general aero-
bic benefits, weight loss, stress management, etc.). These people usually admit
the benefits of regular exercise but "just don't like it" or "just don't get around
to it." The problem here is often one of delayed reinforcement versus immediate
averSlveness.
When we talk about relative motivating strength and reinforcement
strength, it is important to remember that research has shown that in order to
be optimally effective, the consequence must immediately follow the behavior
in question. It is the immediate consequence that has the greatest influence.
That is, the farther removed in time a particular consequence is, the less effec-
tive it is likely to be.
This rule of proximity between behavior and consequence helps explain
many situations in our society that seem illogical. Examples include: (1) the
destruction of our environment, which, while an obviously aversive conse-
quence that ultimately affects us all, is relatively far removed or delayed in time
compared to the pressures on business to make relatively immediate profits;
and (2) the failure of the majority of Americans in the 1970s to respond to the
relatively remote notion of an energy crisis by accepting relatively minor, but
more immediate, inconveniences in driving habits and other uses of finite ener-
gy sources. On an individual level, we all know how the immediate reinforce-
ment of smoking a cigarette outweighs the potential long-term consequences of
avoiding heart disease and cancer. People wanting to lose weight often respond
to "Just one more bonbon" rather than to the less immediate consequence of a
healthier, more attractive body. Certainly a lot of mental gymnastics goes on to
justify the apparently illogical behavior, but the justification is a cover-up, not a
cause. The dynamics of reinforcement remain the same. It is easy to see how
the tremendous long-term benefits of exercise can be easily overpowered by the
apparently minor, but more immediate, pleasure of sitting at home or the
inconvenience of getting ready for and performing the exercise.
While there may not be any realistic way to motivate people to exercise
who have no interest in doing so, there are some things that can be done to help
those individuals who admit they know they should, but "just don't like it" or
"just don't get around to it." These methods, of course, require the cooperation
of the individual in question. They are based on rearranging the consequences
in the individual's life (according to principles of reinforcement already men-
tioned) to encourage exercise rather than discourage it.
There is a whole host of additional behavioral procedures that could be
used to attempt to motivate people to increase their exercising behavior. Exam-
ples of suggested methods based on these procedures which have been used
with some success include:
1. Contingency contracting procedures. The first contract procedure de-

scribed earlier (she runs, he cleans house) could be changed to an exchange of
prearranged completed tasks, regardless of the length of time required to com-
plete them. The exercisor should be rewarded afterward, not before, with
something pleasurable to increase the general level of reinforcement (Cautela,
1984).
2. Social reinforcement. Carron and Spink (1993) have shown that many
of the same strategies that have been used to build team cohesiveness on com-
petitive sport teams are also effective in recreational and noncompetitive situa-
tions, such as exercise classes, to increase participation in those programs.
Working out with a friend of similar ability is often helpful. The mutual encour-
agement helps at times when one is tempted to skip or skimp on workouts. But
be careful it does not backfire and result in mutual discouragement. Many
people I know are involved in running. In several instances the running has
been a result of friendships. One friend and I have served as overt real-life
models for many of our other friends and some relatives. The enthusiasm with
which we talked about running (particularly about races with free beer, food,
and T-shirts, all extrinsic, contrived reinforcers) interested some. As one or two
joined in, they interested others. A major event in this process was the 1977
Cape Cod Relay, an eight-person 80-plus-mile race from Plymouth Rock to the
Provincetown Monument. Although the team we entered tied for last place the
first year, a tremendous feeling of camaraderie developed which, I think, caused
other friends to feel left out and want in. In 1978, we entered two teams in the
relay (including the 1978 last-place team) and so much enthusiasm was gener-
ated that we had to turn several people down. This social reinforcement was
responsible for increasing running rates in most cases, but in six cases actually
started people running. In the 1980s, we typically finished very close to the
middle in a field of 300 teams.
3. Premack principle. According to the Premack Principle (Premack,
1959), relatively high-frequency behavior can be used to reinforce a relatively
low-frequency behavior. For example, a chain-smoker having trouble getting
around to doing his income taxes may decide to allow himself a cigarette only
after doing a half-hour work on the taxes. I know of a group of graduate
students who used this method to get through a particularly scholarly text,
Bandura's Principles of Behavior Modification (1969). They alternated reading
chapters of The Godfather with chapters of Bandura. A person reading a book
she "just can't put down" might allow herself to read only after exercising. In
other words, people using this system do not get their apple pie until they eat
their mashed potatoes.
4. Response cost. Another technique that has been effective in motivating
well-intentioned individuals involves having the person write out a number of
checks to a person or organization the reluctant runner does not like (e.g., a
particular political candidate). The checks are held by a monitor. At the end of
each week during which the client has completed an agreed upon task, such as
running 10 miles, one check is returned to the client. If, on the other hand, the
client fails to meet this goal, the monitor mails the check. The selection of the
right potential donation recipient for each client is crucial, but one or two
cashed checks can work motivational wonders.
Fixx (1980) lists several additional recommendations to get normally
healthy individuals started and involved in running. These include:
1. Decision process. Do not make a decision every day to run or not, make
a decision once to run every day and then do it without thinking about
it (thought stopping).
2. Thoughts about the consequences. Bring the delayed rewards to the
present, such as running off a chocolate sundae or away from a long-
needed operation or from medication that is no longer needed (self-
directed covert conditioning).
3. Vary the program. For example, changing the running course lessens
reinforcer satiation.
4. Goal setting and progress reviews. For example, keeping track of total
miles, minutes run, heart rate, weight, and so forth.
During the 1980s, Martin, Dubbert, and Epstein (1983) investigated fac-
tors that might help predict which indiduals were likely to drop out of medi-
cally prescribed running programs. Among the characteristics they identified
that were associated with dropouts were smoking, being overweight, inactivity
during leisure time, poor credit ratings, attempting too much too soon, poor
form, training alone, and lack of home support. Interventions they found that
helped maintain participation included contracting, consequence management
(earning money or having client deposit money or personal items to earn back),
lotteries for attendance, and individually designing programs for participants.
Before applying these or any psychological techniques, it is necessary to
closely examine the reasons for resistence to exercise and to tailor the treatment
to the individual. Some cases may be relatively straightforward whereas others
could require a good deal more preliminary assessment. In any event, there is a
trend in psychology today toward assessing and treating the problem where it
exists (the home? the school? the gym? the track?) rather than totally in a
psychologist's office. There is another trend toward teaching clients self-control
techniques, like some of the covert conditioning procedures that will be dis-
cussed later, so that they can take a more active part in their own treatment and
become more independent of, rather than dependent on, their psychologist.
Both of these trends can be helpful to the goal of improving exercise habits.
Training to Run Races

Training programs can be classified in several ways. One way of classifying
training programs is time versus distance. Some may prescribe how far to run
each day regardless of how long it takes, while others tell us how much time to
run regardless of how far one gets. Although some very good distance runners
recommend time training, based on my experience and that of several runners
with whom I have consulted, it has a built-in danger. That is, people generally
do not enjoy the physical discomfort that usually goes with running fast. To
escape or avoid the immediate aversive experience, they start to gradually run
more slowly and therefore cover less distance in the same time. Subsequently,
both the quality and quantity decrease. Distance proponents, on the other
hand, tend to speed up, perhaps to get it over with sooner, avoiding and
escaping the aversive experience, thus increasing the quality while maintaining
the quantity.
A second debate is over the benefits of long, slow, distance training (some-
times referred to as LSD) compared to doing less quantity but greater quality in
the form of more speed work and training at closer to race pace. A behavioral
point of view would predict that you get better at doing what you practice
doing and that seems to be the case here. If you practice running long and slow
you may get to be able to run for a long time, but it is going to be slowly. If you
practice running fast, you get better at it, but you also increase the likelihood of
injury. So to do your best and minimize boredom, you should mix speed and
distance work. Ignoring the speed work can also result in slower running than
one might have been able to do before training. This result might be predicted
from a Pavlovian perspective, since running slow and running fast are incom-
patible behaviors and a situation analogous to retroactive inhibition may occur.
One of the hallmarks and strengths of behavior analysis is the emphasis on
collecting and recording objective data about specific behaviors. This is useful
in sports applications as well. Dedicated runners often keep log books, diaries,
charts, and all sorts of records of training programs and racing accomplish-
ments. This is a very compatible area for running and behavior analysis. The
standard behavior chart used by precision teachers and other Ogden Lindsley
disciples is particularly useful in this regard. In 1984, Patrick McGreevy pub-
lished an article in The Journal of Precision Teaching describing how he used
the chart over a period of 2.5 years as he progressed from 1.25 miles on his first
run to completing his first marathon (26.2 miles). The visual display provided
by the chart also helps to see clearly the decreasing benefit of additional train-
ing miles as total mileage increases.
COVERT BEHAVIOR
The term covert behavior refers to thoughts, images, and feelings that can
be observed by the individual experiencing those events, but they are not direct-
ly observable by others because they occur "beneath the skin" or within the
organism. Covert behaviors are assumed to be no different from overt behav-
iors in so far as they interact with each other and obey the same laws of
learning. [For a more complete discussion of these assumptions, see Cautela
and Kearney (1986, 1990).J
The use of behavior modification techniques employing imagery and other
covert behaviors has become quite common. Bookstores shelves are lined with
seemingly endless rows of books promoting all sorts of imagery techniques for
self-improvement. In recent years the use of hypnosis and a wide variety of so-
called "mental imagery" techniques have been rapidly spreading in the field of
sport and exercise psychology. In addition to health-related uses such as weight
loss, smoking cessation, and stress management programs, topics often include
building confidence, overcoming fears, and yes, improving your athletic perfor-
mance at every sport from archery to yachting.
The most common uses of imagery include mental rehearsal of various
kinds and relaxation training. One of the major advantages of using imagery
procedures to assist practice and game preparation is that the more gamelike
the conditions are during preparation, the greater the transfer of skills from
practice to competition. There are no practical limits to the content of the
imagery used other than the sport psychologist's creativity and the athlete's
imagery ability, both of which can be improved with proper training. These are
the same advantages that apply to more clinically based imagery applications
of behavioral principles such as social skills training and the desensitization of
phobic behaviors.
The covert behavior engaged in by runners and other athletes is an area of
increasing interest to sport psychologists. Most runners would probably agree
that the question they are most commonly asked by nonrunners is "What do
you think about when you run?" or "What should I think about when I run?"
This is a highly researched area. It appears that there are two commonly used
strategies runners use when racing or on training runs. These are often referred
to as dissociative strategies and associative strategies.
Dissociation supposedly distracts from the pain and discomfort. Good
runners have reported doing things like visualizing themselves chopping trees
and stacking wood, listening to Beethoven, and reliving their educational ca-
reers while running. Others have employed mantras such as repeating the word
"down" with every footstep. Morgan, Horstman, Cymerman, and Stokes
( 1983) demonstrated that by getting runners to concentrate on chasing a spot
on the road ahead and repeating "down," they could run further at maximal
aerobic power than without it. Since numerous physiological measures were
monitored and controlled, they concluded that the improved performance was
not because of lowered heart rate and so forth from the meditation, but actually
resulted from the greater tolerance brought about by the distraction. An inter-
esting study might compare the use of the word "up", but many runners might
find it harder to say that while running.
On the other hand, according to Morgan (1978), world-class runners are
more likely to use associative strategies. They report paying very close attention
to what is going on. He reports that the very best runners monitor themselves
constantly, for example, how their bodies feel or where they are in a race, and
do not dwell on unrelated matters like school, friends, and so forth. They scan
their bodies for signs of trouble developing that might require adjustment such
as slowing down slightly to avoid fatigue or oxygen debt after drifting across
the aerobic-anaerobic threshold (that is, into oxygen debt), or adjusting one's
stride to compensate for muscle problems, or directing oneself to relax more.
Monitoring includes checking on one's respiration, temperature, heaviness in
the calves and thighs, abdominal sensations, mental states, and so forth. Mon-
itoring would also include assessing one's position in the race relative to the
competition and prerace plans.
A related psychological strategy sometimes used for dealing with pain is
based on paying very close attention to the physical sensations involved, never
labeling them as pain but rather in terms of their component parts such as heat,
pressure, and so forth. It may be that while monitoring themselves very atten-
tively in this manner, those runners who use associative strategies also receive
the benefit of experiencing less pain and discomfort.
In another study Okwumabua, Meyers, Schleser, and Cooke (1983) found
it was more effective for novice runners to use dissociative strategies and as they
become more skillful switch to more associative strategies. A danger of the
dissociative strategies is that by cutting oneself off from sensory feedback the
possibility of injury and heat stroke or exhaustion is increased.
Two other phenomena may be of interest here. A not uncommon side effect
of distance running (and other endurance events such as triathlons) that some
of the greatest athletes have experienced, even on national television, is diar-
rhea. Some runners have found it helpful in delaying if not preventing the
inevitable to visualize themselves in very cold water or sitting on cakes of ice.
Here is where it is critical to include the sensation of coldness in imagery as well
as the visual sensations. This may be more helpful to people who have had
similar in vivo experiences. A second phenomena that I have observed but not
seen reported in the literature is that some runners, around 15-20 miles into a
reasonably good run, occasionally begin to emit vocal and motor tic behaviors
similar to symptoms of Tourette's syndrome. It could be speculated that bio-
chemical imbalances that occur when runners "hit the wall" may have some
similarity to those associated with Tourette's. The author would appreciate
hearing from any readers with information on this.
The examples above help exemplify the countless uses of imagery devel-
oped by athletes to help meet their individual needs while performing. We will
now turn to a discussion of some of the imagery-based procedures developed by
psychologists that have applicability in sports.
Covert Conditioning and Related Procedures

While a plethora of imagery-based techniques have been used in sport
psychology, including mental rehearsal (Garfield & Bennett, 1985) and emo-
tive imagery (Murphy, Woolfolk, and Budney, 1988), the two that appear to
have the soundest scientific bases are Richard Suinn's (1976) visuomotor be-
havior rehearsal (VMBR) and Joseph Cautela's (Cautela & Samdperil, 1989)
sport application of covert conditioning, imagaletics. A detailed history and
discussion of other forms of imagery used in sport psychology can be found in
Murphy (1990). VMBR and covert conditioning procedures also have in com-
mon that their earliest reported applications involved clinical rather than athle-
tic cases (e.g., Cautela, 1966; Suinn, 1972). After developing VMBR and using
the procedure to successfully improve the performance of collegiate ski racers
in the early 1970s, Suinn went on to become the first psychologist assigned to
the United States Olympic team in 1976.
VMBR is a three-part procedure in which the athlete is initially relaxed
using a shortened version of Jacobsonian progressive muscle relaxation. The
relaxation training is accompanied by imagery training that includes emphasis
on tactile, auditory, emotional, and muscular sensations as well as visual. This
is followed by the use of imagery to practice specific psychological and motor
skills, and then to rehearse going through a specific event, such as skiing down
a particular course. Corrections in technique are often made in imagery, with

the athlete sometimes rehearsing the event in slow motion.
Some of the similarities and differences between VMBR and imagaletics
may be inferred from the following example of imagaletics:
Imagine you are about to take a penalty kick. You look at the goal, feeling
somewhat excited but calm and confident. You decide where you want to
kick the ball and glance at that spot. You begin to run toward the ball
looking at it as you step next to the ball with your left foot, and your right
leg swings forward and your shoe lace contacts the ball. You continue
forward with your right leg coming through the ball, and you watch the
ball fly past the goalkeeper into the goal. Now quickly shift to a scene in
which you are riding on a new ten-speed bike. It is a warm, late summer
day, and the breeze against your skin as you quickly peddle down hill feels
great. The sun glistens on the bright blue paint of the bike and you feel
happy from head to foot, and delighted with your early birthday present.
You have just experienced a single learning trial (repetition) of covert
positive reinforcement (Cautela, 1970). The scene described above was actually
used by an ll-year-old soccer player to help learn to kick with her nondomi-
nant foot. (In this case, the naturally left-footed kicker was learning to use her
right foot.) In an experimental training program that involved weekly periods
of actually taking 10 practice kicks each day or imagining 10 kicks as described
above, the player went from 12% scoring (6/50) before treatment began to
48% (24/50) after 1 week of covert conditioning training.
Imagaletics (Cautela & Samdperil, 1989) is the term used to describe the
application of covert conditioning to athletic performance. The term covert
conditioning refers to a family of psychotherapy procedures developed by be-
havioral psychologist Joseph Cautela and his colleagues primarily in the 1960s
and 1970s. Covert conditioning combines the imagery work of psychiatrist
Joseph Wolpe with the laws of learning discovered by psychologist B. F. Skin-
ner. Over 400 professional journal articles and books have already been pub-
lished on covert conditioning (see Cautela & Kearney, 1986, 1993), establish-
ing its effectiveness in changing human behavior.
The basic principle underlying both Skinner's operant conditioning and
covert conditioning is that the immediate consequences of our behavior or
actions are critical in determining the likelihood of our doing the same thing
again. For example, if a pitcher throws a low outside fastball (behavior) and
gets a strikeout (consequence), he is more likely to throw another low outside
fastball in the future (positive reinforcement). On the other hand, if the pitch-
er's curve ball hangs and is hit for a home run, he is less likely to throw it again
( punishment).
Although covert conditioning has been around a little longer than VMBR,
its sports applications are more recent. Published case reports in which covert
conditioning procedures have been employed have included applications to the
sports of wrestling (Rushall, 1988) and rowing (Rush all, 1993). Earlier uses of
covert conditioning were primarily for experimental and clinical purposes. As

with VMBR, covert conditioning also emphasizes a multisensory approach to
imaging and "being in" rather than observing the scenes. A major distinction,
however, is that covert conditioning includes scenes of contingent conse-
quences, which mayor may not be related to the target behavior. There is some
anecdotal evidence that unrelated scenes may be more effective in athletic appli-
cations because competitive sports scenes sometimes lead to an increase in
anxiety. Research has shown, however, that both related and unrelated scenes
are comparably effective with nonathletic behaviors in covert positive reinforce-
ment. (Kearney, 1984).
Advantages of adopting a covert conditioning approach include the avail-
ability of the knowledge base accumulated through decades of experimental
and clinical applications and the strong operant learning theory foundation
upon which it is based. Key to this knowledge is the importance of applying
these procedures in accordance with the learning principles upon which they
are based, just as in their clinical applications. For example, the number of
learning trials, schedule of reinforcement, clarity of imagery, length of scene
presentation (15-30 seconds is typical) are all important variables. It is impor-
tant to note that in covert conditioning, while both the behavior to be modified
and the consequences are usually presented in imagery, this is not always the
case. As long as one of the two elements is engaged in covertly the procedure is
considered covert conditioning.
The most readily applicable covert conditioning procedures to sport psy-
chology are described below:
1. Covert positive reinforcement. In covert positive reinforcement (CPR)

the behavior to be strengthened is followed by a reinforcing consequence:
Imagine you are standing on the 40-yard line with your team trailing 21 to
20, and 4 seconds left in the game. You are feeling confident and relaxed.
You see the center snap the ball back to the holder and you begin to move
forward. You hear the crowd cheer and the sounds of the defense charging
toward you. Your eye is on the ball as you plant your left foot and swing
your right leg forward. Your foot strikes the ball and follows its flight over
the charging defenders and through the goal posts. Reinforcement.
Although the related consequence of scoring the field goal that was incor-
porated into this scene may be an effective reinforcer, the word "reinforce-
ment" spoken by the psychologist signals the athlete to switch to a visualiza-
tion of a prearranged reinforcing scene that may have no relation at all to the
target behavior. An example might be a scene of enjoying beautiful fall foliage
on a pleasant drive through the countryside.
2. Covert modeling. Clinically, covert modeling is often used when the
client has excessive difficulty experiencing the target scenes. The client then
visualizes another individual, known as the model, engaged in the sequence of
behaviors. In some cases, usually called covert self-modeling, the client uses
imagery to visualize him- or herself as the model, as if watching a video of

oneself.
Covert modeling has additional advantages in imagaletics. If, for example,
athletes wish to improve their form, they may review in imagery the form of an
expert, such as how a world-class figure skater like Nancy Kerrigan performs a
particular jump and landing, or how Diego Maradona makes a particular feint
while dribbling a soccer ball. The athlete might then insert him- or herself in
the same scene, repeating it then with perfected form.
Over two decades ago I personally used covert modeling to increase both
my own rate of exercise and that of a friend. At the time (summer 1972) we
were both working as lifeguards for the Cape Cod National Seashore. Our
beach was preparing for a lifesaving competition held among the Cape Cod
beaches at the end of each summer. Unfortunately, rather than getting ourselves
in condition for the competition, my friend Ken and I were more interested in
reading about the upcoming summer Olympics. We became particularly fasci-
nated by an American wrestler named Dan Gable. Gable had quite a reputation
for the seemingly fanatical extremes to which he went in building his endurance
and conditioning. A number of articles we read implied that it was his condi-
tioning rather than basic wrestling skills that got Gable to where he was. Kenny
and I began using covert images of Gable working out and thoughts about
what Gable would do if he were in our place to motivate ourselves to intensify
our training. After we started using this method, we also began to increase our
conditioning workouts. Unfortunately, we began working almost exclusively
on conditioning and neglected to work on our lifesaving skills. Subsequently,
although Dan Gable went on to become an Olympic gold medal winner, we did
not successfully defend our lifesaving championship.
3. Self-control triad. The self-control triad is a three-step procedure that is
useful in reducing unwanted covert behaviors and improving concentration.
The three steps are a sequential application of thought stopping, relaxation,
and a reinforcing scene. The self-control triad is particularly useful when the
athlete is about to perform or is already in the process of performing an event.
A baseball player who was hit by a pitch his last time at bat might use the self-
control triad while in the on-deck circle to stop thinking about how he was hit
by a pitch his last time up. A gymnast waiting for her turn on the uneven
parallel bars might use the self-control triad to control anxiety.
Imagery can also be useful while in the act of running. For example, when,
through self-monitoring, a runner becomes aware his or her form is faulty,
imaging correct form in covert self-modeling can be helpful in quickly return-
ing to form. Also, in later stages of a race as one becomes more tired, one's form
begins to deteriorate. Making a greater effort assisted by covert self-modeling
can at least temporarily return and maintain more efficient form for a period of
time or be helpful in changing form as necessary, such as shortening stride,
switching from heel to toe running and leaning into a hill to climb, or changing
the rate of leg turnover for a finishing kick. Changing gear after more than 20
miles can be a lot more difficult than it may seem. One imagery technique that
has been used effectively involves selecting a competitor maintaining a similar
pace approximately 40 to 50 yards ahead on the course. The runner then
projects an image of him- or herself casting a fishing line and hooking the
competitor in the back. The runner then gradually imagines him- or herself
reeling in the opponent as he or she gradually increases his or her speed. A
related image that has been used to maintain pace and help keep from falling
behind in later stages of races involves visualizing a towline fastened around the
leading runner, with the trailing runner visualizing holding the other end of the
line, being towed along like a water-skier. When wishing to speed up more
gradually with no runner in view on the course ahead, it is sometimes helpful
to project an image of a competitor a little way ahead on the road and then
either "reel him or her in" or have him or her tow you along.
Additional Considerations
Know the Athlete

Imageletics is more likely to work the better the specific program fits the
individual athlete:
1. Imagery ability. In order to increase the quality of scenes visualized, as

many sense modalities as possible should be used in scene presentations. The
athlete should be instructed to try to actually experience the events as real-
istically as possible, rather than watching him- or herself as if watching a
home video. Individuals find certain sensations easier to imagine than others.
Some may find it easier to imagine the sounds of cheering fans than the sight
of a playing field. Swimmers may find it easier to experience the feel of the
water or the taste of the chlorine. Although imagery ability can be improved
with directed practice, emphasis should be placed on the individual athlete's
stronger modalities when possible. It can also be helpful to monitor the imag-
ery from time to time by having the athlete describe the scenes he or she is
visualizing.
2. Idiosyncratic consequences. As mentioned earlier, the immediate con-
sequences of behavior are critical in determining the likelihood that the same
behavior will be repeated. It is very easy to fall into the trap of assuming that
the same consequences are rewarding or reinforcing to everyone. But not every-
one enjoys chocolate ice cream or Willie Nelson music. We must not take it for
granted that a related natural consequence (for example, sinking a basket after
shooting the ball exactly as instructed by the coach) is always reinforcing to the
particular individual athlete with whom we are working. Questionnaires such
as the Reinforcement Survey Schedule (Cautela & Kastenbaum, 1967) can be
very helpful in identifying likely reinforcers that appeal to the individual before
using them in actual practice.
Know the Behavior

People tend to do things the way they practice doing them. Habits are
formed by performing the same act over and over again, whether a good habit
or a bad habit. Whether practicing a motor behavior sequence overtly or
covertly, it is important to pay close attention to the fine details of proper form.
The practical application of this is that the person directing an athlete's imagery
to improve form must (1) know the proper form of the behavior being taught
that is likely to work best for this athlete, and (2) be able to describe the
behavior effectively. This often requires consulting with the coach as well as the
athlete to find out for sure just what he or she should be doing. For example, it
would probably do more harm than good to describe Ted Williams' batting
stance and bat grip to a right-handed singles hitter who specializes in choking
up and punching the ball to the opposite field. To paraphrase Richard Suinn,
"If practice makes perfect, than imperfect practice makes imperfect; so as a
word of caution, be sure you are visualizing the right way to do something."
Know the Procedure and the Learning Principles

upon Which It Is Based
Since so many authors have rushed to jump on the imagery band wagon,
the quality of the available programs varies tremendously. A major flaw in
many imagery programs is that they are neither based on nor consistently
applied according to scientific behaviorological principles. A review of unsuc-
cessful clinical and experimental applications of covert conditioning (Cautela
& Kearney, 1986, pp. 151-181) revealed that in nearly all cases the procedure
was not properly employed consistent with the learning principles on which
they were based. Individuals considering using these procedures must acquire a
thorough understanding of them to increase the likelihood of success.
FUTURE DIRECTIONS
If this chapter had been written just a few years earlier, the major future
direction predicted would have to have been an explosion in the use of imagery.
In the 1990s, however, sport fans who regularly follow the Olympic Games on
television could not help being inundated with reports about the lives of indi-
vidual athletes and their training practices. These reports often tell us how this
figure skater or that gymnast uses imagery to rehearse every detail of her
routine, or we hear how archers and divers use imagery to improve their
concentration, or perhaps we hear how a decathlete uses relaxing imagery to
insure a restful sleep the night before the final events. The use of imagery,
however, is no longer restricted to world-class athletes. Perhaps inspired by
well-known models, the use of imagery to help train athletes at all levels is
becoming more and more commonplace. Not only is imagery widespread at the
professional and collegiate levels, it is beginning to permeate the high school

ranks as well. Specialty camps for high school athletes playing sports such as
basketball and lacrosse are including imagery training in their programs. Rick
Sewall's SoccerTech is a well-known soccer camp in the Boston area that em-
phasizes training in the proper and precise performance of soccer skills or
technique. Inspired by Hubert Vogelsinger, considered by many to be the best
soccer coach in the United States, SoccerTech has begun to use imagery along
with other more traditional teaching methods to enhance the performance of
its 7- to 14-year-old campers.
Since the imagery applications have already been demonstrated to be effec-
tive and are becoming more generally recognized every year, it is not hard to
predict that the use of imagery in sport and exercise will continue to expand.
On the other hand, while other new directions may be more difficult to foresee,
suggestions for future directions can be made.
The focus of sport psychology to date has been almost exclusively on the
individual athlete or team, that is, those who are directly engaged in the athletic
activity. From a behavioral perspective, however, we are especially concerned
about the environment in which the athlete functions and how that athlete and
environment interact to modify the athlete's behavior. After all, learning has
often been said to be a change in behavior that results from interaction with the
environment.
Parents and teachers are part of the social environment. The extent to
which their behavior helps shape the behavior of their children and students is
well established. Considerable research has been reported in journals such as
Education and Treatment of Children, Journal of Applied Behavior Analysis,
and Journal of Behavioral Education that has studied specific behaviors of
parents and teachers and how those behaviors in turn affect the behavior of
children.
Being a coach is very much like being a teacher. Just as what parents and
teachers do and do not do affects the performance of their children, the same is
certainly true with coaching. An important area for future research should be
to examine the behavior of coaches more closely. Given the experience and
expertise of behavioral psychology in conducting this sort of research, this is a
natural area for behaviorally oriented sport psychologists to investigate, and it
is not without precedent.
A number of years ago, Tharp and Gallimore (1976) wrote an interesting
article on the coaching behavior of John Wooden, generally considered to be
the greatest college basketball coach of all time (10 national championships in
12 years). They identified certain factors in his behavior that they felt helped
Wooden to be so effective. One key to Wooden's success was that a very high
percentage of his statements, whether positive, negative, or neutral, contained
specific instructions describing the proper behavior. That is, Wooden was rare-
ly general in his statements, and although he used praise or what might struc-
turally appear to be positive reinforcement sparingly, his statements were spe-
cific and repetitious, with the intent of having the correct behavior become
automatic. While many others surpassed Wooden's accomplishments as a play-

er, few have rivaled his success as a coach. The difference seems to be his
teaching ability.
The failure of other more successful athletes as coaches has demonstrated
that being able to perform the skills at even a world-class level is not sufficient
to be an effective coach (and may not even be necessary). The ability to teach
those skills so that the athletes under the coach's tutelage are able to perform
those behaviors is necessary. It may be that very highly skilled athletes are at a
disadvantage when trying to coach precisely because they are highly skilled.
That is, since they are capable of executing the various skills so fluently, they no
longer break the complex skills down into their component parts and describe
and/ or demonstrate them in ways that athletes still trying to learn these skills
can effectively acquire them. A giant step toward learning how to most effec-
tively coach athletes can be learned by studying the behavior of effective
coaches and using that knowledge to improve the coaching ability of other
coaches and instructors.
The United States is usually thought of as having major professional
leagues in four team sports: baseball, basketball, football, and hockey. Al-
though soccer is by far the world's most popular sport with more countries
belonging to FIFA, soccer's international governing body, than to the United
Nations, the United States was still without an operating national professional
soccer league until 1996. On the other hand, soccer is the fastest-growing team
sport in the United States, currently second only to basketball in numbers of
participants. There is no shortage of books on coaching soccer, but the quality
varies greatly. Some, such as Coaching Soccer Effectively (Hopper & Davis,
1988), which is part of a larger project called the American Coaching Effective-
ness Program, reflect varying degrees of behavioral influence. In this case,
teaching progressions for shaping a number of key soccer skills appear to be
well developed. A wide open area for future applications of behavioral sport
psychology would seem to be the sport of soccer.
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18
Training the Client

to Be Empathetic
Joseph R. Cautela
INTRODUCTION
The assumption that the nature of the relationship between the therapist and
client is an important factor in the therapeutic process and outcome has led to
much theoretical speculation and research on possible relationship variables
that may have therapeutic relevance. The assumed importance of empathy on
the part of the therapist has led to efforts to ensure empathetic characteristics
by focusing on empathy training for the therapist. However, while much has
been written about the importance of the nature and degree of empathy of the
therapist, there has been little focus on the empathetic characteristics of the
client. Further, there has been little discussion and research on the necessity of
training the client to have appropriate empathy, which will facilitate relief of
presenting symptoms and increase quality of life. Orlinsky and Howard (1986)
did not find any studies where client empathy was included within a process
outcome study. There are a number of therapeutic values in having the client be
appropriately empathetic in daily living. The result of empathy training should
lead to improving the human condition, not only of the one being trained, but
also of many others who come into contact with the client. The advantages of
teaching empathy to the client can include the following:
Joseph R. Cautela • Behavior Therapy Institute, 10 Phillips Road, Sudhury, Massachusetts

01776, and Harvard University Health Services, Cambridge, Massachusetts 02138.
337
1. Clients will:
• be better able to predict the responses of others
• increase tolerance toward others
• reduce aggression toward others
2. Empathy training will:
• help in conflict resolution
• help therapy be more effective
• help reduce objectionable behaviors such as teasing of others
• lead to action in helping others, for example, charity, food donated,
money donated, giving car rides, taking care of the sick
• promote maturity and self-differentiation
While this chapter focuses on teaching clients empathy in the therapeutic
situation, the training can benefit the client in interactive situations to promote
improved relationships among individuals. These situations include:
• Prisons (conflict between guards and prisoners)

• Marital situations (conflict between husband and wife)
• Family situations (conflict among siblings)
• The workplace (conflict among employees, between employees and em-
ployers)
• The community (conflict between police and members of the commu-
nity, prejudice between different groups)
• The world of education (conflict between teachers and students)
It is logical to assume that the more individuals in the world who have appro-
priate empathy, then the more the world would be a safer and more enjoyable
place in which to live. The focus of this chapter will be on the teaching of
empathy to clients in therapeutic settings. Empathy training for interactive
situations can be done in both individual and in group sessions.
A moderate number of publications have been devoted to the importance
of empathy by the therapist. In these studies, often the term empathy is not
defined and the training of the therapist not described. If the procedure is
described, often there is a lack of clarity in the description. Another problem is
the lack of agreement as to the definition of empathy either in abstract or
operational terms. In an excellent review of therapist empathy in counseling,
Barkham (1988) concludes that difficulty arising from lack of agreement on
definition of empathy behaviors has led to inadequate research and equivocal
results (so much so that it is difficult to appraise the validity of the construct of
empathy and the role of empathy in clinical practice). In addition to the prob-
lem of definition, another reason that outcome studies do not support the
efficacy of therapist empathy could be that the focus has been solely on the
clinician's empathy to the neglect of the client's empathy. One of the major
influences that contributed to this neglect has been the work of Carl Rogers
(1957, 1961). According to Rogers, one of the major influences on client
18 • TRAINING THE CLIENT TO BE EMPATHETIC 339
growth is the therapist's empathy. Only recently has there been a concerted
effort in some quarters to focus on the interactive components between the
client and the therapist. Speculations concerning the therapeutic alliance
and/ or therapeutic bonding have only recently received some extensive atten-
tion. While this chapter will focus on teaching clients empathy, it is teaching
within the context of therapy as an interactive process between client and
therapist; that is, constant communication throughout therapy between client
and therapist. It is obvious that the therapist should have the same empathy
behavior both covertly (thoughts, feelings, and images) and overtly (expres-
sions to the client, both nonverbal and verbal). In fact, the therapist should
practice and train to be empathetic in daily life.
CLINICAL OBSERVATION AND EMPATHY TRAINING
Therapeutic strategies develop out of clinical observation and the thera-

pist's model of the parameters that affect behavior. Since Freud's view was that
human behavior was primarily influenced by unconscious factors, he developed
strategies to manipulate those factors. Carl Rogers postulated that uncondi-
tional acceptance and genuine regard for individuals is important to their well-
being (Rogers, 1957). Therefore, in the therapeutic dyad the therapist should
communicate unconditional acceptance and genuine caring to the client in
order to effect therapeutic change (growth), that is, the therapist should have
empathy for the client. Mostly as a result of Roger's influence, there has been a
great deal of emphasis on therapist's empathy as a therapeutic skill; therefore, it
was important that therapist training include the teaching of empathy.
During my 35 years of therapeutic experience I have treated a variety of
populations ranging from the developmentally disabled to psychotic individu-
als. Also, I have worked therapeutically with a wide variety of behavior disor-
ders. My therapeutic approaches have included nondirective therapy, dynamic
therapy, and (for the last 25 years) a behavioral learning approach. In all my
therapeutic experience, regardless of the population being treated, the problem-
atic behaviors being treated, or my therapeutic approach, it has always been clear
to me that communicating empathy was usually necessary but not sufficient in
the therapeutic dyad for optimal effective treatment. In recent years I have also
become increasingly aware of how important it is for the clients' well-being that
they have a certain degree of empathy toward others. Clients are often so
concerned with their own fears and problems that their focus is self-centered and
they find it difficult to be empathetic toward others. This lack of empathy quite
frequently results in anger toward others, intolerance, and poor social interac-
tion with significant others. Therefore, I have gradually developed therapeutic
strategies based on the behavioral model (especially covert conditioning) to
teach the clients to be empathetic. The goal of this empathy training (ET) is to
increase the probability of therapeutic success and increase their quality of life.
DEFINITION AND CHARACTERISTICS OF EMPATHY

It is not the purpose of this chapter to present an extensive review of the
literature on empathy or to present the various definitions proposed by differ-
ent authors. It is important, of course, to present my working definition of the
construct of empathy and its various characteristics. According to my defini-
tion, empathy is the behavior of experiencing the feelings, thoughts, and images
of others. Empathy, as I employ the term, is not role substitution; that is, what I
would do if I were in someone else's place. Empathy is not sympathy, which is
concern for someone else's plight.
When you have empathy for someone, you experience the feelings,
thoughts, and images that someone else is experiencing. Empathy is usually not
a unitary trait. Individuals can be empathetic to certain ethnic groups but not
to others. Empathy can be experienced toward certain classes such as battered
women, the homeless, and yet not toward others such as the police. Empathy
can be expressed in degrees and is not necessarily an all-or-nothing behavior.
Empathy can also be influenced by the context of the situation; for example,
there was public outrage recently when it was revealed that a dog was buried
alive. It can be assumed that in general there was more empathy for this dog by
more people than for many dogs killed in hit-and-run accidents. Two other
empathy characteristics, negative empathy and empathy satiation, will be de-
scribed in more detail because of their relevance for social interaction and the
therapeutic relationship.
Empathy Satiation
Reinforcer satiation occurs when repeated presentations of a reinforcer
causes the reinforcer to lose some of its reinforcing value; for example, constantly
listening to the same song, or eating the same food every day can lead to reducing
the reinforcing value of the song or food. Stimulus satiation occurs when
repeated presentations of a stimulus weaken a stimulus-response connection.
Empathy satiation can occur when an individual is constantly exposed to
empathy stimuli. A wife who constantly receives complaints from her husband
about his depression or pain can sometimes lose a degree of empathy toward
him. In these situations, it can be explained to the husband that his constant
expressions of feeling depressed or in pain will gradually affect his wife in such
a manner that she will lose some compassion and even try to avoid him. He can
be instructed and taught how not to complain unless it's absolutely necessary.
The wife can be taught not to reinforce the complaints because, in the long run,
that will increase the number of complaints and misery.
Negative Empathy
It is important to emphasize that not all empathy has positive characteris-
tics. In some situations or circumstances, empathy can have negative processes
and outcomes. It is useful therefore to distinguish between positive and nega-

tive empathy.
Negative empathy effects judgment and procedures that could be detri-
mental to self or others. Some examples:
• A physician or psychologist who is so empathetic to relatives or loved
ones that her judgment or performance in a professional capacity could
be detrimental to them
• A parent who is so empathetic with his children that he has difficulty
setting limits
• An employer who is so empathetic with her employee that she does not
criticize her performance or terminate her employment, even though the
employee cannot perform the job adequately
• A boxer who is afraid of hurting his opponent
I had a client who was in treatment because he was so afraid of hurting his
patients that he felt he could not function as a dentist anymore. Further analy-
sis revealed that this dentist was not afraid of criticism from his patients or that
he was going to lose them as patients. He simply had too much empathy for his
patients. There are some individuals who are so empathetic with characters in
movies and novels that when the characters are having difficulties, they become
over empathetic so that they cannot continue to watch or read about them.
Sometimes after exposure to watching and reading about the plight of the
characters, they get depressed and find it difficult to function.
The Clinician and Negative Empathy

The clinician who focuses primarily on the treatment of posttraumatic
stress disorder (PTSD) should be especially aware of negative empathy that
could occur in his own behavior. The treatment of PTSD of patients in Veterans'
Hospitals can be especially traumatic for the therapist (Chiaramonte, 1992).
Williams (1989) presents an interesting discussion of empathy and burnout in
the helping professions. When negative empathy occurs in the therapist, then
reduction of case load, cessation of treatment for a while, social support for the
therapist from colleagues, and individual treatment can help alleviate this con-
dition. I have found that teaching relaxation and the self-control triad (Cautela,
1983) is helpful in restoring positive empathy. On a cultural level, constant
exposure to the brutalizing of victims as shown by the media can lead to a state
of empathy immunization.
ASSESSMENT OF EMPATHY
Assessment of the dyadic therapeutic situation involves the interview pro-

cess and the administration of the Empathy Survey Schedule (ESS). During the
interview, spontaneous statements of the client and responses by the client to
the therapist's questions will reveal some information concerning the client's
empathy in general and empathy toward specific groups or individuals. Exam-
ples of empathy-related statements by the client are:
• "Last week when I went to pick up my employment check for the first
time, most of the other people in line looked like losers."
• "My wife is always complaining about some ailment; she drives me
crazy."
• "Welfare is a free lunch; we should get rid of it."
• "My mother is always feeling sorry for herself. She ought to stop whin-
ing."
Examples of therapist's empathy-related questions are:
• "How does your wife feel when you criticize her in public?"
• "Can you imagine what the Jews feel like when someone paints a swasti-
ka on one of their temples?"
• "Did you ever wonder how your daughter felt when you tried to get into
bed with her?"
• "Don't you know how much it hurts your children when you neglect to
pick them up for your weekly visitation rights?"
Of course, these statements and questions are made as part of the issues under
discussion during the therapeutic session.
Administering the ESS

The ESS consists of 20 questions related to empathy behavior. The client is
asked to answer the questions on a one-to-five scale. I have found it useful to
administer the ESS (see Table 18.1) to keep a focus on areas that need ET and
as a catalyst to start discussions. At first glance it seems obvious that most
individuals would bias their answers in the direction of feeling humane, sensi-
tive, and understanding. But when I asked clients empathy-related questions
before I developed the ESS, I was surprised by the anger and lack of empathy in
some of their answers. Some examples:
• "Elderly people are just a burden on society." (Q. 5, 6)
• "People are pampered too much. They ought to be corrected for their
faults in a stern manner." (Q. 14)
• "If someone is lonely, that's their fault; they should try to meet people by
joining clubs or take some courses." (Q. 3)
• "When a friend is in pain, I feel sorry for that person, but I try not to
think about it. I try to ignore it." (Q. 3)
• "The Golden Rule is all right in theory, but in practice, if you behave that
way you often get screwed." (Q. 20)
• "The homeless don't deserve any help. They want to be that way." (Q. 19)
When these questions were presented in the questionnaires and the an-
swers were discussed, sometimes there were similar nonempathetic responses to
some of the questions. When I explore the reasons for some of the answers that
18 . TRAINING THE CLIENT TO BE EMPATHETIC 343
Table 18.1. Empathy Survey Schedule
Directions: In order to increase the effectiveness of our sessions, please answer the following
questions. Before you answer the questions, try to imagine a scene suggested by each
sentence. Circle the number that best applies.
1 = Not at all 2 = A little 3 = A fair amount 4 = Much 5 = Very much
I. I cry at weddings. 2 3 4 5
2. I cry at sad scenes when watching a movie. 2 3 4 5
3. When a friend is in pain, I feel like I am in pain. 2 3 4 5
4. When I see deformed people, I wonder what it would be 2 3 4 5
like to be deformed.
5. When elderly people are ridiculed, I wonder how I'll feel 2 3 4 5
when I am old and may be ridiculed.
6. When I see elderly people being ridiculed, I imagine how 2 3 4 5
terrible they must feel.
7. When someone is in pain, I can almost feel the pain 2 3 4 5
myself.
8. When someone I know loses a loved one, I wonder what 2 3 4 5
it would be like to be that person and be losing the loved
one.
9. When I see a movie, I identify strongly with one or more 2 3 4 5
of the characters.
10. I feel bad when I see starving people. I can feel their 2 3 4 5
misery and hunger.
II. When an animal is hurt, I believe that the animal feels 2 3 4 5
pain like we do.
ll. When someone tells me that they have a terminal illness, 2 3 4 5
I can imagine how fearful they must feel.
13. I get a feeling of loneliness when I know someone else is 2 3 4 5
lonely.
14. When someone else is criticized, I feel as though I am 1 2 3 4 5
being criticized.
15. When my spouse (significant other) or close friend is sad, 2 3 4 5
I can feel the sadness.
16. When my spouse (significant other) or close friend is 2 3 4 5
happy, I can feel the happiness.
17. When other people are laughing and having a good time, 2 3 4 5
I sometimes feel jealous.
18. When other people are laughing and having a good time, 1 2 3 4 5
I often feel good all over.
19. Homeless people don't deserve pity or help; they want to 2 3 4 5
be that way.
20. I really believe the "Golden Rule"-do unto others as 2 3 4 5
you would have them do unto you.
indicate lack of empathy, the discussions usually reveal some relevant issues.
When one client was asked (when he circled a 1, which is the lowest indicator
of empathy, on the question about the terminally ill) if he knew someone who
was terminally ill, he answered, "Yes, and I hope she croaks." His wife had run
away from home with his children. Another client who answered 1 on ques-
tions 5 and 6 was abused as a child by his parents. My clinical impression is
that depressed individuals, individuals with somatic complaints, rebellious
teenagers, self-made successful business people, and lonely individuals indicate
lack of empathy as revealed by our discussions and their answers on the ESS.
Scoring the ESS

The ESS can be scored by adding up the circled numbers. Questions 17
and 19 should be added in reverse order (if the score is 1, then the score given in
getting the total score is 5; if the score given is 2, then the total score is 4; the
answer 3 is scored 3; the answer 4 is scored 2; the score 5 is scored 1). The
maximum score is 100. The higher the score, the greater the empathy.
One example of how the clinician can use the ESS score is to compare the
scores of various diagnostic categories. Recently I compared the scores of my
present clients with the scores of an equivalent educational and socioeconomic
group of non clients (N = 30). The scores of the clients ranged from 40 to 73,
with the mean of 55.6. Nonclients had a range of 63 to 85 with a mean of 75.8.
The two highest scores were from clients who had been severely depressed but
have made substantial progress in therapy. The two lowest scores were from
depressed clients who have made relatively little progress. [Keeping some form
of systematic data on clients follows the scientist-practitioner model suggested
by Barlow, Hayes, and Nelson (1984).J I administered the ESS to a client's
husband to help determine the accuracy of her belief that he was a cold person
to all except her. She believed that the plights of their children or others did not
seem to affect him, even though he did appear empathetic to her own situation.
In fact, he scored a 40 on the ESS. Now that I have been asking my clients to
take the ESS as part of my admissions battery, I will be able to gather more data
at various stages of therapy. Problematic behaviors for which ET is especially
indicated are:
• Domestic violence
• Child molesting
• Obscene phone calling
• Constant criticism of children by parents who use little or no reinforce-
ment
• Marital conflict
• Teasing
• Rebellion toward parents (more destructive than the norm)
• Resentment toward authority such as teachers and supervisors
• Resentment at the lack of sexual response by spouses or significant
others
• Depression that indicates lack of caring about the problems of other

people (this is less true of depressed individuals who have had some
successful therapy)
When I believe that a client can benefit from empathy training, I usually
say something such as the following: "In my experience, the degree of empathy
of clients usually has something to do with their problems. By empathy I mean
the extent to which you can actually experience some of the emotions,
thoughts, and feelings of others in certain situations. For example, if someone is
ridiculed by someone else, how much can you feel his shame and feeling of
rejection? Often how we get along with other people depends on how we can
empathize with each other."
Then an example is given related to the client's problem. Such an example
for a client who reported constantly becoming angry at his supervisor who
criticizes him follows:
"Can you imagine how much your manager is afraid that he will be judged
harshly by his bosses if the work of the guys that he supervises isn't up to
expectations? ,.
METHODS OF TRAINING CLIENTS IN EMPATHY
The Use of Covert Conditioning in Teaching Empathy

The covert conditioning (CC) model involves a set of assumptions and
procedures (Cautela & Kearney, 1986). The main assumption holds that covert
behavior (thoughts, feelings, images) obeys the same laws that govern overt
behavior. Covert and overt behaviors are controlled by laws of learning. While
the laws of learning are derived from both classical and operant conditioning,
the focus of CC is on operant conditioning.
The CC procedures are analogous to the operant conditioning procedures
of positive reinforcement, extinction, punishment, negative reinforcement and
response cost. The CC procedures are covert positive reinforcement (Cautela,
1970a), covert extinction (Cautela, 1971), covert sensitization (Cautela, 1967),
covert negative reinforcement (Cautela, 1970b), and covert response cost (Cau-
tela, 1976b). The other two CC procedures based on the operant model are
covert modeling (Cautela, 1976a) and the self-control triad (Cautela, 1983).
Overt modeling is assumed to be a behavior that was reinforced at a high level
in early childhood and then maintained throughout life on a thinner (less
frequent) reinforcement schedule. The self-control triad will be described in
some detail relative to its application to ET. In applying the CC procedures, the
client is asked to imagine performing the behavior to be changed and then
imagine appropriate consequences to modify that behavior; for example, if the
behavior to be changed is smoking, then the client is asked to imagine having
an urge to smoke and then imagine an aversive scene such as feeling nauseous
(covert sensitization). If the behavior to be increased is paying more attention to
a teacher, then the client is asked to imagine the behavior of focusing on what
the teacher is saying and then imagine a pleasant scene (covert positive rein-
forcement). A more comprehensive discussion of the assumptions, procedures,
and evidence for the efficacy of CC can be found in the Covert Conditioning
Handbook (Cautela & Kearney, 1986) and in the Covert Conditioning Case-
book (Cautela & Kearney, 1993). The CC procedures primarily applied to
teach empathy are covert positive reinforcement, the self-control triad, and
covert modeling.
Covert Positive Reinforcement and Empathy

In employing covert positive reinforcement (CPR), the client is instructed
to imagine the target behavior to be increased. When the target behavior can be
imagined with the desired effect of clarity and detail, then the client signals by
raising the right index finger. At that point, the therapist says "reinforcement"
and the client imagines a pleasant scene. When the scene is experienced as
pleasant, the client again signals.
In the CPR method of teaching the client to be empathetic, the client
imagines being different individuals who are experiencing either aversive reac-
tions or pleasant or calming covert behaviors and then imagines the reinforcing
scene. A 10-year-old boy who was constantly teasing his 7 -year-old sister in
front of her friends was asked to imagine being his sister while she was being
teased by him. He was also asked to imagine the shame, anger, and fear of
rejection she reported experiencing. When he could be involved in the scene in
both clarity and feelings, he signaled and then the therapist said "reinforce-
ment." The scene was taped and the boy was asked to play the tape (under
parental supervision) at home every day and during every office visit until he
reported he could actually experience his sister's reactions and the sister report-
ed that he was no longer teasing her under any circumstances.
A wife who resented her husband watching baseball games on television
expressed the desire to be able to watch the games with him and learn to be
able to enjoy watching them herself. A conversation with the husband revealed
that he was delighted that his wife wanted to watch the games with him. He
said that one reason she did not want to watch the games was because she really
did not understand the game with all its nuances. We all agreed that he would
teach his wife different aspects of the game while watching it with her. He was
to be patient, have a noncritical tone, and praise her when she indicated that
she was understanding certain parts of the game, for example, a double steal.
Covert positive reinforcement was employed by the wife before and after each
game. In these scenes, the wife tried to imagine the joy and satisfaction her
husband was feeling when he figured out a strategy and his team was winning.
After a month, they were enjoying the game together, exchanging ideas about
strategy and evaluation of hitting, fielding, and pitching.
When first presented with the scenes in utilizing CPR in ET, some clients
have trouble experiencing the empathy behavior and complain about the lack
of being able to empathize. The therapist should indicate, "Of course you will
have trouble at first; if you didn't, we wouldn't have to do the scenes in the first
place. But as you continue practicing and really trying to get involved in the
scenes, you will start to experience what is in the scenes."
The Self-Control Trial and Empathy

The self-control triad (SCT) is a CC procedure that is used to reduce the
frequency, intensity, and duration of behaviors. In employing the SCT, the
client is instructed to yell "stop" to himself covertly and then do relaxation
breathing by taking a deep breath and saying the word "relax" covertly while
exhaling and trying to feel a wave of relaxation starting at the top of his head
and going to the toes. After the relaxation breathing, the client imagines a
pleasant scene. Saying "stop!" interferes with the ongoing response to be re-
duced. The relaxation breathing also acts as a distractor and reciprocally inhib-
its the response. The pleasant scene is a distractor and reciprocally inhibits and
reinforces the use of the triad when needed for reducing a particular response.
In employing the SCT, the client is asked to imagine situations in which he
usually criticizes, yells, or hits someone. In the scenes as the client is about to
yell, hit, or criticize someone, the client uses the SCT and then says, "What am
I doing?" This is followed by a number of possible statements such as, "Oh, I
am really hurting his feelings," ''I'm being too hard on her," "He doesn't
deserve this cruel treatment." The client is then instructed to use the SCT in the
external situations whenever engaging in behavior that would be hurtful to
someone else. The client is also asked to record the hurtful situations that
occurred during the day and then imagine the situations again, but this time he
does not make the hurtful response but handles the situation in a kinder or
gentler manner. The kind or gentle response is followed by imagining a pleas-
ant scene (CPR).
Covert Modeling and Empathy Training

Covert modeling (CM) is a CC technique analogous to overt modeling
(Ban dura, 1969). In employing eM, the client is asked to imagine observing
the model performing target behaviors and then receiving particular conse-
quences. In the Bandura model, observational learning is based on the contigu-
ity model in which the behavior of the model and interaction with the environ-
ment is verbally and imagery-encoded by the observer. In the CC model, the
consequences are necessary for observation to be encoded.
In utilizing CM in ET, the client is asked to imagine observing the model
being empathetic and then is asked to imagine a pleasant (reinforcing) scene.
The empathy-teaching situations that the client is asked to imagine are related
to his own problems. A sample scene follows.
A father who was constantly critical to his son was asked to imagine a
father complimenting his son. In the scene the son smiled after the compliment
and hugged his father. In another scene a father screamed at his son and the son
cried and said, "Why are you screaming at me? You really hurt my feelings and
make me afraid."
The scenes are taped so that the client can play them at home. Different
models are used of different ages and genders. Models familiar to the client are
employed. Also, particular models with whom the client is having difficulty at
the present time, for example, spouse, friend, teacher, or relative, are used in
the scenes. If the client does the homework and is able to be involved in the
imagery, after a number of trials there is a noticeable change in the client's
relationships with the ones whom the models represent. The clinical evidence
comes from the client's own verbal report and that of significant others. The
significant others report that the client's behavior toward them has changed for
the better. "He seems more understanding than he used to be." "He really
seems to be listening to me." "He actually is being nicer to me now."
Other Procedures to Increase Empathy

In addition to CC procedures, other methods such as bibliotherapy, shap-
ing, relaxation, and behavioral rehearsals, are also employed. Bibliotherapy
involves suggestions to see certain movies and read certain books and articles.
The material suggested is intended to teach the client by vicarious modeling
and also supply information that will affect the client's perception of issues,
groups, or individuals. Examples are:
• Suggesting articles, movies, and documentaries related to domestic vio-
lence to a client who is beginning to show signs of violence toward his
spouse
• Exposing a client who teases his classmates to material that emphasizes
how the victim feels and reacts to teasing
• Suggesting to a client (who was so prejudiced against Jews that he did
not want his daughter to marry a Jewish student) that he see the movie
"Schindler's List." (The movie had a profound impact on his attitude
toward Jews. This was used in conjunction with the CC procedures.)
Shaping is an operant method of reinforcing successive approximations to
the target behavior. In the Environmental Test Chamber (the so-called Skinner
Box), the rat or pigeon is reinforced for approaches to the lever or disk. The
reinforcers are withheld until the organism makes a movement that is closer to
the mechanism that operates the reinforcer than the previous movement. Shap-
ing an individual to approach a feared object by reinforcing the individual each
time he gets closer to the feared object is another example.
Much of psychotherapy is effective because of shaping the verbal behavior
of the clients when certain responses are made. For example, if the therapist
wants to increase the self-esteem of the client, then any time the client makes
responses that indicate being a worthwhile person, the therapist may say,
"That's a good point" or "That's an insightful statement that you just made."
Other examples include, "That took courage" or "Your social skills are im-
proving." Anytime during the therapeutic sessions that the client makes a
statement that is empathetic or approaches empathy, the therapist may use
verbal reinforcement such as, "You really have compassion" or "You really can
feel your father's misery, can't you?" Often a prompt is needed, such as, "How
would you feel if your husband criticized you in front of your friends?" "Did
you notice if your mother was anxious on the plane?" "Can you imagine how
much pain your mother endured as she was battered by your father?" After
discussing the movie "Schindler's List" with a client who seemed to show little
or no remorse for the suffering of others, I inquired, "Can you imagine what it
must have been like to be a Jew in Poland or Nazi Germany at that time?"
Case Study
A 34-year-old father of four was referred because he was lonely and de-
pressed. He had no friends and only one or two acquaintances with whom he
and his wife socialized occasionally. He was a foreman in a plant, where the
men and women complained that he was constantly giving them negative
feedback in a harsh manner and that he never gave them positive feedback. He
would often berate workers in front of others. He readily confessed to his harsh
managerial style and justified it by saying, "They are a bunch of lunkheads who
are lazy and stupid." He felt that the only way to whip them into shape was to
constantly hammer home what they did wrong, and he had no time to pull
them aside from the assembly line to speak to them alone.
An interview with his wife and children revealed that he behaved the same
way at home as he did at work. He would constantly scold the children for even
minor infractions of the many house rules. He also constantly belittled his wife
in the presence of the children. When confronted with accusations by his
family, he was quite surprised that they saw him as unyielding, constantly
critical, and never praising them for anything they did. The children performed
well in school; his wife was passive to him and a devoted mother to her
children. He thought he had the perfect household because he was so strict and
constantly correcting their behavior. He knew that his family sometimes re-
sented his authoritarian manner, but he was shocked at how angry and bitter
they felt toward him. He said he did not realize how much he hurt them when
he scolded or corrected them. He thought their reactions were normal reactions
of individuals who were told to do what they did not want to do. When I told
him that his family described his criticism as a whiplash that stung very deeply,
he said that they were exaggerating and that he lived with a family of wimps. I
told him that what counted was not how he perceived the yelling and criticism,
but how they reacted to it subjectively. I also told him that I believed that they
were telling the truth from their point of view. His reaction was one of amaze-
ment and confusion. He asked, "Well, what do you want me to do? That's how
I have treated people all my life and it seemed to work, I have a good job and a
nice family!" I responded, "Well, your way punishes and hurts people. Why do
you think you have hardly any friends? Why do your workers seem to hate
you? Why does your family avoid being near you as much as possible? Why is
your family angry at you?" He replied, "I don't know. When I was young, my
father used to yell and scream at me and while it bothered me, I was determined
that he was not going to get the best of me by beatmg me down. The same with
my foreman when I was on the line. I never let him know he often humiliated
me." I pointed out that maybe his family reacted differently than he did. I told
him, "The trouble is, you don't have enough empathy for them. You say you
love them but you don't realize how much you hurt them when you correct
them, insult them, tear them down, and humiliate them. Do you know what I
mean by empathy?" He answered, "Is it something like sympathy?" Then I
explained that sympathy is feeling sorry for someone else's problems or situa-
tions. "Empathy occurs when you try to imagine what it would be like if you
were that person and that the terrible and bad things were happening to you as
they are to that person. It is not the same as you putting yourself in someone
else's place. It doesn't mean, "What would I do if I were in someone else's
place?" It is, "What would I do, feel, think, and imagine if I were that person?"
I then said to him, "Do you want me to teach you to be empathetic especially to
your family and to the people with whom you work? I think that if you can
learn to be empathetic, you will get along better with people, they will like you
more, your family will love you more, and your fellow workers will even work
harder for you and cooperate more." After I convinced him that I really meant
what I said, we cooperated on the following procedures: behavioral rehearsals,
covert modeling, and covert reinforcement.
In employing behavioral rehearsals, we acted out scripts in which he some-
times played himself and sometimes he was one of his family members or
workers while I acted as he did. The scenes consisted of sometimes his doing
the criticizing or humiliating while I (playing a worker or family member) told
him how much it hurt or got me upset. Other times I criticized him while he
played himself and sometimes I played his boss, co-worker, or family member.
In CM I had him imagine he saw someone like himself bullying and insulting
others; then they would tell him how they felt and sometimes yelled at him or
criticized him back. When using CPR I asked him to imagine a scene in which
the worst kind of insult was given to him by someone he respected and then I
had him imagine he was devastated and then say to himself, "Oh my gosh, is
that how it hurts when I do it to someone else?" Then he imagined a reinforc-
ing scene. Apparently the scenes and the rehearsals were effective because he
seemed appropriately pained at the expected times.
I taped all the rehearsals and scenes and asked him to play them every
night until the next session. His progress was monitored by my seeing a mem-
ber of the family every other week and getting his verbal report about work.
After just six sessions, his family reported that he was hardly yelling at all and
was much more considerate than ever before. He reported that his workers
were friendlier and were actually putting out more work. Of course, our re-
hearsals and scenes involved his being kind and considerate and then others
responded favorably. At the end of 12 more sessions, he was discharged because
he seemed more at peace with himself and was getting along well most of the
time with almost everyone.
Problems and Caution in Employing ET

It is important to tell the client why it is probably helpful to receive ET in
general or in a particular area. It should be explained to the client why ET is
part of the treatment process, even though empathy behavior may not appear
related to the presenting complaint. The therapist must make explicit how and
why ET will be helpful. In my early experience in using ET, when I thought I
was dealing with universal values such as the Golden Rule or concern for the
terminally ill, I did not see the need to give the rationale for ET. On a few rare
occasions a client would accuse me of brainwashing, especially if they knew me
as a behavior therapist. One client said, "1 didn't come here to get empathy for
my parents. They are the cause of all my problems." Sometimes there is resis-
tance even if a client does believe that ET is necessary to resolve a particular
problematic behavior. One common concern of the clients who have difficulty
in cooperating is that if they have too much empathy, someone will take advan-
tage of them. We then discuss that this does not have to be the case. Being
empathetic does not mean being naive or not being careful to evaluate situa-
tions, for example, if empathy is being encouraged by unscrupulous individuals
who are trying to get money or influence from the client.
FUTURE CONSIDERATIONS AND ET
This chapter probably presents the first theoretical model and procedures
for ET of a client. The assumptions and procedures have primarily been derived
from the author's theoretical orientation and clinical practice. The focus on
training a client to have empathy to help resolve problematic behavior and
increase the quality of life has face validity and is a logical extension of the
current theoretical speculation and investigations concerning the dyadic thera-
peutic relationship.
While this preliminary attempt to present a model for ET may present
some clinical insights to the practitioner and provide strategies for treatment,
clinical testing and experimental investigation are necessary to establish the
efficacy of the model. Also, research is necessary to establish the viable vari-
ables responsible if outcome studies indicate positive results.
It is hoped that this chapter will stimulate both clinical and experimental
investigations of some of the strategies and assumptions concerning ET pre-
sented here, as well as developed independently by others. Some suggested
research studies are:
1. Compare therapeutic outcome of groups treated with a focus on ET
with equated groups receiving no ET.
2. Compare ET with other treatment strategies.
3. What populations are more apt to receive therapeutic benefit with ET?
4. What maladaptive behaviors are more apt to respond to ET treatment?
5. In my experience, ET is definitely indicated for maladaptive approach
behaviors that involve another victim. Investigations could compare
therapeutic outcome of treating maladaptive approach behaviors (such
as child molesting, rape, stealing, domestic violence, and assault) with
ET- and non-ET-focused therapies.
6. Will studies bear out the assumption that ET is more necessary for
therapeutic success with maladaptive approach behaviors as compared
with maladaptive avoidance behaviors (such as anxiety-related avoid-
ance behaviors)?
7. In order to receive cooperation (and for more honesty) in filling out the
ESS, I have now developed a rationale to present the ESS as part of a
battery of inventories given to the client at the beginning of therapy.
Will there be significant changes in how the client fills out the ESS at
the termination of therapy? Will the changes be related to the degree of
therapeutic success?
8. Will the ESS, as it is now or with some modifications, be a useful
instrument for research? Can reliability and validity of the instrument
be established? At the present time, the ESS is merely an inventory that
is used as an aid to the interview. Other inventories that I have devel-
oped such as the Reinforcement Survey Schedule (Cautela & Kasten-
baum, 1967; Cautela, 1972) and the Adolescent Reinforcement Survey
Schedule (Cautela, Cautela, & Esonis, 1983) have been the basis of
reliability and validity studies by other investigators (Kleinknecht, Mc-
Cormick, & Thorndike, 1973; Mermis, 1971; Holmes, Heckel, Chest-
nut, Harris, & Cautela, 1987; Cautela & Lynch; 1983).
9. If the ESS can be made reliable and valid, then research investigations
can compare the degree of empathy across various groups and catego-
ries such as gender groups, ethnic groups, socioeconomic groups, occu-
pational groups and criminal groups, as well as categories such as
educational level and intellectual level.
REFERENCES
Bandura, A. (1969). Principles of behavior modification. New York: Holt, Rinehart & Winston.
Barkham, M. (1988). Empathy in counseling and psychotherapy: Present status and future direc-
tions. Counseling and Psychological Quarterly, 1, 407-428.
Barlow, D. H., Hayes, S. C, & Nelson, R. O. (1984). The scientist-practitioner: Research and
accountability in clinical and educational settings. Oxford: Pergamon Press.
Cautela, J. R. (1967). Covert sensitization. Psycbological Record, 20, 459-468.
Cautela, J. R. (1970a). Covert reinforcement. Behavior Therapy, 1, .3.3-50.
Cautela, J. R. (1970b). Covert negative reinforcement. Journal of Behavior Therapy and Experi-
mental Psychiatry, 1,273-278.
Cautela, J. R. (1971). Covert extinction. Behavior Therapy, 2, 192-200.
Cautela, J. R. (1972). Reinforcement survey schedule: Evaluation and current applications. Psycho-
logical Reports, 30, 683-690.
18 • TRAINING THE ClIENT TO BE EMPATHETIC 353
Cautela, J. R. (1976a). The present status of covert modeling. The journal of Behavior Therapy and
i:xperimental Psychiatry, 7, 323-326.
Cautela, J. R. (I976b). Covert response cost. Psychotherapy: Theory, Research and Practice, 13,
397-404.
Cautela, J. R. (1983). The self-control triad. Behavior Modification, 7(3),299-315.
Cautela, J. R., & Kastenbaum, R. A. (1967). Reinforcement survey schedule for use in therapy,
training and research. Psychological Reports, 21, 1115-1130.
Cautela, J. R., & Kearney, A. J. (Eds.). (1986). The covert conditioning handbook. New York:
Springer.
Cautela,.J. R., & Kearney, A. J. (Eds.). (199.3). The covert conditioning casebook. Pacific Grove,
CA: Brooks/Cole.
Cautela, J. R., & Lynch, E. (1983). Reinforcement survey schedule: Scoring, administration and
complete research. Psychological Reports, 53, 447-465.
Cautela, J. R., Cautela, J., & Esonis, S. (1983). The adolescent reinforcement survey schedule. In
Forms for behavior analysis with children (pp. 46-49). Champaign, IL: Research Press.
Chiaramonte, J. A. (1992). And the war goes on. Social Work, 37, 469-470.
Holmes, G. R., Heckel, R. v., Chestnut, E., Harris, N., & Cautela, J. R. (1987). Factor analysis of
the adolescent reinforcement survey schedule (ARSS) with college freshmen. journal of Clinical
Kleinknecht, R. A., McCormick, C. E., & Thorndike, R. M. (1973). Stability of stated reinforcers
as measured by the reinforcement survey schedule. Behavior Therapy, 4, 407-41.3.
Mermis, B. .J. (1971). Self-report of reinforcers and looking lime. Unpublished doctoral disserta-
tion, University of Tennessee, Knoxville, TN.
Orlinsky, D. E., & Howard, K. I. (1986). Process olltcome in psychotherapy. In S. L. Garfield &
A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 311-.,81).
Chichester: John Wiley.
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change.
joumal of Consulting Psychology. 21, 95- 1(U.
Rogers, C. R. (1961). On becoming a person: A therapist's view of psychotherapy. Boston, MA:
Houghton Mifflin.
Williams, C. A. (1989). Empathy and burnout in male and female helping professionals. Research
in Nursing and HC<llth, 12, 169-178.
VI
Developmental Considerations
19
The Making of a Stable Family

Glenn I. Latham
After 30 years working with families in trouble, the lament of parents is still the
same: "We were never taught how to raise kids." In this chapter I address
sewral specific parenting skills that are anchored in the science of human
behavior. Specifically, I identify three basic principles of human behavior that
are particularly relevant to parenting. Next, I describe four things parents must
do when their children behave well. Last, I discuss four things parents must do
when their children misbehave.
At the outset, three things must be clear. First, everything contained in this
chapter is anchored in solid science. Though anecdotes are used from time to
time, they are not used to prove a point; rather, they are used to illustrate a
point. Second, given the vastness of the topic being addressed (i.e., parenting), it
is not possible here to cover the width, breadth, and depth of the topic. Soon
after he had published his monumental theory of relativity, at a press confer-
ence Albert Einstein was asked by a reporter to give a layman's definition of
relativity. Einstein replied, "If a person sits on a hot stove for 2 minutes, it
seems like 2 hours, but if he sits next to a pretty girl for 2 hours, it seems like 2
minutes." The reporter responded, "I would like something a little more tech-
nical than that." Einstein answered, "Ah, now that will take more time."
Though I address a number of foundation issues in this chapter, it is not
possible to go much beyond that, though it should be understood that there are
many sources to which a serious student of parenting could turn to deal with
virtually any parenting problem (Latham, 1994). I refer to the contents of this
Glenn I. Latham • Department of Special Education, Center for Persons with Disabilities, Utah
State University, Logan, Utah 8432].
357
358 VI • DEVElOPMENTAL CONSIDERATIONS
chapter as "foundation issues." I have chosen that term carefully because I fully
believe that no matter how much more detailed or complex or in-depth one
would be in fashioning human behavior in a family setting, it would be built on
the foundation issues discussed in this chapter.
Third, the reader must understand that there is no such thing as a surefire
approach to parenting. There is no strategy, no matter how well founded and
how solidly anchored in science it might be, that will be absolutely effective
with absolutely all children in absolutely any setting. The science of human
behavior, like the science of medicine, is an inexact science. We have all had the
experience of going to a doctor and, upon having a medication prescribed,
heard the doctor say, "Try this." Why did the doctor not say, "This is abso-
lutely certain to fix you up?" The answer is obvious: There is at least some
probability that it would not work. Nevertheless, in deciding on the prescrip-
tion, a competent doctor would have done everything in his or her power to
increase, to the highest level possible, the probability that the medicine would
work. In some instances, those probabilities are much higher than in other
instances.
And so it is with human behavior. Though in all instances we cannot
predict results with absolute certainty, we do know that under certain condi-
tions the probabilities of our interventions producing the desired effects arc
greater than in other instances. Our job, therefore, is to create an environment
in which the probabilities for success are remarkably increased. As with the
practice of medicine, that is much more easily done in some instances than in
others. For example, the probability of successfully eliminating the inconsol-
able crying behavior of a healthy baby is much higher than is the probability of
eliminating the antisocial behaviors of a violent teenager who is under the
reinforcement control of fellow gang members. Still, in either instance, the
probabilities of being successful in shaping behavior in the right direction are
increased dramatically with the skillful application of the principles of human
behavior; which brings us to the first major section of this chapter.
THREE BASIC PRINCIPLES OF HUMAN BEHAVIOR
Though there are many principles of human behavior, only three are dis-
cussed here. It is my experience, after having spent a professional lifetime
working with parents, that these three principles are particularly important
and applicable in the shaping of a stable family.
Behavioral Principle 1: Behavior Is Largely a Product of Its

Immediate Environment
Simply put, shape the environment and you will shape the behavior. The
first lesson to be learned by parents is the importance of creating an environ-
ment in the home that will encourage and reinforce appropriate behavior. Most
home environments arc reactive. That is, children behave in age-typical ways,
19 • THE MAKING OF A STABLE FAMILY 359
including sibling rivalry, name calling, shouting, and even fighting, and parents
react to those behaviors in kind. They shout back and they hit back and they
name call, and do almost exactly what the children do. Recently, a mother was
in my office complaining about the fighting between her 11- and 9-year-old
sons. She said, "Yesterday my ll-year-old knocked his 9-year-old brother to
the floor, and while his brother was on the floor crying, he kicked him!" I
asked the mother what she did. She answered, "Well, I kicked him!" (meaning
the ll-year-old).
Before parents can hope to create a stable family, they must learn to
proact, not react. They must learn to create a proactive environment in the
home, which I define as a positive, reinforcing, facilitating environment that is
managed by stable parents. How to do this is discussed in some detail in later
sections of this chapter.
In the more general sense, however, creating a proactive environment in
the home can be greatly enhanced, as suggested by Cautela (1993), by "raising
the general level of reinforcement" in the home. That can be accomplished, in
large measure, through laughter, touch, talking, and listening. As illustrated in
Figure 19.1, the frequency and duration of these kinds of interactions between
parents and their children decreases dramatically with age, when, in fact, each
of these classes of interactions should remain high in frequency and duration,
regardless of age.
Laughter
Laughter, of course, is laughter with, not laughter at. It is humor that is
done at no one's expense and that is wholesome and in good taste. Its therapeu-
Adolescence
, /'
,/
~:
,:
,,
,
/
Birth Adulthood
Age
Figure 19.1. The decline in parent-child physical and verbal contact, over time.
tic value has been well documented (Cousins, 1979). When my six children
were at home, I never allowed a day to go by without sharing a humorous
anecdote or introducing humor in some tasteful way. It is the leaven in the loaf
of parenting: it keeps things light.
Touch
There is a long history of research and clinical work that documents the
value of appropriate touching. The skin is the largest organ of the body, having
an adult weight of about 16 pounds and an area of about 20 square feet (Rae,
1991). It contains more nerve endings than all other organs of the body com-
bined, and it loves to be appropriately touched. Good advice in this regard is
given by the US Surgeon General: "Hugging is non-fattening, naturally sweet,
and contains no artificial ingredients. It is wholesome and pure and, most
important, fully returnable" (Staff, 1989, p. 6).
Appropriate touch comes in many forms: a hug, a pat on the back, a gentle
stroking of the arm, even an elbow in the ribs of an adolescent boy by his
playful and affectionate father. In the raising of my children, I found no better
means of communicating my love and affection for them-all the way into
adulthood-than through appropriate physical touching. One of my daughters
had a sign hanging on her bedroom wall that read: "Four hugs per day for
survival, eight hugs for maintenance, and twelve hugs for growth." Parents
must be certain that they do not allow the annoying and even distressing
behaviors of their children to keep them from making appropriate physical
contact. Parents often complain to me that their children do not like to be
hugged or complain at being hugged. In some instance, though rare, that might
be so. Nevertheless, there are other ways of making appropriate physical con-
tact than by hugging, including a pat on the back, a gentle stroking of the
fingers across the shoulders, and so on.
Talk
Appropriate verbal interaction between parents and their children is also
an important way of raising the general level of reinforcement in the home.
Such interactions include shooting the breeze, verbal praise, expressions of
affection, and the acknowledgment of compliant, appropriate behavior, to
name a few. Unfortunately, as noted by Sidman (1989), "It is not unusual to
find parents who seldom speak to their children except to scold, correct, or
criticize" (p. 23).
As a caution, when parents shoot the breeze with their children, it must be
a risk-free interaction. This means that during the conversation there is no risk
of the conversation deteriorating into an excuse to criticize children or to
deliver some profound moral lesson that is sure to turn them off. Too often,
parents distort and ruin an otherwise pleasant conversation about the happen-
ings of the day, for example, by using it as an opportunity to get some point
across about what the child should be doing better or should not be doing at
all. Once children learn that there is risk of this sort from talking to their
parents, they will simply quit talking to their parents. It becomes a coercive
experience, and, as noted by Sidman (1989), coercion encourages people to
avoid, escape, or countercoerce. With children, they will simply avoid talking
with their parents if the probability is high that a talk will lead to an unpleasant
message about one's inadequacies. Consider the following examples and non-
examples of how to and how not to just shoot the breeze with children (Tables
19.1 and 19.2).
Listening
Parents need to attentively listen to their children with interest and under-
standing. That means turning off the television, putting down the newspaper or
book, and eliminating other dis tractors that get in the way of being attentive.
As a distraught teenager once told me, "My parents never look me in the eye
when we talk. It's always through a newspaper, with an occasional glance away
Table 19.1. Situation: A Daughter Defending Her Friend
Supportive Nonsupportive
Daughter: I really feel bad for Helen. She's preg- [ really feel bad for Helen. She's preg-
nant and her boyfriend doesn't want nant and her boyfriend doesn't want
to have anything to do with her any- to have anything to do with her any-
111ore. lTIOrc.
Mom: She must really feel terrible. I'm cer- Well, it was bound to happen. Just a
tainly proud of you, Honey, for being matter of time. Play with fire and you
so concerned about her. WILlt can we get burned. ['m not the least bit sur-
do to help her) prised, nor do [ feel sorry for her. She
knew what she was getting into when
she got mixed up with that loser. Just
don't you get involved. Stay clear of
her. It's her problem. l.et her solve it.
Daughter: [ don't know, Mom. It's so complex. Mom! How can you say that) Helen's
But I'm going to keep being her a neat gal. She just made a mistake.
friend. No one is perlect! Not you or me.
Don't be so hard on her.
Mom: Good for you. A true friend is worth Neat girls don't go to bed with dumb
more than gold. Certainly that's so in guys. You bet she made a mistake,
situ,ltions like this. You're a good girl, and she'll pay for it the rest of her
Honey. [ love you. life. As for you, young lady, don't you
dare do a stupid thing like that.
Daughter: [ love you, Mom. It's so great talking I can't believe you, Mother! (as sbe
to you~even about difficult things leaves in a huff).
like this. You really understand.
362 VI • DEVELOPMENTAL CONSIDERATIONS
Table 19.2. Situation: A Son Defending Himself
Supportive Nonsupportive
Dad: That was quite a ball game last night. That was quite a ball game last night.
Your school really pulled it out of the Your school really pulled it out of the
fire in those last few minutes. fire in those last few minutes.
Son: Yeah. Squeaky, our point guard, was re- Yeah. Squeaky, our point guard was re-
ally hot. ally hot.
Dad: Indeed he was. And besides his ball-han- Indeed he was. And besides his ball-
dling skills, I understand he's a fine handling skills, I understand he's an excel-
young man. lent student who hits the books like crazy
every night. What kind of CPA does he
have to maintain to stay on the team?
Son: He really is. He's in a couple of my He IS a good student. I have some
classes and he's super friendly. classes with him and he does well. He
has to keep at least a C + average to be
on the team.
Dad: The next time you see him, tell him I'm amazed he does so well with all of
what a great job I thought he did in that his athletic responsibilities. By the way,
game. what's your CPA this year?
Son: I'll do that. He'll be happy to hear it. I don't know for sure. Somewhere be-
tween a C and a C+.
Dad: Let me know when the next ball game Now, Son, you can surely do better than
is. Maybe we can go together. that. Surely you have more time to study
than Squeaky does. I mean with the
amount of time you have, you should
have a solid B average-or better!
Son: I'll do it, Dad. Sounds fun. I'm doing all right in school. I'm pass-
ing. What's the big deal?
Dad: I'll look forward to that. Just passing! I know you can do better
than that. If a kid on the basketball
team can do it, you can. You're just as
smart as Squeaky.
Son: Me, too. I gotta run, Dad. See ya. Hey, what's this all about? What has
Squeaky got to do with me. He lives his
life and I live mine, and that's just how I
want it!
from the TV; or when I know very well they are preoccupied by something else,
and whatever I have to say is really of no importance."
Remember, behavior is largely a product of its immediate environment;
therefore, the responsibility of parents is to create a stable, proactive environ-
ment in the home; that is, a positive, supportive, facilitating environment.
Appropriately shape the environment and the environment will shape the be-
havior.
Behavioral Principle 2: Behavior Is Shaped by Consequences

It is what follows behavior that determines whether that behavior will be
repeated (Bijou, 1993, pp. 63-78). In a home and family setting, this takes on a
special meaning in light of the quality of interactions between parents and their
children. Of all the consequences that reinforce the behavior of children, I have
found nothing to be more powerful than parental attention. Over the years, as I
have worked with families, I have been interested to note that, on average, more
than 95% of all appropriate child behavior never receives any parental atten-
tion whatsoever. It is simply ignored, very much in harmony with that genera-
tions-old caution to "leave well enough alone." On the other hand, parents are
five to six times more likely to pay attention to their children when they are
behaving inappropriately. Now, the question arises: If behavior is shaped by
consequences, if parental attention to behavior is a powerful consequence, and
if the behaviors that receive parental attention are annoying, inappropriate
behaviors, which behaviors are being reinforced? The answer is obvious: an-
noying, inappropriate behaviors. For the most part, ironically, the very behav-
iors that annoy and concern parents are the very behaviors they are encourag-
ing; hence, those are the behaviors that are most likely to reoccur predictably.
Children can get so starved for parental attention that there are almost no
lengths to which they will not go to get it. The young parents of two small
children recently told me that they were concerned that they were giving inordi-
nate amounts of attention to their children when they behaved in an annoying
or inappropriate way, and that virtually all of that attention was unpleasant and
aversive. "We were raised this way, and promised ourselves we would not treat
our children the way we had been treated. But here we are doing the very same
things to our children that we hated having done to us when we were children.
We know that our children annoy us to get our attention, which is what we did
when we were children. We soon learned that the only way to get our parents'
attention was to do something bad, and even though the attention we got was
usually unpleasant, even painful, it was better than no attention at all." As will
be discussed later, a critical foundation skill of parenting is to be able to
distinguish consequential from inconsequential behavior, and to respond ap-
propriately to each.
Behavioral Principle 3: Behavior Is Ultimately Shaped Better by

Positive Consequences Than by Negative Consequences
In the International Encyclopedia of Education (Bijou, 1988), Dr. Sidney
Bijou wrote, "Research has shown that the most effective way to reduce prob-
lem behavior in children is to strengthen desirable behavior through positive
reinforcement rather than trying to weaken undesirable behavior using aversive
or negative processes" (p. 448). Despite this well-documented behavioral fact,
the overwhelming inclination of parents is to try to control their children's
behavior using aversive, negative, and/or coercive processes. In other words,
parents try to make their children behave using threats, physical force, verbal
outbursts of anger, and so on. Recalling Sidman's (1989) work, coercive efforts
to control behavior encourage people to want to escape or avoid the coercer,
and when able to do so, to countercoerce (in other words, get even). This was
dramatically illustrated for me recently while waiting to catch a plane. Seated
across from me in the passenger lounge was a young family composed of a
mother, father, and a little boy, who I estimated to be about 5 years old. The
boy was sitting between his parents and was engaging in a lot of the age-typical
behaviors of a little boy about to get into a huge airplane and fly off into the
sky. He was giddy and a bit rambunctious and obviously very excited to get on
board. The father became more and more annoyed at the boy's behavior.
Abruptly, he looked angrily at the boy, and raising his hand in a menacing
gesture, said harshly, "Sit down and be quiet or I'm going to smack you one!"
The little boy immediately sat still. Very still, in fact. He looked up sadly into
his father's face then quietly slipped off his seat and took the empty seat on the
other side of his mother. As he settled in, he snuggled up closely to his mother,
putting both arms around her arm and pulling himself close to her for safety
and security. That little boy, in the face of coercion, quietly avoided and escaped
his father. Imagine what will happen between this boy and his father 10 or 12
years from now when the boy is not only able to escape and avoid but is able to
countercoerce! We see countercoercion being exercised by adolescent children
all of the time in the form of skipping school, staying out late at night, eagerly
violating home rules, stealing money from parents and other family members,
and so on.
Negative, aversive, coercive methods of managing behavior are insidious
for at least two reasons. First they create the appearance of being effective. That
is, like the little boy in the air terminal who fell silent beneath the rage of his
father, children will often immediately comply, giving the parent reason to
believe that what was done worked: the kid shaped up immediately. What the
parent does not realize is that the behavior that was attacked coercively contin-
ues to repeat itself time after time after time; that coercion is having no posi-
tive, lasting effect on improving the behavior. The child is not learning a better
way of behaving; hence, he continues to behave in the same maladaptive way,
only to be responded to by the parent in an equally maladaptive way.
The second reason negative, aversive, coercive measures are insidious is
that they have acquired pseudovalidity, having been woven into the fabric of
childrearing for generations-even millennia. It goes like this: "That's how my
grandfather raised my dad, and it's how my dad raised me. We turned out okay,
so that's the way I'm going to raise my kids." It is that very same vacuous
mentality that has produced the tyrants of our age: Joseph Stalin, Adolph
Hitler, Saddam Hussein, and the list goes on. In Roderick's (1994) recent
newspaper article chronicling the rise of Mao Tse-tung, the author noted that,
"A cruel father and a difficult earlier teacher bred in him the spirit of rebellion
that led naturally to revolution" (p. 17). A perfect description of the effects of
coercion leading to countercoercion.
The following section describes specific things parents should do when

their children behave well, since, as noted by Bijou (1988), "Research has
shown that the most effective way to strengthen desirable behavior in children
is through the use of positive reinforcement" (p. 448).
WHAT TO DO WHEN CHilDREN BEHAVE WEll
[n my three decades working with parents, a parent has yet to come to me

and ask, "What do [ do when my child behaves well?" Yet that is the most
important question of all. If the day ever comes when parents look first at
opportunities to positively, proactively interact with their children when they
behave well rather than waiting to react negatively and coercively when they
misbehave, a whole new era will have dawned on the role of parents as child-
rearers and the business of parenting and the business of growing up will
become much easier and much more pleasant for parents and children.
In this section I discuss four things parents should do when their children
behave well. To be effective, each of these must be an integral part of a whole.
Parents must become skillful with each of these strategies and be able to use
them in a timely, consistent manner. Anyone of these, used alone, is simply not
adequate.
Strategy 1: Verbally Acknowledge Appropriate Behavior

in a Positive Way
I was recently invited to give a talk to a large group of high school students
about the importance of positive human interactions. When I concluded, the
teacher did something that left a lasting impression on me. She asked the
students to indicate, by a show of hands, how many of them were regularly
criticized by their parents for the things they did wrong. Every hand shot into
the air! The teacher then asked, by a show of hands, how many were regularly
praised by their parents for the things they did right. Not one single hand went
up!
For starters, I suggest that parents keep a written record of the quality of
the interactions between them and their children, using the simple tally system
shown in Figure 19.2. I ask parents to describe the interaction and then indicate
whether it was a positive interaction or a negative interaction, with the goal
being that they should make a conscious effort to have no more than one
negative interaction for every eight positive interactions. Though I understand
full well that such a ratio is arbitrary, it at least gives parents something to work
toward that is definitely in the right direction. As I noted earlier, my data
indicate that parents are five to six times more likely to attend to their children
when they behave inappropriately than when they behave appropriately, and
this strategy is simply a means of reversing that and heading the parents in the
right direction. Hopefully, of course, negative interactions will cease altogether.
366 VI • DEVHOPMENTAL CONSIDERATIONS
Description of the Interaction +
Figure 19.2. Assessing the quality of parent-child interacting.
As parents and grandparents, my wife and I never have negative interactions

with our children or grandchildren. To do so would be absurd! It is so ineffi-
cient and counterproductive.
Evidence of the value of a positive rather than a negative approach to
problem solving was recently illustrated by a student of mine (Reed, 1994),
who was concerned about the "incessant whining" of his 6-year-old daughter.
He took data for 1 week on the quality of his interactions with his daughter,
including the frequency of her whining behavior. He took the data between
4:00 and 8:00 PM each day, since these were the times when he was most likely
to be home with her. As described below, on average, she whined 13 times each
day, during which time he averaged ten negative interactions and only three
positive interactions. The ratio of negative to positive interactions was a little
greater than three to one. Following is a description of Reed's positive approach
to problem solving and a report on the results. Figure 19.3 graphically portrays
the effect of treatment.
1. Prohlem Behavior: My 6-year-old daughter whined too often about too
many things, and I was too negative/coercive when she did.
2. Baseline Data: I took data for one week, between 4 PM and 8 PM each
day. Here are the average number of times the critical behaviors oc-
curred:
Average number of times my daughter whined: 13
Average number of times I was negative/coercive: 10
Average number of times I was positive: 3
3. Problem-Solving Procedure
• Target Behavior: To eliminate my daughter's whining and to elimi-
nate by being negative/coercive.
• Intervention: Put whining behavior on extinction and selectively rein-
force nonwhining behavior.
20
18
16
14
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Positive R + ...,., Whining .~~ Coerc.ion
Figure 19.3. The effects of treatment on the elimination of whining behavior.

4. Results: After 7 weeks, the whining behavior was completely gone, and
by the 8th week, 1 was averaging 20 positive interactions per day and
no negative/coercive interactions. Also, my daughter's appropriate be-
havior generalized to several other desirable behaviors, without any
formal intervention, including:
• Getting out of bed in the morning without being told.
• Making her bed daily.
• Getting ready for the day without the usual help from Mom and Dad
by
a. dressing herself,
b. combing her hair, and
c. putting her stuffed animals on her bed.
• Setting the table for breakfast.
• Following her parent's model by hugging and reinforcing her broth-
ers, sisters, Mom, and Dad.
• Being generally helpful with family/home activities.
It is interesting that in addition to improvement in the target behavior, the child

began engaging in so many other appropriate behaviors without any formal
intervention. The fruits of positive consequences!
Strategy 2: Acknowledge Appropriate Behavior Intermittently

The power of the intermittent schedule of reinforcement in shaping behav-
ior is well documented and does not need further elaboration here. 1 have found,
however, that to operationalize the intermittent schedule of reinforcement as a
parenting strategy, parents need to be provided with a structure within which to
apply the strategy. For this reason, I suggest that they have numerous positive
interactions with their children per hour that are delivered intermittently in the
form of a touch, a wink, a smile, or a pleasant verbal acknowledgement of what
was done that brought parental attention (which is addressed more completely
below in strategies 3 and 4).1 have parents who aim at having as many as 15 to 20
positive interactions per hour with their children, resulting in very high rates of
appropriate behavior and few if any inappropriate behaviors.
To help parents remember to have a sufficient number of intermittently
delivered positive interactions, I further suggest that they use a few well-placed
reminders. Some of my parents put a nickel or a quarter in their shoes and
occasionally (i.e., intermittently) as they become conscious of the coin being
there, they are reminded, "Have I had a positive interaction with my children?"
Some parents will tilt a picture on the wall a little off level as a reminder. Others
will place a knickknack or a flower or some other decorative item out of place.
When they see the item out of place, it reminds them to have a positive interac-
tion with their children. Without some sort of a crutch-i.e., a prosthetic
(Lindsley, 1963) to lean on-the events of the day can become so hectic that
parents simply forget to have an appropriate number of positive interactions
delivered in a random, intermittent manner. As discussed in strategy number 3

below, when done appropriately, 15 to 20 intermittently delivered positive
reinforcers per hour is not at all unreasonable.
Strategy 3: Acknowledge Appropriate Behavior Casually and Briefly

As parents happen upon their children behaving appropriately, that is the
time to deliver a positive reinforcer. As unaffected and unceremoniously as
possible, a parent should acknowledge the behavior using only a few words and
taking only a few seconds, and then move on to other things. For example,
suppose that two children are playing nicely together, and "playing nicely
together" is a behavior the parent wants strengthened. The parent would casu-
ally walk up to the children, say, "You children are having lots of fun playing
together so nicely," give them a smile and perhaps a gentle touch, then move
on. This example took fewer than a dozen words and less than 4 seconds to say.
Typically, if verbal praise is used, the interaction requires only eight to ten
words, and takes only a few seconds. This being the case, if parents have 20
interactions per hour and each interactions takes only 3 seconds, that means
that parents are spending only 1 minute per hour in positive interactions with
their children. Surely that is not too much to ask of any parent!
It is critical that these interactions be casual and occur in the normal
course of a parent's comings and goings through the house or while with the
child elsewhere: grocery shopping, at the park, at friends and relatives, at
church, or wherever. Frequent positive interactions, delivered casually and
briefly and intermittently cumulatively can have a powerful reinforcing effect
on behavior.
Strategy 4: Describe the Behavior Being Reinforced

As illustrated above, when verbal praise is used to reinforce a behavior, it
is important that the parent use language that describes the behavior being
reinforced. Rather than simply saying "good boy" or "good girl," the parents
should describe the behavior that is being attended to: "Thank you for coming
to dinner when called," "Thank you for being so kind to your sister," "I like
the way you're working so hard on your homework."
Interestingly, it is not unusual for a child to react inappropriately to verbal
praise. For example, suppose that a brother says something nice to his sister
and the parent decides to acknowledge that by saying, "Billy, I appreciate you
being so kind to your sister." It is not at all unlikely that Billy might look up at
the parent and say, "I hate my sister! She's the dumbest thing I've ever known."
Should this, or a similarly inappropriate response follow the delivery of verbal
praise, the parent should simply walk on without the slightest acknowledge-
ment of the boy's comments. All of the attention should be left only on the
positive character of the boy's interaction with his sister, as discussed in more
detail below.
Verbal praise that is delivered descriptively becomes instructive, and in

time children will learn what it is that gets their parents' attention. They learn
that if inappropriate behavior is not attended to, why waster time on it!
If the environment has traditionally been reactive and parents have tended
to use coercive, negative, and aversive methods for managing behavior, the shift
to a positive, proactive approach might prompt children to increase, tempo-
rarily, the frequency and duration of inappropriate behavior, i.e., an extinction
burst (Sulzer-Azaroff & Mayer, 1991, p. 409). If that happens, parents should
not be alarmed; rather, they should stick with the program and within a very
short period of time, generally within a few days at most, the inappropriate
behavior begins to fade rapidly and appropriate behavior will rush in to fill the
void and even increase in duration, frequency, and type, as illustrated by Reed
(1994).
What parents need to realize is that behavior is largely a product of its
immediate environment. Once children learn that: well-placed positive conse-
quences issue from appropriate behavior, and the environment is rich with
positive reinforcers for appropriate behavior, those are the behaviors that will
most likely reoccur.
WHAT TO DO WHEN CHILDREN MISBEHAVE
Occasionally, even in the most proactive, positive environment, children

will behave badly. In the next section, I discuss four things parents should do
when their children behave inappropriately. Again, each of these strategies is a
part of a working whole. In fact, when the four strategies described above
relative to appropriate behavior are used in conjunction with the four strategies
about to be described relative to inappropriate behavior, the net effect is a
system of childrearing and behavior management that is almost certain to
succeed. An analogy is found in the fable of the bundle of sticks: individually,
each stick can be broken easily, but bound together into a bundle, they arc
almost impossible to break.
Strategy 1: Ignore Inconsequential Behavior

When dealing with inconsequential, age-typical, garden-variety weed be-
havior (that is, behavior that does not threaten persons or property), the single
best response is to simply ignore it; just pay it no attention. As I have studied
behaviors in families, I have been interested to note that about 98 % of the
behaviors children engage in that annoy their parents are inconsequential be-
haviors that should simply be walked away from. Most sibling rivalry, most
name calling, most out-of-sorts behaviors, though annoying, are of no conse-
quence whatsoever and simply deserve no parental attention. When left alone,
they tend to fade away usually without a trace. It is when parents make a big
fuss about these things, scold children, get after them, threaten them, and so on
that these behaviors tend to persist.
I had an experience recently with my 2-year-old grandson that beautifully

illustrates the power of the extinction strategy in dealing with inconsequential
behaviors. He and I were playing with his Lego toys when all of a sudden, for
no apparent reason, he threw a Lego toy at me. Without appearing to be the
least bit upset or affected by this, I simply stood up and walked away. To have
said something like, "Jacob, you shouldn't throw Lego toys at Grandpa. You
could hurt Grandpa," would have been totally inappropriate and would have
served no function other than to reinforce the inappropriate behavior. I stayed
away for about 30 seconds then returned to the table where Jacob was playing
and picked up where I had left off, without saying a word. I certainly did not
say something dumb like, "Now Jacob, if you'll play nicely, Grandpa will play
with you." Again, saying something like this simply reinforces the very behav-
ior I wanted to get rid of. Rather, I just started playing Lego toys as though
there had been no interruption. Only a few seconds passed and Jacob threw
another Lego toy at me. Again, I just turned and walked away, repeating exactly
what I had done before. After 30 to 40 seconds, I returned and began playing
with Jacob again, as though nothing had interrupted our play. After a few
seconds, Jacob picked up a Lego toy and pretended like he was going to throw
it at me. But he stopped, looked at me and smiled, put the Lego toy down and
began playing with it appropriately. It was at this point that I acknowledged his
appropriate behavior by saying, "Jacob, thank you for playing so nicely with
your Lego toys." That was the end of any inappropriate behavior on my
grandson's part. Without one single critical or coercive reaction, the inap-
propriate behavior was gone, and was replaced immediately with high rates of
appropriate behavior.
Strategy 2: Selectively Reinforce Other Appropriate Behavior

When adult attention is directed toward children who are behaving appro-
priately, though other children are behaving inappropriately, the probability is
great that the inappropriate behavior will soon extinguish, and before long, all
the children will be behaving as they should. A few years ago I was invited by a
school district to do some in-service training of teachers of emotionally dis-
turbed children. For reasons unknown to me, the school system was experienc-
ing an inordinate amount of behavior problems in the schools, particularly in
their self-contained classes for seriously emotionally disturbed and behav-
iorally disordered children.
When my host and I arrived at the first classroom to be visited, we were
met by sheer pandemonium. In fact, we had to quickly step aside as a boy ran
out of the classroom with the teacher in hot pursuit. The classroom (as shown
in Figure 19.4) had two doors in it, and out of the other door ran the aide,
chasing another boy. Across the room a third boy was standing on some book-
cases, and just as we entered the classroom he leaped into the air trying to grab
the light fixture hanging from the ceiling. Fortunately, he missed the light
fixture though he went crashing to the floor, knocking over a chair in the
1J:l
CI.l
..III
~
D
0
D
00
0
D0
<0
0
D
0
Figure 19.4. Classroom configuration.
process. Within a matter of only a few seconds, the classroom teacher returned
dragging a kid behind her who was kicking and screaming. She was followed
shortly thereafter by the aide dragging another child into the classroom. As the
classroom teacher went past us, my host, a school district official, whispered to
her, "We need to talk," and they left the classroom. That left five wild kids, the
aide (who by now was crying), and me. I walked over to the aide and asked her
if I could be of help. Choking back the tears, she said, "Yes, please."
I quickly surveyed the situation and decided, of course, that I was simply
going to put all of the inappropriate behavior on extinction and look for an
appropriate behavior that was worth acknowledging. Unfortunately, none of
the children were behaving in an appropriate way, so I had to look for some-
thing that approximated appropriate behavior. Happily, I found it in the form
of a worksheet laying on the desk of one of the students. Without saying a word
or even making eye-to-eye contact with any of the students, I walked over to the
desk where the worksheet was lying and looked at it intently. In fact, I began
interacting with it as though it was alive: I ran my finger across the page,
moving deliberately from problem to problem. I shook my head in approval of
problems that had been answered correctly. I even vocally interacted with the
paper by saying, "Yes, this problem is done correctly. That's good."
Before I began this intervention, I set my stopwatch on zero. I wanted to
see how long it would take to get the students in their seats and on task using
only positive methods. It has been my experience over the years that, when
addressed appropriately, such results can be accomplished under positive con-
ditions within 1 minute and 45 seconds.
Within about 22 seconds, the boy who sat at the desk where I was standing
sat down. I immediately patted him on the back, looking him squarely in the
eye, and with a smile on my face, quietly said, "Thank you for taking your
seat." We then began discussing his work. A few seconds later another student
sat down at his desk across the isle. I told the boy with whom I first began to
work to complete a few other problems and I would be right back. I then
moved to the boy who had just sat down and said, "Thank you for taking your
seat. May I see your work?" He immediately took a social studies assignment
out of his desk and began to explain it to me. Again, I directed my complete
attention to this boy and the appropriate manner in which he was responding.
Almost instantly, the other three children took their seats and, in turn, I visited
them all. From the time I set my stopwatch until every child was in his or her
seat engaged in appropriate academic behavior, only about 1 minute and 39
seconds had elapsed, and I never had to raise my voice above a whisper.
Though this illustration relates to a classroom experience, the same suc-
cess, the same results, can be realized in homes. By selectively reinforcing the
appropriate behavior of other children, while putting on extinction all inconse-
quential inappropriate behaviors, the inappropriate behaviors will ultimately
fade away, the victim of no parental attention.
Strategy 3: Stop, Redirect, Then Reinforce Behavior

Occasionally, children will behave in ways that cannot be ignored. These
are what I call consequential behaviors and include verbal and physical assaults
that could hurt others, be damaging to property, or might be damaging to the
child him- or herself. Obviously, it would be irresponsible to just walk away
from such situations.
The typical approach parents use to deal with such behavior is to call out
in loud and angry tones, "Stop that, and stop it right now!" The parent might
even intervene physically by jerking or spanking or hitting the child. Once the
behavior has been stopped, the parent then typically delivers a tongue-lashing,
punctuated with ill-chosen, inappropriate, unenforceable threats, then storms
off in a huff. Though the behavior may have been stopped for the moment, the
child has not learned anything about behaving appropriately, and the quality of
the environment in the home has deteriorated to the point of being nothing but
negative, reactive, and coercive. Rather than simply stopping inappropriate,
consequential behavior, parents need to redirect the child's behavior into some-
thing appropriate that can subsequently be reinforced. I call it the stop, redi-
rect, reinforce strategy.
For example, suppose that an older brother is hitting his younger sibling
with the intent of being hurtful. Calmly, resolutely, and in complete control of
his or her own emotions, the parent should move close to the assailant and, if
there is no likelihood that the assailant will strike back at the parent, the parent
should put his or her hand on the child's shoulder, look directly into the child's
eyes for a few seconds, then say in a calm, controlled voice, "No, Son, that
behavior is not acceptable in this house." Care should be taken that nothing is
said about the fighting behavior nor that a big to-do is made about how
someone might get hurt, and so on. As with the delivery of verbal praise, only a
few words should be used and only a few seconds should be taken to deliver
them. If the child argues back by saying something like, "Well, it was her fault.
You're always picking on me. She gets away with everything. I hate her guts,"
the parent must respond proactively, with empathy and understanding, by
saying something like, "I can tell you're very upset. I can imagine that you
might feel this way. Nevertheless, that behavior is not acceptable in this house."
When parents are confronted with angry, defensive outbursts, the absolutely
best approach is to respond with empathy and understanding, while restating
their expectations. In such an environment, the likelihood of the child arguing
more than twice in defense of his inappropriate behavior is very remote. (My
data show that 97 out of 100 times, when such a strategy is employed, the child
will not retaliate more than three times.)
Once the child's anger has subsided and the inappropriate behavior has
stopped, it is time to redirect the behavior. It is at this point that the parent tells
the child what he is expected to do. This could include any number of things:
go outside and play, keep your hands and feet to yourself, do a chore that is
waiting to be done, and so on. It might go like this:
FATHER: "You may remain here, Son, but I expect you to keep your hands and
feet to yourself."
SON: "But it wasn't my fault! You want me to leave her alone even though she
started it. That isn't fair! I'd like to beat her brains out!"
FATHER: "I'm sorry you're so upset, Son, but if you want to stay in this room,
you'll need to keep your hands and feet to yourself."
SON: "Well, what are you going to do to her? She started it! I ought to be able
to finish it."
FATHER: "Son, if you want to remain here, what do I expect you to do?"
SON: "You want me to keep my hands and my feet to myself. But what I want
to do is punch her eyes out!"
FATHER: "But what are you going to do instead, Son?"
SON: "I'm going to leave her alone, but she better not start something like
that again or I'm going to punch her out!"
FATHER: "I'm glad you know what I expect and I appreciate your assurance
that you are going to keep your hands and your feet to yourself. Thank you
very much."
The father then walks away without expressing any anger or frustration in
either what he says or how he postures himself.
In this entire encounter, the father never allowed himself to get dragged
into the bottomless pit of trying to figure out what is fair and who is to blame.
With empathy and understanding, he acknowledged the boy's anger and frus-
tration, each time reiterating his expectation of the direction the boy's behavior
is to take.
19 • THE MAKING OF A STABLE FAMilY 375
Thus far, the behavior has been stopped and redirected. But the complete
power of this strategy is not realized until the redirected behavior has been
reinforced. To do this, the father should wait a minute or so, and then if the
child has indeed behaved appropriately in the intervening minute or so, the
father should acknowledge that casually, briefly, and descriptively: "Thank
you, Son, for maintaining such good control of your behavior. That's super."
Then the father would pat the child on the back or in some other appropriate
way make positive physical contact.
Strategy 4: Avoid Parent Traps

As 1 have worked with families, I have been impressed at the misguided
efforts parents frequently take in their desperate attempts at managing their
children's behavior. A careful analysis of these desperate efforts has revealed
what I have chosen to call "parenting traps." Following is a brief discussion of
the eight most common traps:
Trap 1: Criticism
Verbally berating children because they do not perform well functions as
no incentive whatsoever to perform well; rather, it simply heightens the child's
sense of inadequacy and dampens any desire to improve behavior. Under the
guise of "constructive criticism," parents fool no one! Statements like the
following have virtually no value at all: "I simply can't understand why you
didn't do better on that examination. We all know that you have the ability if
you would just apply yourself. Is it too much to ask you to simply do as well as
you know you can do?" The parent is simply lashing out in frustration, and the
child knows very well that what was said was simply a thinly veiled tongue-
lashing by a concerned but angry, desperate, out-of-control parent.
Rather than using criticism, parents should genuinely express their con-
cern for the child's well-being, restate their expectations of the child, and then
manage contingencies, which in turn manage the behavior. For example:
PARENT: "Honey, we just want you to know that we are concerned about your
success at school and expect you to do your best."
CHILD: "I am doing my best. What more do you want out of me?"
PARENT: "We expect you to apply yourself and take your studies seriously.
What do we mean when we say 'apply yourself?'"
CHILD: (Disgusted) "I know what you mean! You want me to get my dumb
homework done and handed in. I hate that class. The teacher is a number
one jerk. It's so boring!"
PARENT: "Right on! Getting your homework done and handed in on time will
be a great first step. What else do we expect?"
(Note: No mention was made of "dumb homework," the teacher as a "jerk,"
or the "boring" class. The attention was focused entirely on getting the
homework done and handed in.)
CHILD: "I don't know."

PARENT: "When exam time rolls around, what do we expect you to do to
prepare for the exam?"
(Note: Parents should never tell a child something he or she already knows;
rather, they should create a setting in which the child is invited, free of risk,
to do the telling.)
CHILD: "Study. I know, study. What a waste of time studying for that dumb
class !"
PARENT: "You got it right, there! Study is the key. And when you do these
things, Honey, that is, do your homework, hand it in, and study for your
exams, really valuable privileges will be yours. What are some of these
privileges? "
(Note: At this point, consequences for compliance or noncompliance are
then discussed, as per the Premack principle (jensen, Sloane, and Young,
1988, p. 67). That is, once the less desirable task is completed (study/
homework), desirable privileges will be forthcoming. It's Grandma's Law:
eat your vegetables and you can have pie and ice cream.)
This puts the responsibility to perform where it should be: on the child. The
responsibility of the parent is to create an environment that will give the child
reason to perform as well as he or she is able to.
Trap 2: Sarcasm
As with criticism, sarcasm has absolutely no healthy quality about it what-
soever. It is a desperate attempt to manage behavior in the absence of skills or
competence. Calling a child a "sissy" or using words like "cute" and "pretty
boy" often serve no purpose other than to degrade a child and put distance
between that child and his or her parent(s). Working with a IS-year-old boy of
a couple who had come to me because they were having difficulty with his
behavior, the boy said to me, "My parents are always reminding me that I'm
not dumb; I'm smart enough to get into trouble all the time."
Parents typically use sarcasm, hoping it will function as something of a
shock treatment that will help make a point they have not been able to make in
the past. Parents must understand, unequivocally, that such statements do not
deliver any kind of useful message nor provide any incentive whatsoever to
behave better. They are nothing more or less than coercive statements that
encourage their children to escape and avoid the coercer.
Trap 3: Threats
Threats tend to be useless and counterproductive for at least two reasons.
First, they are almost never carried out, and second, they are typically so
outlandish that they could not be carried out even if the parents wanted to. For
example, consider this: In a rage, the parent shouts, "Okay, buster. You did it
this time. You are grounded for 6 months. Do you understand?! SIX
MONTHS! No car, no TV, no allowance, no nothing," then off the parent
stomps, flushed with anger, breathing heavily-and half an hour later saying to
himself or herself, "You idiot. How are you going to get out of this mess? Will
you never learn?!"
An effective antidote to threat making is for the parent to stop, take a
couple of deep breaths, say, "I fear that I might handle this situation badly if I
proceed feeling as I do. Excuse me for a few minutes while I regain my compo-
sure. I'll be back soon." The parent then retires to a quiet, secure place, calms
down, practices a proactive response, returns, and says, "Now, regarding this
matter, it is obvious that your behavior has earned some unpleasant conse-
quences. We need to discuss those now," then proceed proactively!
The results of such a calm, deliberate, positive, proactive response is gener-
ally startlingly effective, and the exercise of self-control modeled by the parent
will, with rare, rare exception, have a profound, instructive effect on the child's
ability to proactively handle anger and stress in his or her own life. Rather than
using threats, parents should focus on applying earned consequences that (1)
are given free of anger, (2) clearly signify what will follow, and (3) are carried
out as stated. Again, for emphasis, they must be reasonable and fit the offensive.
Trap 4: Logic
Using logic is typically an ill-fated attempt to make adult wisdom attractive
to a child. It seldom works! I have yet to have a parent come to me and say
something like this: "Upon explaining things logically to my child, my child said
to me, 'Mother, what a powerful point you have just made! I can now clearly see
the error in my thinking. hom this day forward, I will make certain that my
hehavior is guided by your wise and mature counseL'" More likely, children will
counter adult logic with statements like, "Oh, you just don't know what you're
talking about." To them, it is not wisdom of the ages, it is wisdom of the aged,
and they just do not identify with it. So parents are well advised to save their
breath when tempted to use logic as a behavior management tool.
It is certainly appropriate to usc logic to explain a situation or to help a
child understand why something happened or will happen in the future. If used
this way, I suggest it be done when the child is calm and able to be reasoned
with.
Trap 5: Arguing
Since we already know that arguing is a totally and absolutely ineffective
way of managing children's behavior, I shall not spend any time readdressing
that point. There is, however, a form of arguing that is so subtle that parents do
not even realize they are arguing; rather, they see themselves as being compas-
sionate and concerned. Therefore, I call it "compassionate arguing," but it is
arguing nonetheless. It goes like this:
CHILD: "I just don't have any friends. I must be the ugliest kid in school."
PARENT: "Now, now, you're not ugly at all. Your a fine-looking individual
and you have every reason to be proud of who you are."
CHILD: "No I am not attractive and I don't have any reason to be proud of
myself! If I was as good as you say I am, I'd have more friends than I know
what to do with! You know as well as I do that I don't have any friends!"
PARENT: "What do you mean you don't have any friends? You have friends
over at the house all the time. You obviously have a whole lot more going for
you than you think you do."
CHILD: "Hey, who you think my friends are and who I want to be my friends
are two different things. If you knew how things really were in my life, you'd
know I'm as unattractive as I know I'm unattractive!"
In such an exchange, we observe an interesting variation to arguing. The parent
is arguing in behalf of the child-which the child rejects-and the child is
arguing in behalf of his or her own perceived inadequacies-which the parent
rejects. But no matter how the encounter is analyzed, the end result is that
everything the parent is saying and everything the child is saying simply rein-
forces the child's perception of his or her sense of inadequacy. The child, in fact,
is arguing in defense of his or her perceived inadequacy!
However it is structured, arguing is counterproductive.
Trap 6: Questioning
Parents are forever questioning children about their inappropriate behav-
ior: "Why did you hit your sister?" "What in the world are you doing?" "How
many times am I going to have to tell you to stop that?" and so on. Unless
parents need information to help solve a problem, they should never-I repeat,
NEVER-ask a child a question about his or her inappropriate behavior. There
are three reasons for this. First, questioning a child about his or her inappropri-
ate behavior often encourages the child to lie. Such questioning tends to be
threatening and, at the time, lying can seem to be a very easy and convenient
way to get out of a hot spot. Second, when parents ask children questions about
their inappropriate behavior, they do not want an answer so much as they want
compliance-or an assurance of compliance in the future-and an answer,
whether it's true or not, satisfies neither. For example, consider the following
scenano:
PARENT: "Why did you hit your sister?"
CHILD: "I hit my sister because she is ugly, and I was only trying to fix her
face."
The child answered the question. Did the answer provide the parent with any
information that would help solve a problem? How likely is it, for example,
that the parent would answer by saying, "Oh, I see. Yes, you are correct. Your
sister is ugly and we certainly should do something about that. I'm glad you
have called that to my attention. We'll get right busy on it." Such a response,
obviously, is as absurd as the child's answer.
Did the answer provide any assurance that the child would no longer hit
his sister? How likely is it that the father would respond by saying something
like, "Very well, Son. It was perfectly okay for you to hit your sister that time if
you can assure me that you have gotten that out of your system and you will
never hit your sister again." Another absurd answer to a dumb question.
Parents virtually never ask children questions about their inappropriate
behavior for any constructive or problem-solving purpose. They ask questions
because at the moment it is a handy way of blowing off steam. Unfortunately, in
the final analysis, the relationship between the parent and the child is made
worse rather than better.
The third reason one should never ask a child a question about his or her
inappropriate behavior is because it simply directs a lot of parental attention to
inappropriate behavior; hence, increasing the probability that inappropriate
behavior will reoccur. Again, parents should never ask a child a question about
his or her inappropriate behavior unless they really need information to solve
problems. When two of my children were young, the older of the two fed his
younger sister a bottle of baby aspirin. The question, "How much aspirin did
she eat?" was reasonable because it made it possible for us as parents to
determine whether or not our daughter needed to have her stomach pumped,
which it turned out was necessary. To have asked our son, "Why did you feed
your sister those aspirin?" would have done nothing but delay treatment. (By
the way, we had both their stomachs pumped. Good use of natural conse-
quences!)
Trap 7: Using Force

Coercive attempts at managing behavior evidence themselves in the use of
physical or verbal force more than in any other way, and the results are predict-
able: an inclination on the part of children to avoid, escape, and/or counter-
coerce. When using force, parents of young children plant the seeds for misery
that will certainly corne into full bloom during adolescence (Sidman, 1989).
Parents can get away with using force when their children are young, but when
the children get older, it becomes increasingly less effective, more divisive, and
can effectively destroy all bonds between parents and their children. In this
regard, my advice to parents is simple: Unless what you are about to say or do
to your children has a high probability for making things better, do not say or
do it.
Trap 8: Despair, Pleading, Hopelessness

Consider this frequently heard parental lament to a noncompliant child:
"I just don't know what I am going to do with you! I have tried everything I
know. I am simply out of ideas. I don't have the foggiest notion what it's going
to take to get you to shape up! Do you have any ideas?!" What is the parent to
expect from something like this? Obviously, the parent is not looking for an
answer. Recalling trap 6 discussed earlier, how likely is it that the child would
say, "Well, mother, as a matter of fact 1 do have some suggestions for you. 1 have
been spending some time in the library reading in the behavioral literature and
there are some distinct possibilities there for improving your parenting skills. If
you would like, 1 would be more than happy to discuss that literature in depth
with you, and between the two of us 1 am sure we can figure out a way of
shaping me up while at the same time making you a competent parent." Believe
me, if a kid came back with a response like this, he or she had better be out of
arms length of the parent, otherwise the encounter could degenerate from
verbal to physical-fast!
Obviously, comments like this do nothing more than convince children
that their parents are incompetent and do not know how to raise children. A
simple, easy-to-apply strategy can successfully function as an option to every-
one of these traps. That alternative contains a well-coordinated mixture of
empathy, understanding, directiveness, and consequences. It goes like this:
PARENT: "I'm sorry you chose to behave that way. 1 assume that at the mo-
ment you regarded that to be a reasonable option, even though, looking back
on it, it was obviously a poor choice. What would have been a better way of
responding?"
CHILD: "I did exactly what I wanted to. 1 hate my sister, and I want to hit her
every chance 1 get."
PARENT: "It's obvious to me, Son, that that's what you want to do. What do I
expect you to do?"
CHILD: "Well, you expect me to leave her alone."
PARENT: "Correct, Son. That's an excellent answer. I appreciate that mature
response. 1 expect you to keep your hands to yourself even in instances where
your sister makes you angry. Now, I'd like you to show me what you are
going to do in the future if your sister annoys you and you feel like hitting
her. Walk across the room and pretend that your sister is near you, has done
something to annoy you, and you feel like hitting her. Show me what you're
going to do."
CHILD: (The child walks across the room and role-plays walking away from
his imaginary sister.) "I suppose that's what you want me to do."
PARENT: "Correct, Son. That is exactly what 1 expect you to do. You have just
demonstrated to me what you will do in the future. You will simply walk away
without hitting your sister or saying mean things to her. Furthermore, Son,
when you do control yourself that way and just walk away from your sister
rather than hitting her or being mean, you will earn some very valuable privi-
leges. What are some things around the house that you really enjoy doing?"
CHILD: "Do you mean to tell me that if I hit that stupid sister of mine I'm not
going to be able to play with my Nintendo?"
PARENT: "Okay, Nintendo is one of those privileges you enjoy. What other
privileges are there here at the house you enjoy a lot?" (Everything else the
child said was "noise" and should just be ignored.)
CHILD: "Well, 1 like riding my bicycle, and I like watching television, and I'm
also glad that I get an allowance."
[Note: Inviting the child to identify privileges he or she really enjoys is the best
way to identify what consequences are the most valuable to the child and will
likely have the greatest effect on managing the behavior (Jensen et aI.,
p.67).]
PARENT: "I would agree with that, Son. I've noticed that those things really
are important to you, and I want you know absolutely that if you choose to
manage your behavior well-and what do I mean when I say 'manage your
behavior well?'"
CHILD: "It means that I won't hit my sister. That I'll just walk away." (As he
mutters under his breath, "I hate my sister. I wish she'd die.")
PARENT: "Right, Son, that's exactly what I expect you to do: to manage your
own behavior, which means not hitting your sister. And when you do man-
age your own behavior, what privileges will you earn?"
(Note: The emphasis should be on "earned privileges." The child must learn
that there are no noncontingent reinforcers. No free lunch.)
CHILD: "I know what you mean, Dad. You'll let me ride my bike and play my
Nintendo and all that stuff."
PARENT: "That's right, Son. You will earn the privilege of having those things
when you want them. And that's wonderful! On the other hand, Son, should
you fail to manage your behavior well-and what do I mean when I say fail
to manage your behavior well?"
CHILD: "Well, it means I hit my dumb sister."
PARENT: "Right. You'd hit your sister. If you did that, what privileges will you
deny yourself?"
CHILD: "I know what your talking about Dad."
PARENT: "So, Son, what can I expect of you in the future when your sister
annoys you?"
CHILD: "I guess I better leave her alone and just hope that she gets run over
by a school bus."
PARENT: "I'm glad you understand my expectations, Son."
(Note: It is important that all of the age-typical, garden-variety weed behaviors
such as "I hate my sister," "My dumb sister," "I hope she gets run over by a
school bus," are inconsequential behaviors that should just be put on extinc-
tion. Remember, attention should never be given to a behavior that is not to be
repeated, unless it is a consequential behavior to be treated therapeutically.)
CONCLUSION
How children behave is in large measure a function of how well their

parents behave. If parents keep doing what they have always done, they will
keep getting what they have always gotten. This chapter has as much to do with
improving parents' behavior as it has to do with helping children behave better.
Before any attempt is made to "shape up" the way children behave, parents
must "shape up" their own behavior. The making of a stable family begins with
stable parents. I close with these lines from Kahlil Gibran's (1995, p. 18) poem
"The Prophet," a poem for parents:
You are the bows from which your children as
living arrows are sent forth.
The archer sees the mark upon the path of the infinite,
and he bends you with his might that his arrows
may go swift and far.
Let your bending in the archer's hand be for gladness,
For even as he loves the arrow that flies,
so he loves also the bow that is stable.
Acknowledgements. I want to acknowledge in a special way my apprecia-

tion to Dr. Sidney Bijou, Dr. Carl Cheney, and Dr. Waris Ishaq for their excel-
lent reviews of this chapter. Their suggestions contributed markedly to its
technical accuracy.
REFERENCES
Bijou, S. W. (1988). Behaviorism: History and educational applications. In T Husen & T. N.
Postlethaite (Eds.), The international encyclopedia of education (pp. 444-451). New York:
Pergamon Press.
Bijou, S. W. (1993). Behavior analysis of child development. Reno, NV: Content Press.
Cautela, J. R. (1993, March). General level of reinforcement. Paper presented at the fifth annual
meeting of the International Behaviorology Association, Lmle Compton, Rhode Island.
Cousins, N. (1979). Anatomy of an illness as perceived by the patient. New York: Norton.
Gibran, K. (1995). The prophet. New York: Alfred A. Knopf.
Jenson, W. R., Sloane, H. N. & Young, K. R. (1988). Applied behavior analysis in education: A
structured teaching approach. Englewood cliffs, NJ: Prentice Hall.
Latham, G. L. (1994). The power of positive parenting: A wonder way to raise children. Salt Lake
City, UT: Northwest Publishers.
Lindsley, O. R. (1963). Geriatric behavioral prosthetics. In R. Katsenbaum (Ed.), New thoughts on
old age (pp. 41-60). New York: Springer.
Rae, S. (1991). Wrapping the human package. Modern Maturity, /34 (3), 72-94.
Reed, C. (1994). A parent's approach to solving some behavior problems. (Available from Curt
Reed, 775 N. 275 w., Logan, UT 84321.)
Roderick, J. (1994, January 9). An inept ruler and the 20th century's greatest revolutionary. The
Logan Herald journal, pp. 17-18.
Sidman, M. (1989). Coercion and its fallout. Boston, MA: Authors Cooperative.
Staff. (1989, December). Hugging. Hope Healthletter, 9(2), 6.
Sulzer-Azaroff, B., & Mayer, G. R. (1991). Behavior analysis for lasting change. San Francisco:
20
Putting the Gold Back
in the Golden Years
Dawn M. Birk
There are many terms for individuals in the upper age bracket of society. These
include "old," "aged," and "elderly," to mention a few. There are also the
descriptors "young old" and "old old" that are used to further describe and
classify the over-65 population. Generally speaking, none of these terms are
considered flattering (Birkedahl, 1991; Daugs, 1987). Those who might meet
the criteria for classification into one of these categories frequently seek other
ways of describing themselves, such as "seniors" or "senior citizens." They may
also refer to themselves as simply "retirees" and remind themselves that these
are the "golden years." The rejection of certain terms used to describe individu-
als in the upper age bracket suggests that these terms are viewed as unpleasant,
distasteful, or even derogatory. While some cultures and societies view aging
adults in terms of "wise" or "venerable," many individuals continue to associ-
ate aging only with negative concepts such as loss, deterioration, and depen-
dence (Daugs, 1987; Foner, 1986; Janicki & Wisniewski, 1985). This may be
due, in part, to the belief that aging leads to decrements in the quality of life
and brings only decreased functioning, without the possibility of improvement
in any area. This belief of pervasive loss needs modification if one is to make a
therapeutic impact on the aging population. Leaning how to impact people 65
years and over is vital at this time, since it is predicted that by 2030 approx-
imately 20.7% of the US population will be in this age group (Birkedahl, 1991,
Dawn M. Birk • Eastern Montana Community Mental Health Center, 2S07 Wilson Street,
Miles City, Montana 59.,01.
383
p. viii). In order to make therapeutic changes, aging individuals must be pro-

vided with the hope and information needed in order to continue to grow,
change, maintain, and improve the condition and quality of later life.
The myth continues to exist that the aging process leads only to deterio-
ration and that people should feel distressed and fearful about becoming old-
er (Birkedahl, 1991; Hussian, 1981). This would also suggest that, in con-
junction with the physical-mental deterioration associated with growing
older, there is also a decline in the overall quality of life. This is unfortunately
perpetuated by the media in the representation of older individuals. White-
haired men and women are presented in advertisements regarding bladder
incontinence and dentures, while few are seen in sports cars or perfume ads
(Foner, 1986). Even the scientific community tends to preclude older individu-
als from participating in experiments, perhaps due to the stereotypes indicat-
ing that the aged possess too many disabilities to be of use in research (John-
son & Williamson, 1980; Wolfensberger, 1972). The television sitcoms that
portray the lives of older Americans seem to focus their comedy around nega-
tive aspects of aging, often pointing out physical and mental disabilities. For
example, an episode of "The Golden Girls," a television sitcom about four
older women living together, includes jests about physical changes in the fol-
lowing dialogue (Harris, 1991):
DOROTHY: Ma, your stockings are falling down and bagging up around your
ankles.
SOPHIA: What stockings? I'm not wearing any stockings.
While this may teach the general public to laugh at some of the changes that
occur as one ages, the media also appears to be equating growing old with
inevitable and irreversible decline.
There are many positive aspects of becoming part of the 65 and over
population that are typically overlooked. Some physical changes are inevitable
and cognitive alterations may occur, but it has been demonstrated that older
individuals are capable of maintaining and improving many areas of function-
ing (Cooper & Shepard, 1973; Hoyer, Labouvie, & Baltes, 1973; Salthouse &
Somberg, 1982). It has been shown that many factors contribute to an individ-
ual's happiness or satisfaction with life, and these factors, rather than simply
age, impact the person's perceived quality of life and therefore their view of the
condition of life in the later years. Research has demonstrated that locus of
control, health, housing, social support, and sources of reinforcement (Golant,
1984; Schultz, 1976; Ward, 1984; Ziegler & Reid, 1983) impact older individ-
ual's happiness and satisfaction with life. These variables also interact with
each other, further complicating an analysis of those individual factors that are
integral to maintaining and increasing quality of life (Fisher, 1988, Golander,
1987). This chapter consists of an exploration of variables that shape and
improve the condition of life in the later years.
20 • THE GOLDEN YEARS 385
lOCUS OF CONTROL
An individual's responses to the environment can be conceptualized in

terms of internal versus external locus of control. Simply defined, internally
controlled individuals attempt to act upon the environment, while externally
controlled individuals typically do not. Of course, whether a person responds
and the manner in which the individual responds is also influenced by environ-
mental circumstances. However, this is often overlooked when analyzing be-
haviors exhibited by older individuals. Instead, the behaviors of individuals 65
and over are frequently examined in relation to deterioration due to the aging
process (Skinner & Vaughan, 1983).
As individuals age, they encounter fewer situations over which they may
exert control, such as mandatory retirement, illness, and death (Huges, 1976).
Therefore, an aging individual may believe that the responses they make have
little or no impact on the environment due to a lack of reinforcement for
attempting to act (Baltes & Zerbe, 1976). The absence of reinforcers may lead
to a decrease in responding and the person may be said to exhibit evidence of
an "external" locus of control. However, given the same set of circumstances,
some individuals may continue to attempt to make responses and are consid-
ered to be showing an internal locus of control. These individual differences
may be based on previous experiences in which responses were reinforced or
punished (Skinner & Vaughan, 1983) and may lead an individual to be classi-
fied as internally controlled, externally controlled, or they may exhibit situa-
tionally dependent control (Loo, 1979).
Investigators have explored the interaction between locus of control in
aging individuals and the following factors: housing (Tiffany, Tiffany, Camp, &
Day, 1984), health (Rodin, 19116), activity level (Hutchison, Carstensen, &
Silverman, 1983), life satisfaction (Byrd, 1983), and self-concept (Linn &
Hunter, 1979). The results of these lines of research, consisting mainly of
correlational studies (Birk, 19i19), indicate that each of these variables may
impact locus of control or locus of control may influence some aspect of each of
these factors. However, the degree to which locus of control is influenced varies
and is individual-specific. Again, this most likely relates to reinforcement histo-
ry. The existing body of literature on locus of control in the over-65 population
suggests that individuals receiving response-contingent reinforcement, which is
equated with an internal locus of control, report fewer somatic complaints and
are rated as healthier by outside observers than those receiving noncontingent
reinforcement, which is associated with an external locus of control (Birk,
1989; Riddick, 1985; Rodin, 1986; Rodin & Langer, 1977). One theoretical
explanation for these data is that those elderly who learn to cease responding
behaviorally also stop responding physiologically (i.e., immune system stops
fighting illnesses) (Rodin, 1986).
If current literature regarding locus of control in the older population
suggests that those classified as internally controlled report a greater number of
positive aspects of life compared with those eternally controlled, then they may
experience a better quality of life compared to those externally controlled.

Byrd's (1983), Gerber's (1976), and Mancini's (1981) research supports this
contention. In addition, Hunter, Linn, and Harris (1982), and Reid, Haas, and
Hawking (1977) found that older individuals also demonstrate a positive self-
concept in conjunction with an internal locus of control (Mark, 1983). Schultz
and Hanusa (1978) found that when nursing home residents were provided
with response-contingent reinforcement, they demonstrated a decrease in so-
matic symptoms, as reported to nurses, and nurses rated them as healthier
overall than residents provided with noncontingent reinforcement. These re-
ports suggest that the residents having greater control over environmental con-
tingencies, or internally controlled, experienced a better quality of life than
those with less control, or externally controlled. Unfortunately, follow-up data
show that 24, 30, and 42 months after the experiment ended, significantly
more of the group considered internally controlled had died. The experimen-
ters hypothesized that the higher number of deaths was due to reinforcing
responses to the environment during the experiment and then removing the
response-contingent reinforcement following completion of the research. This
sudden shift in contingencies may have led residents to continue to attempt to
obtain reinforcers contingent upon their responses in an environment (i.e., the
nursing home minus the experimenters) where this was no longer possible
(Golander, 1987). Rodin (1986) might interpret these results in terms of the
residents experiencing increased stress levels and decreased immune system
functioning, which may have contributed to death.
The results of locus of control research then lead to the question of what
constitutes quality of life; who should decide what the quality of life should be
and how can it be measured? If individuals classified as internally controlled
report a higher quality of life, a more positive self-concept, and fewer health
difficulties, is it inappropriate to intervene therapeutically at this level if it is
possible that reinforcing the individual's response to the environment may
ultimately decrease lifespan? How environmentally dependent does an inter-
vention need to be so that deleterious effects are avoided? Is lifespan the ulti-
mate measure of quality of life? Should the individual be given the option of
response-contingent reinforcement or is this even possible in the individual's
environment? These questions require further exploration.
LIFESTYLE CHANGES
The most frequently experienced lifestyle changes in the upper age bracket
of the population include retirement, relocation, and loss of loved ones (Myers,
1991). As noted previously, many factors influence the way in which an individ-
ual will respond to these life changes, and this in turn impacts the perceived
quality of life. Several variables may interact such that it is difficult to clearly
distinguish those that directly affect life quality.
While retirement may be discussed in hopeful and sometimes envious
terms by those under 65, aging individuals may not feel quite as anxious to
reach this landmark. This depends on the individual's perceptions of retirement
that are shaped, at least in part, by reinforcement history and current environ-
mental circumstances. It has been found that social class is inversely related to
the decision to retire (O'Brien, 1981). Sheppard (1976) discovered that approx-
imately 50% of blue-collar workers surveyed and only 25% of white-collar
workers would cease working even if provided with adequate retirement in-
come. It may be theorized that those individuals performing white-collar work
have greater flexibility and variability in their workload, as well as maintaining
greater control over reinforcers than is possible for blue-collar workers
(George, 1980; Ward, 1984). Perhaps those people with the ability to obtain
response-contingent reinforcement are less likely to wish to relinquish this for
retirement, a role change that may be viewed as leading to loss of some of this
control and autonomy.
Many individuals may not receive response-contingent reinforcement, and
those employed in repetitive and menial tasks report greater satisfaction in
retirement than those in positions requiring complex skills (O'Brien, 1981;
Ward, 1984). This may be due to the fact that the change in roles, from employee
to retiree, actually leads to an increase in control over reinforcers in the individu-
al's environment. This, however, requires further examination as there may be
many other mediating factors that influence retirement satisfaction.
Older people who view retirement as a time for leisure, travel, and recre-
ation, activities that may be performed based on the individual's choices, may
demonstrate greater satisfaction with this role change. This might then lead to
reports of improvements, rather than decrements, in quality of life. The most
satisfied retirees are those who demonstrate high scores on a preretirement
survey, suggesting a greater expected satisfaction with retirement (Ward, 1984).
This suggests that those with a history of response-contingent reinforcement,
which is strongly linked to reported high levels of life satisfaction and quality of
life (Byrd, 1983; Skinner & Vaughan, 1983), will continue to perceive, expect,
and behave in ways directed at gaining reinforcers contingent upon their re-
sponses, even after retirement. Those who have the expectation of receiving
response-contingent reinforcement in retirement also tend to respond in the
same manner (Ward, 1984).
A 1981 National Council on the Aging survey suggests that income, social
interactions, and activity levels are the variables that have the greatest impact
on perceived quality of life following retirement. The influence of these factors
is compounded by the health of the individuals. In addition, income decreases
may lead to an inability to perform many activities, thus decreasing involve-
ment in social events and contact with others (Ward, 1984). This results in
constricting the individual's ability to obtain preferred reinforcers and may lead
to decreased responding to the environment. This may then lower reported
quality of life, as Ward (1984) suggests. Apparently any factor (e.g., deteriorat-
ing health) that leads to a decrease in reinforcers contingent upon an individu-
al's responses will also result in reported decreased life quality.
While mandatory retirement may be viewed as a removal of control over

one's environment and may be hypothesized to decrease satisfaction in retire-
ment, Kimmel, Price, and Walker (1978) did not find this to be true. Results of
this study indicate that involuntary retirees reported a decrease in quality of life
following retirement due to declines in health and income. They also had
reported a preretirement belief that they would be less happy as retirees than
employees due to decreased environmental control. These data corroborate
locus of control studies that suggest greater perceived control over one's envi-
ronment (i.e., internal control, response-contingent delivery of reinforcers)
leads to higher levels of reported quality of life.
HOUSING AND SATISFACTION
As medical advances extend the average human life expectancy, as the

birth rate declines, and as the number of people who survive to 65 years and
over increases, appropriate housing alternatives must be sought. Two factors
that should be considered in a housing decision are the amount of assistance a
person requires and the available resources. The best housing choice is one that
meets the individual's assistance needs in the least restrictive environment and
is available to the individual when required.
Housing alternatives vary along a continuum that ranges from the aging
individual remaining at home (i.e., aging in place) to the opposite end of the
spectrum where a residential placement, such as a nursing home, is needed.
Obviously, those older individuals who require little to no assistance/ super-
vision have the greatest number of housing alternative and therefore have
greater control over the housing decision. The most independent individual
may opt to remain at home, with or without community assistance (e.g.,
Meals On Wheels). Approximately 75% of retirement-age people decide to
remain in their own homes rather than relocate to a retirement community or
housing complex, as long as independent functioning is possible (Parker,
1984).
Aging in place maintains and facilitates the individual's ability to contact
reinforcers such as family, friends, and a familiar community. These individu-
als, based on existing research, show higher scores on housing satisfaction and
quality of life surveys (Golant, 1984; O'Bryant and Wolf, 1983). Of course, this
needs further exploration, since, as previously noted, many other factors con-
tribute to the reported quality of life, such as health, income, and other vari-
ables. This is particularly true since it may be assumed that aging individuals
remaining in the community demonstrate better health and a higher income,
factors also associated with a reported higher quality of life than those who
must relocate. While it is difficult to sort through the multitude of variables that
may influence quality of life individually or in combination, it is clear that loss
of control over choices and an inability to have control over reinforcers are key
(Rodin, 1986; Skinner & Vaughan, 1983).
With each step along the housing continuum, moving from remaining at
home toward residing in a nursing home, an individual's independence and
control over the environment decreases, leading to decreases in reported quality
of life (Carp, 1985; O'Bryant & Wolf, 1983). While receiving response-contin-
gent reinforcement appears to be essential in maintaining or improving quality
of life, the residential setting may impact the feasibility of providing response-
contingent reinforcement. Continued attempts to gain reinforcers through
one's personal actions may not be reinforcing in some environments. Those
environments that are more constricting (e.g., congregate housing, adult foster
care, nursing homes) do not allow for a great deal of flexibility, variability of
care, or response alternatives, nor is independence generally reinforced. In such
residential placements, most tangible, activity, or verbal reinforcers are deliv-
ered based on caregiver schedules rather than as a result of a response made by
a resident (Colander, 1987). This results in a decrease in the control residents
maintain over reinforcers, which then leads to decreases in reported quality of
life (Byrd, 1983; Mancini, ]981).
Those individuals who have a history of response-contingent reinforcers
may continue to respond despite the change in environmental contingencies.
Frequently, these patients are viewed as "difficult" or "troublemakers," when
in effect they are simply attempting to maintain some sense of control over the
environment (Golander, 1987). As previously stated, those individuals who
attempt to maintain control, even in a total-care setting, report a higher quality
of life on average than those who passively allow others to perform caretaking
duties (Birk, 1989; Tiffany et aI., 1984). The necessity of providing high-quality
care when there is a high patient-to-staff ratio may make the provision of
response-contingent reinforcement impossible. In fact, reinforcement may be
provided for not acting upon the environment, thus shaping passivity in certain
residential settings (Booth, 1986). This impacts reported quality of life and
results in decreased self-concept and life satisfaction (Cohen, Tell, & Wallack,
1986). Family and staff need to take this into consideration when providing aid
for activities of daily living. Although it may be difficult for some older individ-
uals, research suggests that allowing them to take responsibility for as many
activities of daily living as possible leads to increased self-concept and satisfac-
tion (Cohen et aI., 1986; Tiffany et aI., 1984).
Mark (1983) suggested that a decrease in attempts to respond to one's
environment may be adaptive in certain situations. However, this study did not
demonstrate a clear causal relationship between decreased responding and
reported increased quality of life. Schultz and Hanusa (1978) found that nurs-
ing home individuals who had been reinforced for making responses to the
environment showed a higher mortality rate after the intervention phase than
those receiving noncontingent reinforcement. Those receiving response-contin-
gent reinforcement also demonstrated improved health and an overall increase
in life satisfaction during the study. This leads to questions concerning how
quality of life is defined, who determines whether quality of life has improved,
and is lifespan the most appropriate measure of life quality?
lOSS
Unfortunately, aging individuals must cope with an increasing number of

losses due to death and illness. While deaths of spouses, family, and friends lead
to bereavement, changes in older individual's personalities or capabilities due
to illness may also cause grief responses (Myers, 1991). Older people may feel a
decrease in a sense of control as they watch loved ones change, deteriorate, or
die. Declining physical or cognitive functioning in family members may force
aging individuals into the role of caregiver, leading to a decrease in ability to
interact socially and decreased mobility. This can cause both the caregiver and
the individual being cared for to report decreased quality of life (Myers, 1991;
Ward, 1984). It appears that the best way of intervening in this area, in order to
maintain or increase quality of life, is to continue to involve the individual
being cared for in the decisions concerning personal care. This may allow the
individual to experience some perceived control over the environment. In addi-
tion, the caregiver may benefit from respite care to allow more control over
engaging in reinforcing activities.
MAINTAINING AND IMPROVING FUNCTIONING
The tendency exists to focus on the negative aspects of aging, such as

deterioration and loss, rather than emphasizing those skills that remain un-
changed (Daugs, 1987). Such skills are often lost due to physical or intellectual
impairments. This negative emphasis may occur because areas requiring inter-
vention draw the greatest attention, since remediation is required in those areas
rather than areas of functioning that are maintained. While some physiological
changes are inevitable due to aging, others are individual-specific and may be a
result of environmental factors. Cohort groups, a collection of individuals born
within the same time period, also age differently (Foner, 1986), and therefore
this variability must be considered in any analysis of the impact of factors on
agmg.
It has been demonstrated that some individuals, even in the oldest age
categories, maintain sensory functioning and perform as well on some mental
and physical tasks as younger individuals (Riley & Bond, 1983). Also, the
presence of mental illness is no greater in the upper age segment of the popula-
tion than it is in younger adults, and typically those elderly presenting a psychi-
atric disturbance have exhibited a history of psychiatric illness that has per-
sisted over the lifespan (Foner, 1986; Myers, 1991). Continued practice of skills
(e.g., memory, reaction time) has been demonstrated to effectively aid aging
individuals in maintaining and increasing functioning (Birk, 1989; Birren,
Woods, & Williams, 1980; Hoyer, Matteson, & Siegler, 1982). In addition,
older individuals may demonstrate increased coping skills and accumulated
knowledge that is beneficial for maintaining and increasing functioning in
some areas. In fact, Salthouse and Somberg (1982) have found that older
people generally sacrifice speed for accuracy and demonstrate fewer mistakes
on reaction time tasks than younger individuals.
Environmental factors may also contribute to physiological changes, and
this may be seen when making comparisons between cohort groups that have
survived a lifespan extending across particular decades (Foner, 1986). For ex-
ample, Foner (1986) reports that individuals born in the early 1900s demon-
strate smaller statures than those born in the latter half of the century. This has
been attributed, in part, to nutritional differences.
Decreases in intelligence quotients are frequently observed (Botwinick,
1978; Poon, 1980) as age increases. However, allowing older individuals to
practice tasks similar to those presented on intelligence tests, such as the
Wechsler Adult Intelligence Scale-Revised (Wechsler, 1974), may result in in-
creases in these scores (Lachman, 1981). Also, while older people, on average,
show memory and processing deficits greater than the average individual under
65 years old, it appears that some of these declines may be due to environmen-
tal changes rather than physical alterations. For example, many retirees have
difficulty in immediately responding to questions regarding the date, but this
seems to be more a matter of not being required to maintain this information,
since they may have no set schedule or appointments as do employees and
students (Daugs, 1987; Mace & Rabins, 1991).
One very sensitive area regarding the aging population is the older individ-
ual's interest and ability to engage in sexual intimacies. Masters and Johnson
(1970) performed extensive research in the area of aging and sexuality. The
results of this study suggest that a man may demonstrate an increase in time
required for erection to occur, a decrease in ejaculation, and an increase in the
amount of time between an erection and an orgasm. They found that women
show decreases in vaginal lubrication, a decrease in contractions during or-
gasm, and a decrease in vaginal expansion during intercourse. However, the
overall results of the research clearly demonstrate that sexual activity continues
throughout the lifespan, with the exception of certain curtailing factors such as
loss of sex partner, poor health, and cognitive impairment. Some older individ-
uals appear to be fearful of engaging in sexual activities due to the ever-present
stereotypes regarding expectations that people over 65 do not engage in inti-
macies (Foner, 1986).
While the aging individual may be unable to directly impact many of these
areas of functioning, it is important to emphasize those facets of the individu-
al's life over which he or she does have control. Those areas that produce
reinforcement should be emphasized, and memory aids or practicing certain
skills may be useful in teaching the aging individual how to cope with declines
as well as how to maintain and improve functioning. This increases the proba-
bility that one will continue to respond to the environment and that he will
receive response-contingent reinforcement in those areas. Education regarding
myths and stereotypes about the aging process may also aid individuals in
understanding expected changes, limitations, and areas in which functioning
should be maintained. It has been demonstrated that information of this nature
also increases an individual's sense of control over the environment and leads to
increased quality of life (Clum, Scott, & Burnside, 1979; Drobnies, 1984;
Wallston, 1983).
TREATMENT ISSUES AND APPROACHES

Individuals entering psychotherapy present a variety of problems, and the
older population may experience some age-specific difficulties. They may show
evidence of various Axis I and Axis II disorders that have been present through-
out the individual's lifespan. However, in addition the aging individual may
exhibit an increase in Axis III diagnoses, many of which contribute to Axis I
disorders (Mace & Rabins, 1991). These include" for example, dementia and
organic mood disorders. The environmental changes that aging people encoun-
ter also lead to an increased need for psychotherapeutic intervention. Thera-
pists may need to focus on coping with illness, cognitive and physical deteriora-
tion, lifestyle changes, and death.
Older individuals may need to learn appropriate ways of coping with their
own illness (e.g., Alzheimer's disease, multi-infarct dementia) or the deteriora-
tion of a loved one. In the initial phases of some dementias, the individual is
aware that cognitive abilities, most frequently memory, are declining. This is
frightening, and often the person reacts with irritability and anger (Mace &
Rabins, 1991). Therefore, it is likely that not only the aging individual but
family and staff members who serve as caregivers must be incorporated into
any therapeutic intervention in order to educate them about the individual's
behaviors (Pinkston & Linsk, 1984). Family members and staff of residential
settings may be required to cope with an increasing number of inappropriate
behaviors that are typically seen in the course of dementias (Mace & Rabins,
1991; Pinkston & Linsk, 1984). Therapists must be prepared to intervene with
all involved.
Aging individuals may show an increased number of adjustment disorders,
compared with the under-65 population, due to physiological and lifestyle
alterations. Coping with physical changes that are a natural part of the aging
process may be one source of distress in some older individuals (Birkedahl,
1991). Changes in lifestyle may also lead to difficulties in coping and contribute
to psychological stress. Moving from one residence to another brings about a
multitude of changes, such as separating from family members and longtime
friends, parting with usual routines, familiar streets and communities, and
simply living in a new home setting. Sometimes lifestyle changes include remar-
riage, perhaps after death of a spouse, and this may arouse feelings of guilt or
distress (Birkedahl, 1991; Daugs, 1987).
Psychotherapeutic interventions that may be used in the aging population
range from standard psychoanalytic techniques in individual therapy to behav-
ioral interventions designed for use by caretakers (Myers, 1991). While chemo-
therapy may be beneficial for older individuals, the benefits for this particular
type of intervention must be carefully weighed, since psychotropic medication

is not typically well tolerated by older people. Electroconvulsive therapy (ECT)
is sometimes used as an alternative to chemotherapy, and in some respects there
are fewer side effects than those that occur in chemotherapy. ECT does not
result in the extrapyramidal side effects that frequently occur in the over-65
population using psychotropic medications. In fact, Prudic and Sackeim (1990)
found that ECT is effective in 40-50% of depressed patients who have not
responded to trials of antidepressants. However, they report that this interven-
tion is typically viewed as a last resort when all others have failed. A complete
review of the risks and benefits of chemotherapy and ECT will not be offered
here; instead, the focus will be on psychotherapeutic approaches for older
clients.
Providing response-contingent reinforcement has been found to be an im-
portant aspect of healthy aging (Byrd, 1983; Rodin, 1986). This should then be
a focus in any treatment modality. The sense of control is not likely to be
restored through simply utilizing chemotherapy or ECT, since the patient has
no control over the physiological changes that occur as a result of these modes
of therapy. However, individual psychotherapeutic approaches may be highly
effective in restoring control. Literature exists on the use of cognitive behavioral
therapy (Thompson et aI., 1991), psychodynamic therapy (Silberschatz & Cur-
tis, 1991), hypnotherapy (Holt, 1991), and group therapy (Finkel, 1991; Les-
zcz, 1990) in the over-65 population. Behavioral approaches to working with
older individuals demonstrating physical and cognitive deficits may also be
highly effective when utilized by caregivers (Hussian, 1981, 1985; Pinkston &
Linsk, 1984).
According to Thompson et al. (1991), cognitive-behavioral therapy ap-
pears to be most effective in those elderly demonstrating affective disorders.
These researchers have experienced success with a cognitive-behavioral ap-
proach, particularly in individuals with reactive depressions, and it is useful in
about 50% of those elderly presenting personality disorders (Thompson et aI.,
1991). Emery (1981), Gallagher and Thompson (1981), and Thompson, Wag-
ner, and Zeiss (1989) found that this approach may be even somewhat effective
in those elderly experiencing mild levels of dementia. However, those demon-
strating severe memory impairments do not respond well to cognitive-behav-
ioral therapy and likely require an alternative treatment approach. One of the
major benefits of attempting cognitive-behavioral therapy as an initial treat-
ment is that it is a non intrusive method of intervening compared with chemo-
therapy and ECT and may be used in conjunction with either of these. Also, the
main emphasis of this approach is to aid the patient in controlling both his
overt and covert behaviors (Yankura & Dryden, 1990). This approach results in
effectively teaching the aging individual how to gain control over his rein-
forcers.
Silberschatz and Curtis (1991) point out that Sigmund Freud had indi-
cated that older patients might be too treatment resistant to benefit from
psychoanalysis and that such great changes would need to be made that thera-
py could extend indefinitely. However, this does not appear to be the case.
Silberschatz and Curtis (1991) have discovered that a psychoanalytic approach
to the difficulties of neurotic older patients can be successfully used in a time-
limited model. Using approximately 16 sessions, these researchers have found
that insight-oriented therapy can be highly effective once rapport is established
with elderly clients. In fact, one of the greatest drawbacks to a psychoanalytic
approach may be the aged individuals themselves (Blum & Tross, 1980). Blum
and Tross (1980) suggest that older people are uncomfortable with psycho-
therapy perhaps in part due to previously shaped beliefs that they should be
capable of solving their own problems. This discomfort with therapy may lead
to expectations that therapy will not work, perhaps producing this result since
patients may be unwilling to accept the therapist's interpretations. Psycho-
analysis generally is not effective in patients demonstrating cognitive impair-
ment, although each individual may need to be evaluated individually to assess
whether this approach may be attempted (Lazarus, 1984).
There is little research available on hypnotherapy with aged patients, and
the data available are conflicting (Berg & Melin, 1975; Holt, 1991). Holt
(1991) has utilized hypnotherapy in the elderly population, frequently in con-
junction with chemotherapy, and found it to be effective to varying degrees,
depending on the individual. It might be hypothesized that this approach
would not be ideal if the thrust of therapy should be to aid the patient in
gaining control, since hypnosis requires a great deal of trust in and reliance on
the therapist and his or her ability to perform this procedure (Spiegel & Spie-
gel, 1978).
Finkel (1991) has completed a review of existing literature as well as
having personally utilized group psychotherapy with individuals over 65.
While Finkel suggests that even those with mild forms of dementia may partici-
pate, Leszcz (1990) has explored the use of group psychotherapy with cog-
nitively intact elderly. Interestingly, the results of these and other studies (e.g.,
Baker, 1984; Gallagher, 1981; Rush & Watkins, 1981; Yesavage & Karasu,
1983) indicate that, while the most effective group therapy models vary de-
pending on the composition of the group, there are several factors that appear
to lead to favorable outcomes. Therapy groups that teach aging individuals
ways to actively make changes in the environment, that provide socialization
that is reinforcing to group members, and that focus on ways to increase
member's self-esteem through teaching methods of impacting the environment
are key components of group psychotherapy with the aging population. This
supports locus of control literature indicating that response-contingent rein-
forcement is an important element of healthy aging.
Finally, behavioral approaches may be highly effective in working with
aging individuals who show varying degrees of cognitive impairment if utilized
appropriately by caregivers (Fisher & Carstensen, 1990; Hussian, 1981, 1985;
Lundervold & Jackson, 1992; Pinkston & Linsk, 1984). Hussian's research
(1981, 1985, 1987) demonstrates that behavioral interventions, as utilized by
staff members in residential treatment facilities for the elderly, the beneficial for
both increasing appropriate behaviors and decreasing inappropriate behaviors,

even in severely cognitively impaired residents. Burgio and Engel (1987) have
indicated that behavior modification procedures may be used to effectively
reduce urinary incontinence in both community-dwelling and nursing home
residents. Stock and Milan (1993) have demonstrated the benefits of using a
behavioral approach to increase healthy dietary choices in independently
dwelling individuals over 65 years. Pinkston and Linsk (1984) focused on ways
in which the family of an aging individual might effectively intervene in order to
increase the individual's independent functioning. Overall, it appears that this
technique may be highly effective because it enables the older person to consis-
tently contact the contingencies governing his behaviors, thereby allowing
greater control over reinforcing events (Fisher & Carstensen, 1990).
Another important consideration when determining an appropriate treat-
ment approach for a particular patient is the treatment provider. In certain
settings, it is not the psychologist that provides direct care to the patient. In an
unpublished study, Birk and Johnson (1992) assessed 70 nursing staff members
from four geriatric residential facilities to determine nursing staff acceptability
of treatment for residents of geriatric facilities. The Treatment Evaluation In-
ventory (Kazdin, 1980) was utilized to determine which of the five treatments
was rated most acceptable by nurses for each of five behavioral problems
presented. Results indicate that the staff view certain treatments as more ac-
ceptable for some problems than others. It was also found that, while staff
rated behavioral approaches as being significantly more acceptable or as ac-
ceptable as psychotherapy (i.e., "talk therapy"), they indicated that having staff
discuss the behavior directly with the resident was equally acceptable. The use
of medication or simply ignoring the behaviors were the least acceptable ap-
proaches. These data suggest the need for psychologists to offer a variety of
treatment approaches and to involve staff in interventions when performing
consultations regarding geriatric residents.
CONCLUSIONS
While some unpleasant changes such as wrinkles and graying hair may be
inevitable results of the aging process, there are many positive aspects of grow-
ing old that need to be emphasized. These include physical and cognitive
functions that are maintained, as well as skills that may be stabilized or im-
proved with practice. If social scientists wish to improve the human condition,
it is necessary for us to learn how best to instill hope and the highest quality of
life possible across the lifespan. Research in the areas of locus control, social
change, and clinical interventions suggests the necessity of teaching, shaping,
and reinforcing individuals for exerting control over the environment. Aiding
aging individuals in maintaining a high level of independent functioning, mo-
bility, and social interactions are central to improving the condition of life in
later years. Allowing the media to continue focusing on the negative aspects of
growing old only allows for the preservation of unfavorable stereotypes. This
leads the under-65 population to view old age with dread, while those 65 and
over may assume that they may anticipate only declining physical and cognitive
functioning in the future. This is unfortunate, since research also indicates that
having expectations of satisfaction in retirement and later years impacts report-
ed satisfaction once individuals do reach the upper age bracket.
Further experimentation is necessary in order to clarify variables impact-

ing an older individual's perceived control. While increased control over rein-
forcers may not necessarily lead to increased lifespan, research thus far indi-
cates that it results in improvements in several aspects of life. The availability of
response-contingent reinforcement increases self-concept, leads to reported im-
provements in health, and increases reported life satisfaction. However, each of
these variables needs to be clearly operationalized and further research com-
pleted before the relation between perceived control and life quality can be fully
understood. In addition, investigators should explore methods of providing
individuals with the knowledge and tools necessary to maintain and improve
the quality of life in the later years. In this manner, the gold may be put back
into the "golden years."
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VII
Philosophical Issues
21
Wisdom as the Key

to a Better World
Richard Garrett
B. F. Skinner (1971) begins his book, Beyond Freedom and Dignity, by review-
ing some of the "terrifying problems that face us in the world today." Skinner
notes that "technology itself is increasingly at fault" and that "the application
of the physical and biological sciences alone will not solve our problems."
Skinner's diagnosis is that "we need to make vast changes in human behavior"
(pp. 1, 2). This author agrees wholeheartedly with Skinner on all of these
points. However, quite a different vision from Skinner's concerning the kind of
changes humans need to undergo and how they may be brought about will be
presented in this chapter. In particular, my contention is that universal wisdom
is the key to bringing about the better world we all need and want.
THE LINK BETWEEN WISDOM AND A BETTER WORLD
A better world is a world in which people live better lives. This may sound
like a rather bland, if not trivial, truth. Nonetheless, it is the truth and it is the
truth that above all others we need to keep in plain view as we go about trying
to build a better world or we are only going to make matters worse, as too
often happens with the best of intentions. For this truth defines our goal, the
goal we can all agree on and the goal that needs to take priority over all others.
Assuming we can all agree that what is needed and what is important
Richard Garrett • Graduate Center, Bentley College, Waltham, Massachusetts 02154.
403
404 VII • PHilOSOPHICAL ISSUES
above everything else is a world in which people live better lives, we still have a
long way to go before we can reach an agreement about much more. For we
must still ask a number of questions: In what sort of world would people live
better lives? Indeed, what do we mean by "better lives?" Is such a world
possible? And if it is possible, how is it possible? When we confront these
questions, we quickly discover that our agreement comes to an end. Yet these
are precisely the questions we need to face and answer if we are going to have
any real hope of building a truly better world. Moreover, if we are going to
succeed in our efforts, we are going to have to work cooperatively on these
matters, and that means some shared understanding concerning the answers we
give to these questions.
It is right here that we can see the link between wisdom and a better world.
For wisdom (in the practical sense) may be defined as that understanding which
is essential to living a better life. The more wisdom a person has, the more they
understand about living a better life, and the ideally wise person would under-
stand how to live the best life possible. To the extent that a person is wise, then,
she could give us answers to the questions posed above and they would be the
right answers-the ones that would in fact enable us to build a better world. A
foolish person may also provide us with answers to the above questions, but
however good his or her answers might sound, they would be the wrong
answers-the ones that would only get us into trouble.
Given the definition of wisdom assumed in this chapter, it is difficult to see
how anyone could disagree that wisdom is the key to a better world. For as
defined, wisdom is precisely that understanding that is essential to living a
better life and so to building a world in which people can live better lives. Even
Skinner would have to agree with our claim so far, for he himself argued that
the essential understanding (the essential wisdom) was provided by his own
experimental analysis of human behavior. So he appreciated the need for wis-
dom, since (defined as the chapter defines it) he indeed thought he had discov-
ered the essential wisdom.
All the same, the vision that will here be presented will differ from Skin-
ner's in some very important ways. In order to further clarify the conception of
wisdom proposed in this chapter, we need to consider the following three
questions: What is possible? What really matters? And how can we build a
better world? Answering these questions, even in a partial way, can help us to
achieve a deeper understanding of what wisdom is, how it can be achieved, and
what its role is in building a better world.
WHAT IS POSSIBLE?
Some people think that a better world is not at all possible, so that the
search for wisdom (the search for an understanding of how to live better) is
futile. King Solomon expresses such a view in Ecclesiastes, saying that "every-
thing is vanity" and that wisdom itself is "a useless chasing after wind" (Living
21 • WISDOM AS THE KEY 405
Bihle, 1971, pp. 137-138). The idea here is that the human condition is so
horrible and so hopeless that it is utterly beyond redemption, that nothing
whatever can make things better for us. Various reasons have been given for
such pessimism: (1) old age, sickness, death, the loss of loved ones, wars,
natural disasters, and numerous other afflictions that we ultimately cannot
foresee or control; (2) humans are hopelessly selfish and morally corrupt (our-
selves included), so that betrayal, injustice, and the oppression and exploitation
of the weak are fundamental, eradicable conditions of human existence; and
(3) human life is meaningless, the positive goals and value we seek in our lives
and in the things we do are utterly subjective and insignificant.
Most people have the good sense to reject such extreme pessimism. Yet, the
pessimist raises some questions that deserve our consideration. Before attend-
ing to these questions, however, in order to have a clearer perspective on the
matter, it will be useful to consider just why it is sensible to reject the pessi-
mist's view of things.
Consider the following examples concerning what it is better to believe:
1. A student has just been presented with a proof of the Pythagorean
theorem.
2. A scientist has just observed that a certain meter reads 0.0027l.
3. An athlete, Mary, is about to participate in an Olympic contest and is
wondering if she can win the gold metal.
In cases 1 and 2, it is very clear what it is better to believe. In example 1,
providing the proof is a good one; it is better to believe the Pythagorean
theorem then not to, simply on the strength of the proof And in example 2,
provided there is no reason to suspect the meter or the scientists' vision, it is
better to believe the meter reading than not to, simply on the strength of the
evidence. In such cases, we will say that the epistemic justification alone is what
makes it better to believe something. Let us imagine, however, that with respect
to example 3, things are different, that the evidence is quite ambiguous, equally
supporting the belief that Mary will win the gold medal and that her nearest
competitor, Sally, will win it. So, in example 3, there is no epistemic justifica-
tion for believing that Mary will win or that Sally will win (though there may
be very strong evidence, and so epistemic justification, for saying that one or
the other will win). In spite of this, it may be better for Mary to believe that she
will win. For it may be a consequence of Mary's believing such a thing that she
will significantly (perhaps dramatically) increase her chances of winning, and
we may assume that this is a good outcome. We can say in such a case that,
although Mary's belief that she will win is not epistemically justified, it is
nonetheless pragmatically justified.
Turning to pessimism, it must be admitted that pessimists are quite often
acute observers of the human scene; that they have, in attending to the dark side
of life, frequently made penetrating observations about us and the world we life
in. But there is also plenty of evidence on the other side (Smith, 1958), indicat-
ing that there is cause for hope. In the balance, our situation is not unlike
406 VII • PHILOSOPHICAL ISSUES
Mary's. Epistemically, there is as much justification for optimism as there is for

pessimism, as much evidence for hope as for despair. The evidence in the matter
is indecisive. Nonetheless, the argument in favor of optimism is quite decisive,
not on epistemic grounds, but on pragmatic grounds. For we have much more
at stake than Mary does; we have a world, a life, to win and pessimism is the
sure way to lose both. For if we assume that things are hopeless, they really will
be. So, it is little wonder that most people understand this and so sensibly opt
for hope over our despair.
However, to say that hope is a good thing is not to go far enough. For
pessimists, as noted, frequently are perceptive, and the basic "facts" about the
human situation are, as we have noted, ambiguous. The dark side is too real to
be ignored and it must be taken into account in trying to build a better world.
So, what is needed is a hope that is deeply grounded in realism, a robust hope
that exists in the light of an understanding of and not a denial of the dark side
of life. For it is only hope such as this that can enable us to build a truly better
world. What is required is a constant realistic assessment of what can and
cannot be achieved.
As Skinner (1971) noted, in order to deal with the problems that face us
today, "we need to make vast changes in human behavior." Another way to put
the matter is to say that we ourselves are the basic problem. So, in asking what
changes are possible, we must not forget that the basic change that is required
in order to build a better world is a change in ourselves. It will be useful to
consider this matter in terms of what John Dewey (1930) called the "art of
control versus the art of acceptance."
Speaking very generally, some problems arise as a result of conflicts be-
tween what we want and the way the world is. Hereafter, we shall refer to such
problems as world-want conflicts. If a person has cancer, then the way the
world is (the condition of his body in this case) conflicts with the way that
person wants the world to be. If the person has the cancer completely removed,
this is an application of the art of control. For the physician is solving the
problem (ending the conflict) by changing the world. If, however, nothing of
the sort is possible, so that the person only has 6 months to live, the best thing
that can be done is for the patient to accept his situation. This would be an
instance of applying the art of acceptance. When we bring the world into
accord with what we want, we are applying the art of control, while when we
bring our wants into accord with the world, we are applying the art of accep-
tance. Both arts are useful and necessary to living a good life. Indeed, these are
frequently both relevant to a single problem: Radiation treatments may only
extend a cancer patient's life by a year, in which case the necessity of the art of
acceptance still exists.
Pessimists are indeed right to point out that death, illness, old age, the loss
of loved ones, moral corruption, injustice, and many other maladies are a
permanent part of life. We can hope to control some of these things to a point
through science and technology and through changing ourselves. Still, in the
end, we must learn to accept a world in which these things are present. For
fanatics and perfectionists only make matters worse and only add to the
world's problems by their refusal to do so. So the art of acceptance has impor-
tant work to do, and in this regard, therapy, philosophy, and religion have more
to offer than science and technology (though they can help here, too).
Not all problems entail world-want conflicts. Some of our most signifi-
cant problems are better described as want-want problems. Approach-ap-
proach, approach-avoidance, and avoidance-avoidance problems are all ex-
amples. If Victoria wants to marry Bill and also John, or wants to get married
and does not want to get married, then it is what she wants that is in conflict.
One thing that is wanted (or not wanted) is in conflict with another thing that
is wanted or not wanted. It is worth noting that regarding such conflicts, the art
of acceptance is almost always necessary and relevant. For if Victoria chooses
Bill, she will not get John, and if she chooses John she will not get Bill; while if
she chooses to stay single, she will get neither Bill nor John. So no matter what
she does, she will not get everything that she wants. It is of course sometimes
possible to resolve such conflicts by changing the world: If the Victoria in
question happened to be Queen Victoria, then she might change the marriage
laws and get both Bill and John to marry her. But more often than not such
conflicts cannot be resolved by changing the world. So it is what is wanted that
must be changed in order for the person to be happy. Thus, very frequently we
can make the world a better place by simply being very clear about what it is
that we really want and by giving up the less important want, i.e., by applying
the art of acceptance.
Any conflict of wants that a single person might have can exist between
two or more persons. Thus, Victoria's wanting to marry Bill may conflict with
Bill's desire to marry Peg instead or with John's desire to marry Victoria. So
want-want conflicts can be either intrapersonal or interpersonal. So long as
such conflicts are strictly intrapersonal, democratic societies leave it to the
individual to decide how to resolve the conflict. But when the conflicts are of an
interpersonal sort, no society can be indifferent as to how such conflicts get
resolved. Society must set the boundary conditions and this raises not only
legal questions but more importantly moral questions. For morality must ulti-
mately set the boundaries for the civil law itself, if we are going to even
approach a just society and so a better world.
In the next section, we shall consider the implications of all of this for the
concept of the good life. Before doing so, let us return to our original question:
What is possible? It has been argued first of all that we are pragmatically
justified in hoping that we can make things better, that a good life is possible,
and that the opposite assumption of despair is not pragmatically justified. It
was further noted that what needs to be changed above all else is ourselves.
Finally, we have considered the nature and the importance of the art of accep-
tance, since much of the world (including other people) cannot be changed and
so must be accepted as they are. We must somehow learn to live with much of
the world as it is and concentrate on what we can realistically change. This art
of acceptance is something that especially needs to be emphasized, because one
of our problems, especially in the Western world, has been a tendency to focus
exclusively on the art of control. And this exclusive emphasis on the art of
control is one of the main reasons we have made such a mess of things.
WHAT REALLY MATTERS?

We have noted two different kinds of problems, world-want conflicts and
want-want conflicts. Yet, in real life, most problems entail both kinds of con-
flicts simultaneously. The polluted condition of our earth is something we all
(or nearly all) want to see disappear. So this problem entails a world-want
conflict. At the same time, most of us do not want to make the material
sacrifices that are very likely going to be necessary to clean up the earth. So this
very same problem also entails a want-want conflict. And this is the rule and
not the exception concerning life's problems.
Now, earlier we noted that the successful resolution of want-want con-
flicts nearly always involves the art of acceptance, since the extent that such
conflicts can be resolved without giving up something that we want is ex-
tremely rare. So in most cases, we must decide which among the conflicting
wants is most important. Putting matters another way, the successful resolution
of our problems generally presupposes a sound system of value priorities. This
is one of the things the art of acceptance is all about.
The process of establishing sound value priorities is a complex, lifelong
process. But one thing that needs to be taken into consideration in this process
is the fact that human beings are rational in a very distinct sense that is not
known to be true of any other animal. By way of clarifying the notion that
humans are rational, let us consider the following three arguments:
• Argument 1: Smokers are ten times more likely to get lung cancer than
nonsmokers. Smoking is therefore very likely an important causal factor
in getting cancer.
• Argument 2: Driving under the influence of alcohol or drugs dramat-
ically increases the driver's chances of killing someone. Therefore, driv-
ing under the influence of alcohol is morally unacceptable behavior.
• Argument 3: People who disagree with me are a danger to me. I must
therefore take whatever measures are necessary to protect myself from
such people.
Let us make a few observations about these arguments. First of all, while
arguments 1 and 2 are good arguments, argument 3 is a very bad argument and
this is plain to any reasonable person. (For in the first place, the premise in
argument 3 is false. And in the second place, even were the premises true, the
conclusion would not follow). The point is that people have the capacity to
construct arguments and to understand the arguments others have constructed.
More important, they also have the ability to evaluate such arguments and so
to distinguish good arguments from bad ones and, among the good arguments,
those that are better or best. And with practice and study (of logic, philosophy,
science, etc.) people can significantly improve these abilities. So this is part of
what is meant in saying that humans are rational.
There is more. We not only have the ability to reason and to distinguish
between good and bad arguments. When we come across good arguments,
such good arguments have the power to change our beliefs and, in changing our
beliefs, change our behavior. And this can happen even in cases where we do
not want to give up the behavior in question. Thus, arguments such as argu-
ment 1 have resulted in hundreds of thousands of people giving up smoking. In
many (perhaps most) cases, it was not the argument alone that changed
people's behavior. But arguments such as argument 1 played the decisive role.
For it was such arguments that made people realize that smoking is a bad thing
and that ultimately provided the motive for them to change in the first place. So
the second part of human rationality is the fact that good arguments can
radically and decisively motivate humans to change their behavior.
Not only is human rationality a factor in human behavior, it is a very good
thing that it is. For if smoking can cause cancer and if driving under the
influence can kill people, then it is a good thing that people change these
behaviors. So in saying that humans are rational, I am saying something that is
very good about humans and that is particularly important to keep in mind in
our pursuit of a better world. For reason can help us gain the understanding or
wisdom that will make a better world possible. In fact, without reason such
wisdom is impossible.
One of the interesting things about human rationality, something that
really distinguishes us from other animals, is our ability to think about things
that are quite abstract, things that cannot be perceived by the senses. Numbers,
black holes, atoms, electromagnetic fields, principles, and laws (in science,
ethics, and civil life), God or gods, ghosts, and the immortal soul are all
examples of abstract things, things not perceivable by the senses. We are,
moreover, capable of constructing various arguments (pro and can) concerning
the existence of such things or concerning the usefulness or wisdom of believing
in such things. Without the ability to do this, science, philosophy, religion, and
art and indeed all of our institutions and culture would be utterly impossible.
All organisms have a biological history, but only humans have a cultural histo-
ry. And it is possible only because humans are rational. So, this is the third part
of what is meant in saying that we are rational.
The art of acceptance, like every other part of human culture, rests on
human rationality: Reason has a vital role to play in this art, too. For good and
bad arguments can be distinguished concerning the value priorities in light of
which we resolve our various want-want conflicts-whether those conflicts be
of a purely intrapersonal nature or also of an interpersonal nature. In building a
better world, we must confront such conflicts and use our best reason (our best
arguments such as arguments 1 and 2 above) to resolve them. Reason must
guide us so far as it is capable of doing so; otherwise we will never build the
better world we are all seeking.
There are many ways "to skin a cat" and there are many ways to solve our
problems. It is important, therefore, to distinguish between solutions to prob-
lems that are merely effective and those that are truly good. Anything a person
does that ends the conflicts involved in a problem may be considered an effec-
tive solution to a problem. If a young woman needs money to go to medical
school, there is a conflict between her desire to go to medical school and her
lacking the money to do so. Strictly speaking, anything she does that provides
her with the required money (from murder or prostitution to working as a real
estate agent or getting a loan or a scholarship) is an effective solution in the
sense that it will end the original conflict (between wanting to go to medical
school and lacking the money to do so). An effective solution would of course
also be to give up her desire to go to medical school for that would likewise
bring the conflict to an end. Yet not all solutions, even though they may be
equally effective, are equally good. And some are not good at all. A truly good
solution is the best or one of the best among the effective solutions available.
And reason can play a role in determining whether or not a solution is truly
good.
First of all, the identification of the various possible effective solutions to a
problem requires reason. For whether or not a given solution will be effective is
something we can only determine by reasoned argument. Reason also has a role
to play in further determining which among the various effective solutions is
the truly good one. For one thing, this entails a consideration of the side effects
or total consequences that will result from a given (effective) solution. The
likely side effects of getting money by means of murder, by prostitution, by
honest labor, and so forth, will be profoundly different, and it is only by means
of reason that we can anticipate what these various consequences will be. And,
finally, once we understand the various likely side effects that will accompany
the different effective solutions, there is the matter of having sound value priori-
ties by means of which to judge the various alternatives. A person with sound
value priorities would, for example, immediately rule out murder as a solution
to some problem. And reason has a role to play in the determination of sound
value priorities as well.
The determination of sound value priorities is indeed the most fundamen-
tal and most important of the roles reason must play in building a better world.
Yet it is the area that is most often neglected and misunderstood. So this is the
aspect of problem solving that requires the most careful attention. The question
we need to ask is this: What is it that makes one set of value priorities sound
and another set unsound? A step in the right direction is to realize that the
sound value priorities are those that make for a good life, while the unsound
value priorities are those that undermine a person's living a good life. So, to
know what value priorities are sound (i.e., to know what really matters), we
need to ask ourselves what it is to live a good life.
Our interest here is not in what would be a good life for Martha as
opposed to Bill, for it is obvious that in many ways what constitutes a good life
will vary from person to person. Our concern is rather with the basics: What is
it that is essential for anyone to live a good life? We can make a beginning by
focusing on two things: happiness and moral character. For these are two
things that are essential in order for anyone's life to be a good one.
Happiness is something that everyone wants and so is commonly recog-
nized as something essential to living a good life. Nonetheless, people some-
times have different concepts of happiness, so some clarification is in order.
First of all, we need to bear in mind that the word "happiness" as it is ordi-
narily used is an internalist term, i.e., a word that cannot be defined in terms of
people's overt behavior but only by their inner mental states. It is indeed the
sort of thing that, like pleasure and pain, cannot be understood at all by
someone who has not experienced it. Imagine a race of beings who came to
earth and studied our behavior, let us say using something like (or the same as)
Skinner's (1971) principles of reinforcement to do so. Let us also imagine that
these intelligent creatures never experience anything such as we describe as
pleasure, pain, or happiness. They still might be as successful as we are in
applying Skinner's principles to our overt behavior in the limited sense that
they did just as well as we do in predicting and controlling the behavior of
humans. Yet it is very plain that, since they themselves have never experienced
pain, pleasure, or happiness, they would not understand what we meant when
we used the words "pain," "pleasure," or "happiness." In fact, they would not
really understand us. For they would not understand that it is pain that moti-
vates people to take an aspirin when they have headaches or pleasure that
sometimes leads them to engage in sex or go to a gourmet restaurant. They
would say that humans find these things reinforcing (in Skinner's sense of the
word). But they would fail to understand just what it was (the pain and plea-
sure) that made these things reinforcing to us. So pleasure, pain, and happiness
are internal, for they are qualities of experience and they can only be known
from the inside, so to speak.
Pleasure and pain are ingredients of happiness. The more pleasure and the
less pain, all else being equal, the more happiness. Whatever happiness is
exactly, it is made up of qualities of experience such as pleasure (e.g., feelings of
bliss, contentment, joy, ecstasy, rapture, and delight) and the absence of quali-
ties of experience such as pain (e.g., feelings of sorrow, grief, sadness, dejection,
melancholy, and wretchedness). When people use the word "happiness," this is
generally what they have in mind. People's conceptions of happiness differ
because what gives them (or what they think gives them) pleasure and pain or
happiness and unhappiness varies from person to person. But though people's
concepts of happiness differ in this sense, what they generally mean when they
speak of happiness and unhappiness is the same thing. For as the term is
ordinarily used, it means the presence of positive feelings or qualities of experi-
ence such as pleasure and the absence of negative feelings or qualities of experi-
ence such as pain. And in any case, happiness in this sense is something that
everyone wants and that is in fact an essential ingredient in living a good life.
All else being equal, we would all prefer a life that is happy to one that is
unhappy.
Moral character is likewise essential to living a good life. Before consider-

ing why this is so, something needs to be said about what it is to be a moral
person, what it is to have moral character. To this end, it will be useful to calI
on some notions of Martin Buber's (1958), taking certain liberties in interpret-
ing Buber where it seems useful to do so. Buber makes the observation that a
fundamental fact of existence is relationships, and he describes two basic ways
we can relate to the world. The first way is described as an I-it relationship.
Something is an it for us if it is a mere means, an object to be described,
analyzed, dissected, studied, controlled, and manipulated exclusively for our
ends or purposes. So far as we relate to something in an I-it way, its purposes
or ends (if it has any) are invisible and unreal to us. Its have no inside for us. In
contrast, Buber speaks of an I-thou relationship. A thou is never a mere means
to our ends. The ends or purposes of a thou are visible, real, and important to
us. A thou is an ends-in-itself. A thou has an inside for us. If the thou we are
dealing with is another human being, then this places the thou on an even
footing with ourselves. For in all essentials, another human being is like our-
selves. They have longings, desires, hopes, fears, pain, and joy the same as we
have. They, like ourselves, are rational beings, capable of reasoning and relating
to an abstract reality. They, like ourselves, have therefore a viewpoint concern-
ing life and existence. They, like ourselves, can take their stand on their needs,
establish value priorities, define the good life for themselves, and understand
and live a moral life. So far as a person is a thou for us, therefore, we behold a
being whose worth is as great as our own, a being whose happiness we care
about and whose rationality and autonomy we respect.
The care we have for the happiness of others draws us into their lives,
leading us to help them as we can. In contrast, the respect we have for their
rationality and autonomy leads us to stay out of their lives, allowing them to
work out their own happiness and their own conception of a good life. It is
essential for us to do the latter, for if we help them when they do not want us to,
we thereby undermine the respect they have for themselves. That very briefly
and very roughly is the nature of an I-thou relationship when the thou is
another person.
To cultivate moral character in the best and most fundamental sense is to
become a person who relates to others as thous and not as its, as ends-in-
themselves and not mere means. The cultivation of such a character entails, of
course, the cultivation of certain virtues or dispositions such as honesty, moral
courage (or doing what is right in spite of the personal cost), temperance (or the
avoidance of destructive temptations), and the like. For a person lacking such
dispositions will tend to be self-serving and manipulative when dealing with
others and so tend to reduce others to a mere means. So when I speak of
someone who has moral character, I primarily mean someone who regularly
treats others as thous. But I also mean someone who has cultivated all of the
virtues or dispositions, without which it is not possible for a person to treat
others as an ends or a thou.
Why is moral character in this sense essential to living a good life? Intu-
itively, it seems clear that this is the case. But it is also possible to see this
analytically by considering some of the differences between a life lived by
someone who has moral character versus a life lived by someone who is lacking
in moral character.
First, a life lived by someone entirely devoid of moral character would be a
life entirely devoid of any meaning, while, in contrast, a life lived by someone
having the highest moral character is a life full of meaning and purpose. The
ambitions and goals of the immoral person are all ultimately self-serving, and
such goals and ambitions therefore can have no greater meaning or significance
than the little self they serve. In contrast, the ambitions and goals of the person
who has the highest moral character are ambitions and goals pregnant with
genuine meaning and significance. For they are always concerned with others,
not abstract others but concrete, living thous with whom they interact. So one
reason that moral character is essential to the good life is that without it life has
no meanmg.
The second reason is partially related to the first. In serving others, in
taking account of their needs and concerns and in respecting their views and
rights, there arises a certain healthy self-forgetfulness that is spiritually liberat-
ing. The person who is devoid of moral character is constantly focused on his
fate and his well-being and anxiously goes through life, as Buddha put it, like a
leaf in the wind. For such people are constantly at the mercy of all of life's
unpredictable and uncontrollable vicissitudes. In contrast, a person whose
moral character is highly developed is spiritually or inwardly free and indepen-
dent. For a requirement of the highest moral character is moral courage, which
entails placing the moral good (or doing the morally right thing) above person-
al welfare, and it is this quality of moral courage more than anything else that
spiritually frees the moral person from life's uncertainties and perils. It is the
basis of a mastery over life that is unknown, even unthinkable, to the person
lacking moral courage. Yet such mastery over life (such inward freedom) is
essential to living a truly good life.
A third and final consideration is self-respect. There are many reasons why
people are held in esteem or admired. But in the end it is based on the posses-
sion of some virtue or the perception of the possession of some virtue. People
who have money or power or fame, for example, are ultimately esteemed not
for having these things, but for the virtues people assume having these posses-
siems reflect. Wealthy people, for example, are frequently perceived as having a
superior intelligence, wisdom, mastery, and so forth concerning life and ulti-
mately are admired or esteemed for having such virtues (real or imagined). And
the same is true of power or fame. Powerful and famous people are admired for
the virtues people imagine they have. Similarly, people enjoy being praised, not
simply for the praise itself (though it may be a conditioned reinforcer), but
because they assume it is deserved and thereby indicative of some virtue or
virtues. (Just imagine the difference between being praised for something you
rcally did do in contrast with being praised for something you very well know
you did not do and this becomes clear.) Hence, what arouses our esteem for
others or for ourself is the perception of virtue. But the highest virtue and the
virtue most intimately attached to a person's worth is his or her moral virtue.
For we esteem a person of the highest moral virtue even if he or she is lacking in
all other virtues. And conversely, we ultimately have no esteem or at least no
respect for a person totally lacking in all moral virtues, no matter what or how
many nonmoral virtues he or she may have. And this is true whether that
person be ourselves or another. Hence, deep down, the immoral person really
has no self-respect and is in fact full of self-loathing. Living a moral life, then, is
a necessary condition of self-respect and self-respect in turn is essential to living
a good life.
Let us return to our original question: What really matters? What really
matters, we have seen, is to live a good life, and this we have seen entails being
happy and being moral. So when we solve our problems, as we go through life,
if we want to live a good life, then we must choose the solutions that are not
merely effective or easy but those that are conducive to our overall happiness
and consistent with what is moral.
HOW CAN WE BUILD A BETTER WORLD?
In the second section it was argued that we are pragmatically justified in

believing that it is possible to live a good life, and in the previous section it was
further argued that both happiness and morality are essential ingredients of a
good life. So, in this section we must now consider how it is possible to live a
life that is a good one, and that means one that is both happy and moral.
Otherwise, we will be leaving everything up in the air.
The very first problem we need to confront is the conflict (or at least
apparent conflict) between doing what will bring us happiness and doing
what morality requires. In order to sharpen the discussion about this conflict,
I will offer what I believe to be the supreme principle of morality as follows:
Love your neighbor as you love yourself. I shall not here seek to defend the
claim that this is the supreme principle of morality. For I am only using it to
illustrate the tension that exists between doing what is moral and doing what
will promote our own happiness, and, for such a limited purpose, practically
any of the familiar moral principles that might be posed would do just as
well. Hence, since for purposes of illustration one principle will do the job
about as well as any other, I prefer to use the one I happen to believe is the
right one.
Suppose that Torn and Ben are on an island 100 miles from any help, with
only a very small, one-person rowboat as a means of transportation. Suppose,
moreover, all food and water supplies are gone (the island being a small rock
surrounded by a lifeless sea). In short, only one person has any chance of
surviving-whoever takes the boat and heads for the nearest mainland. Ben
(acting on the above moral principle) has offered to have each of them draw
from a deck of cards, with the high card winning, as the way to determine who
wiIl use the boat (even though the boat in fact belongs to Ben). Tom agrees to
this but loses, so that the boat will go to Ben. Now, it is clear that if Tom acts on
the principle of neighborly love, he will let Ben go and wish him well. But let us
also assume that Tom is much stronger than Ben and could very easily overpow-
er Ben and take the boat instead. And let us imagine that Tom could easily do
this without any other person knowing it. Out of consideration for his own
happiness, Tom may well reason that this is what he should do. But the princi-
ple of neighborly love would clearly prohibit such a thing as highly immoral.
The principle says, love your neighbor as yourself, not love your neighbor as
yourself so long as doing so does not interfere with your own happiness. The
latter principle would be absurd, a self-contradiction. For always putting your
own happiness first is precisely not loving your neighbor as yourself. So, it
looks as if Tom is in a situation where he can either choose happiness or
morality, but not both. And, in less dramatic ways, life seems to frequently
present us with situations such as lorn's.
Indeed, some people have argued that the world is such that happiness and
morality are generally in conflict, that we must choose one or the other and
cannot have both. In Woody Allen's film, Crimes and Misdemeanors, we are
presented with a world in which the wicked prosper and the good are crushed.
It is a very old theme and the question it raises is just as important as it is old.
For, as we have seen, both happiness and morality are essential to a good life.
So if the human condition is such that we must choose one and give up the
other, the good life is impossible. It has already been argued that such a
conclusion must be rejected on pragmatic grounds. But if we assume that a
good life is possible, then the question we must ask is this: How is it possible to
be both happy and moral in a world where these two things seem to be in
conflict with one another?
One solution that has been suggested is to liberalize the requirements of
morality so that the conflict between happiness and morality simply disap-
pears. The basic idea is to so loosen the requirements of morality that the
individual agent's happiness is always given a priority. It does not much matter
how this is done. The essential thing is that it would require people to be moral
only up to a point, namely, only up to the point where doing the moral thing is
a serious threat to their personal hatJpiness. But such a proposal is unaccept-
able, both from society's viewpoint and even from the agent's viewpoint.
In the film, Crimes and Misdemeanors, a distinguished and highly hon-
ored physician has an affair that becomes a threat to his marriage and his career
when he tries to end it and the woman (to whom he has continuously lied) says
she will reveal all. Seeing no other way out of his dilemma, he has her murdered
and by the end of the movie he resumes his life as if no such thing ever
happened. Clearly, by all current standards of morality, what he did was wrong.
But if we were to take up the proposal of overriding moral considerations when
they seriously threaten our happiness, then we would have to say that the
physician acted in a reasonable and morally acceptable manner. It should be
obvious that any society that tried to operate according to such a principle
would quickly become a jungle in which no one would be secure. Hence, this
proposal is utterly unacceptable from society's point of view.
It is also unacceptable from the agent's point of view. For previously it has
been argued that only the person with the very highest moral character can find
real meaning in life, be inwardly free, or have a deep and abiding self-respect.
And we can scarcely say this of a character such as Woody Allen's physician in
Crimes and Misdemeanors. For it is precisely the healthy kind of self-forgetful-
ness and attitude toward others as thous (of equal standing to oneself) that
gives life its meaning, that liberates us from the vicissitudes of existence, and
that enables us to truly respect ourselves. (The very idea that Woody Allen's
doctor is a moral hero would be absurd.)
A more promising solution to the problem is offered by Immanuel Kant.
Kant (1956) argues that considerations of personal happiness must always be
subordinated to doing what is morally right. This does not mean (as some
think) that our happiness does not count at all. Rather, it means that the weight
given our personal happiness must be determined by moral considerations.
Kant says we are to treat everyone as an ends-in-themselves, including our-
selves. But, says Kant, our happiness, from the moral perspective, is no more
important than anyone else's and the moral perspective must always be the one
that has the final say in what we do. So for Kant, in this life, happiness must be
sacrificed for the sake of morality. But, says Kant, a world in which it is
regularly possible for those who are immoral to be happy and for those who
are moral to be unhappy is absurd, an affront to reason. It is a world that we as
rational beings cannot make any sense of. Hence, the existence of a loving and
just God along with the existence of an immortal soul and a life hereafter are
requirements of practical reason, postulates of morality.
Kant is sometimes criticized for this argument on the grounds that this
reasoning is inconsistent with his claim that considerations of personal happi-
ness are secondary in moral reasoning. For, it appears, the critics hold, that
Kant is really reintroducing happiness as a motive for moral action by postulat-
ing another world in which the morally good person will be rewarded with a
happy afterlife. Such criticism, however, is unfair to Kant. For Kant says that we
must give a priority to morality over personal happiness whether or not we
accept the existence of God and an afterlife. So the existence of God is not a
requirement for doing what is moral. It is rather a requirement of making sense
out of the world, which is perhaps best described as a spiritual requirement for
beings that are both moral and rational such as ourselves.
Kant's is not the only interesting proposal made. Another has been made
by thinkers as divergent as Plato and Buddha (Plato, 1945; Smith, 1958). Both
Buddha and Plato speak of the necessity of undergoing a transformation. Al-
though Plato talks about education and Buddha the eightfold path as the
means by which the transformation is brought about, they are both talking
about the birth of a new person-a kind of spiritual metamorphosis from an
earthbound caterpillar to an airborne butterfly. In both cases the transformed
person finds happiness through morality.
Our earlier reflections give some support for these claims of Plato and
Buddha. For it was argued that only the moral person finds meaning, freedom,
and self-respect. Now, it seems quite clear that each of these is a necessary
condition, not simply for a good life, but for a happy one. It might also be
argued that these three conditions taken together are a sufficient condition of
true happiness. If this is the case, being happy and being moral are really two
sides of a single coin and in fact are really quite inseparable. For the fully
transformed person, morality is its own reward.
Kant's solution and the sort of solution offered by thinkers such as Plato
and Buddha are by no means mutually exclusive. For Christ spoke of both.
According to Christ, the faithful are spiritually transformed by their love for
God and for their fellow human beings, and thereby find true if imperfect
happiness even in this world and complete and lasting happiness in the next
(Living Bible, 1971, Matthew 5,6,7:1-26). And this is a view commonly held
by many Jews and Moslems as well (Steinberg, 1975, pp. 14-16).
The notion that the very highest moral character and a spiritual transfor-
mation go hand in hand is indeed common to all of the world's great religions
and it is likewise the view of this chapter. For, as argued earlier, the definitive
characteristic of persons of the very highest moral character is the fundamental
respect and care they have for others as thous or ends of equal importance to
themselves. And though the potential for such a character is no doubt given to
every healthy child, its actualization entails a transformation or maturation
that is comprehensive in its dimension and spiritual in its nature. It does not
happen automatically like the growth of hair, but it is the outcome of a deliber-
ate and lifelong struggle.
Our conclusion, then, is that both happiness and morality not only can go
together but do go together and are indeed inseparable. But ultimately how can
such a conclusion be defended to those who reject it. The answer seems to be
that ultimately it cannot be justified by argument alone. Yet it is something
those who are fully transformed, those of the highest moral character, have
claimed again and again. Perhaps an analogy can help. Suppose that humans
were born color-blind, seeing only black and white and various grays in be-
tween, but that some have discovered a certain way of life (including a certain
diet, etc.) that gives rise to seeing colors. The latter group, call them the seers,
would not have an easy time convincing the non seers that there is a radically
different way of seeing or experiencing the world. What arguments could they
give the hardened skeptics to overcome their doubts and interest them in pursu-
ing such a thing? There is none. For the words the seers used to describe the
colors of the world would be full of meaning for the seers but empty abstrac-
tions for the nonseers. Ultimately, the only way the nonseers could bridge the
experiential gap would be to adopt the seers' lifestyle and thereby become seers
themselves. And ultimately, the only way the morally undeveloped can really
understand the moral person's way of experiencing the world is to adopt their
lifestyle-to start acting like a moral person. First comes the behavior, after-
wards the insight.
This latter point is important. The morally undeveloped cannot really

understand the moral life and why it is inseparably linked with happiness. For
they have no experience of such a life. But this means that they cannot really
understand the good life and so are not wise. In order to gain such an under-
standing, they must first learn to behave like those who are moral and thereby
start to experience life as those who care about and respect others do (along
with the meaning, freedom, and self-respect that go with such a life). Initially,
children behave in moral ways, because society reinforces them (in various
ways) for doing so. But if the child's moral development is not in some way
distorted or arrested, she or he learns, more and more, to replace these motives
with moral motives. For she or he learns more and more to identify with others,
to share in their inner life (their sufferings, cares, joys, perspectives, etc.), and so
to experience them as thous and not mere its. And with this comes more
meaning, more freedom, and more self-respect. In general, the more immersed
she or he becomes in a moral way of being on a daily basis, the more under-
standing she or he has of the good life, and so the more wisdom.
Things go the other way, too. It is far from true that the relevant insights
come from action alone. In the first place, moral action is necessarily very
complex and moral decisions therefore entail moral deliberation and moral
principles. And such moral reflection, carried out in a serious way and on a
daily basis, necessarily gives the person a deeper and deeper insight, not only
into morality, but into herself, into life, and into the human condition in
general. Morality is after all concerned with the good life and necessarily has
wisdom as its by-product (when seriously and deeply pursued). Not sur-
prisingly, we can learn a lot, indeed most, from others and so do not have to
think everything through for ourselves. Such deeper wisdom about life in turn
strengthens moral character. So if it is true that greater moral character makes
for greater wisdom, it is also true that greater wisdom makes for greater moral
character. In the end the two go hand in hand. 1
We are now in a position to see more clearly why wisdom is the key to a
better world. First, a better world would be one in which people treat one
another better, and wisdom is a key here. For if wisdom and moral character go
hand in hand, then so do wisdom and treating one another better, for treating
others better is ultimately what morality is all about. Second, as we have seen,
the good life is not simply a matter of getting better treatment from others; but
even more, something that is in our control, namely, treating others better. For
that is what having moral character is about. And this again is inseparable from
having wisdom.
'It is worth observing in this connection that the study of moral philosophy by itself (including its
special applications to medicine, business, law, the environment, etc., and even casuistry, which
discusses particular applications of moral principles) is no substitute for the process of making
real-life moral decisions that affect one personally and concretely. for it is only the latter that
produces moral character and real wisdom. Yet all things being equal, the study of moral philoso-
phy can significantly enhance anyone's wisdom and moral character. It is in fact crucial to the
development of an ethically sound culture.
It is important to emphasize, in this connection, that wisdom is not just for

some (a ruling elite) but for everyone. For the more everyone treats everyone
better, the better for everyone, both (as we have seen) in the giving and in the
receiving of better treatment. There is, moreover, the fact that the better world
must be a fully democratic world. As Winston Churchill wisely put it, democ-
racy is the worst form of government except for all of the others that have been
tried. So a better world will be a world in which democracy survives. But as Ben
Franklin observed, democracy depends on the people being educated, which is
to say not only informed but wise. for fools can too easily elect fools for
leaders. So, if democracy is to thrive and not merely survive, everyone must
become as wise as they have the capacity to be.
Our conclusion is that wisdom is the key to a better world, the necessary
and sufficient condition of people living better lives. Yet many would say that
the world today often seems crazy and out of control, if not controlled by those
who are foolish and only interested in themselves. Perhaps there is something
to this perception. Still, it is by no means the whole story. If we look at the
larger picture, technology, which is often a major source of our troubles, is
likewise a cause for hope: Oddly enough, it is technology that is making
universal wisdom increasingly both a necessity and a possibility.
We do not have to look far to see why more technology necessitates more
wisdom. Consider Adolf Hitler and how close the Nazis came to world con-
quest. In the age of bows and arrows, Hitler's mad dream of a handful of
Germans conquering the world would have been laughable. On the other hand,
had the Nazis succeeded in developing the atom bomb at the beginning of the
war, Hitler's victory would have been a virtual certainty. This is not to mention
the threat of nuclear holocaust, nuclear waste, or the far more subtle ways in
which the misuse of technology is in fact destroying our world. The general
point is that technology amplifies the consequences of our actions and is rap-
idly shrinking the globe, so that we must all learn to deal with our world and
with one another in much better ways than we have in the past or we are going
to cause one another immense pain and suffering, if not destroy everything.
And that means that more and more we are going to need more wisdom and
more moral character, not less, than our ancestors just to get by. So technology
is going to force us to behave ourselves better or else.
Fortunately for us, technology is simultaneously making universal wisdom
more possible. For one thing, technology is making it possible and necessary
for people from diverse cultures to communicate and to interact and so (if they
so choose) to learn from one another, arriving at a deeper understanding of life
and morality. Technology likewise has the potential to widen the circle of those
who have leisure and education and so the opportunity to grow and mature in a
way that is conducive to wisdom. So, if technology necessitates more wisdom
and greater moral character, it also makes these things more possible.
Both the need for and the possibility of more wisdom is manifest in the
existence of the United Nations and its charter. For the United Nations exists
because there has been a growing awareness that the old ways of handling
problems are working less and less. And the moral principles presupposed by
the United Nations (imperfect as they may be) embody the beginnings of the
kind of wisdom we are going to need more of to get us through the twenty-first
century.
The question is where do we begin? Each of us begins where we are.
Teachers, therapists, parents, and others are in a position to influence and
nurture people and business people, politicians, college presidents, leading
artists and intellectuals, and others in positions of great power can help gener-
ate a world culture devoted to wisdom. Indeed, anyone who is wise can make
an impact on those around them. But the very first place each one of us must
start is with ourselves. For unless we ourselves earnestly seek wisdom and grow
wiser and more moral, we are only going to be part of the problem and not the
solution.
CONCLUDING REMARKS
It has been argued that wisdom is that understanding which is essential to

living a good or better life and that such understanding is the key to a better
world, a world in which people live truly better lives. To put some meat on
these bones, it was further argued on pragmatic grounds that it is more reason-
able to hope for a better world than to wallow in despair. Moreover, it was
argued that happiness and moral character are universally essential for living a
good life. But this seems to pose a problem since being happy and being moral
seem to many to be in conflict with one another and so mutually exclusive. As
it turns out, however, this is only how things seem to those whose moral
character is underdeveloped. For those having the very highest moral character
(those who have undergone a spiritual metamorphosis), being happy and being
moral are inseparable. Moreover, being wise and being moral are inseparable,
and it is these two things above all else that are essential to a better world. It is
wisdom in this sense, therefore, that may rightly be said to be the key to a better
world.
REFERENCES
Buber, M. (1958). I and thou. New York: Scribner's.
Dewey, J. (1930). The quest for certainty. London: G. Alan and Unwin.
Kant, I. (1956). Groundwork of the metaphysics of morals (H. J. Paton, trans.). London: Unwin
Hyman.
Living Bible (1971). Wheaton, IL: Tyndale House.
Plato (1945). The republic (1'. M. Comford, trans.). London: Oxford University Press.
Smith, H. (1958). The religions of man (pp. 107-119). New York: New American Library.
Steinberg, M. (1975). Basic Judaism. New York: Harcourt Brace Jovanovich.
22
Afterword
Waris Ishaq
Earlier, in Chapter 13, this handbook was described as a "response to the crises
of ou r times":
• The threat of a nuclear holocaust and an eternal winter. This will remain
until we stop making, testing, and buying and selling nuclear weapons .
• Pollution. Shrinking rain forests. Holes in the ozone layer. Even sun-
bathing has become a health hazard. Too much exposure to the sun's
ultraviolet rays, which are getting through the holes in the ozone layer,
can cause skin cancer.
• Substance abuse and dependency.
• The law-and-order crisis. Drug-related killings and the rate of crime in
general that keeps going up all the time. Small wonder that Americans,
calling TV stations and writing to newspapers, overwhelmingly have
supported Singapore's public caning of an American teenager for van-
dalism and theft.
• Poverty and homelessness. The United States, a nation among the richest
in the world and the only superpower, has more homeless people than
anywhere in the industrialized West.
• The decline of educational standards, the dropout epidemic, broken
homes, juvenile delinquency, and teenage pregnancies. And now AIDS,
the most merciless killer we have known.
Add to these the myriad other problems and threats to the lofty goal of
improving the human condition-problems that are associated with politics
Waris Ishaq • Department of Anthropology, University of Oregon, Eugene, Oregon '17403, and
Mental Health Paraprofessionals Training Division, Pacific Behavior Sciences Center, 2S81 Will-
akenzie Road, Eugene, Oregon 9740 I.
421
422 22 • AFTERWORD
and with political posturing by incumbents as well as candidates for political

office. In the zeal to cut waste and save the taxpayers' money, lawmakers are
advocating a variety of measures ranging from cutting taxes to eliminating not
only the Department of Education itself but also school lunches, as well as
many other social programs including welfare and the health care system.
Mothers of newborn babies must now mandatorily leave the hospital 24 hours
after the delivery-to save costs to insurance providers, but, in the opinion of
many medical professionals, at considerable risk to mothers and the newborn
babies.
As the managed health care system grows, the patient's autonomy be-
comes more restricted. Health management organizations (HMOs) require
every patient to have a primary care provider without whose referral the patient
may not see a specialist, even if he or she has been under the care of a specialist
for many years. The emphasis clearly seems to be on saving costs for the
insurance carrier and not on the patient's well-being. A typical case is a woman,
age 77, with chronic kidney problems and a history of strokes, who was told by
her primary care provider, "There's nothing that your specialist can do that I
cannot do." And the patient was denied a referral to the specialist, a nephrolo-
gist, who had been treating her for many years. The primary care provider also
scrapped a monitoring program instituted by the nephrologist: blood tests for
tracking the abnormal thickening of blood, a condition that had been associ-
ated with her two previous strokes. The patient wonders if she is a victim of
"medical neglect."
Meanwhile, violence remains an endemic problem in the United States as
well as worldwide. The holocaust at the federal building in Oklahoma and the
"Una bomber" scare in Los Angeles show the extent of our vulnerability. Hope-
fully, someday, the culprits will be apprehended and dealt with according to the
law-and this raises some serious questions.
The criminal justice system is based on deterrence through coercion, and
considerable research has shown that coercion breeds countercoercion. Typ-
ically, convicts in penal institutions have been there before; the penitentiary, for
them, becomes a more familiar surrounding than the world outside (see Sid-
man, 1988; Sidman & Ishaq, 1971).
Unfortunately, despite the high caliber of policymakers in the administra-
tion-many of them with graduate degrees from prestigious universities, in-
cluding the Rhodes scholar at the helm of the administration-they have failed
to make use of the talent, know-how, and relevant research experience of behav-
ior and cognitive psychologists (see Skinner, 1971; Sidman & Ishaq, 1991). A
notable omission was the failure of the administration to utilize the know-how
of psychologists (behaviorists as well as cognitivists) in dealing with the tragic
crisis in Waco, Texas. Because of the presence of a cult being a known factor in
the lifestyle in the Waco complex and in the ongoing showdown between armed
federal and state officials and the equally well-armed Davidians, this clearly
was a situation for psychologists to be called in. It is reasonable to expect that
22 • AFTERWORD 423
the lesson of Waco has not been lost, and that the administration will promptly
call in psychologists during similar crises of the future.
As we read in the chapters by the many eminent research scholars repre-
sented in this book, and in their and many others' writings in scientific jour-
nals, solutions are not out of reach. In applied behavior analysis, in cognitive
psychology, and in medicine and surgery, we have come a long way from the
earlier decades of experimentation.
"In addition to alleviating suffering of the human condition on an individ-
ual basis, attempts have been made to deal with improving the human condi-
tion on a more global social level," Cautela writes in his introduction to this
volume. Some of the efforts that deserve special mention are the launching of
the Behaviorlogist journal and the work done by Dr. Buskist and his associates
at Auburn University in Alabama to promote experimental analysis of human
behavior as distinct from experimental analysis of behavior, which traditionally
has focused on animal behavior research. Another landmark, with the promise
of much improvement in the human condition, is the creation of the Skinner
Foundation, headed by Dr. Skinner's pupil, fellow researcher, and daughter,
Julie Skinner Vargas.
As we look into the future, we also have good reason to have great expecta-
tions from Los Horcones, the living Walden Two community in which the task
of improving the human condition has been a top-priority undertaking. Men-
tion must be made also of the expectation that radical behaviorists and cogni-
tive psychologists will bridge the gulf that divides them, in deference to the
shared goal of scholars and practitioners in these two categories: improvement
in the human condition. This expectation (and hope) are based on Catania's
(1984) analysis of the "differences" between radical behaviorists and cognitive
psychologists:
much of the dispute between these two kinds of psychologists is simply a
matter of language. The difficulties persist not because behaviorists and
cognitivists cannot understand each other, and not because there are psy-
chological prohlems that either can resolve that the other cannot, but rather
because the two kinds of psychologists are interested in different types of
questions. The behaviorist tends to be interested in questions of function,
and the cognitivist in questions of structure . ... Although these two psy-
chological orientations differ in their language and in the research prohlems
that they emphasize, they have in common the reliance on experimental
method, the anchoring of concepts to experimental manipulation and ob-
servations, and the assumption that our suhject matter, however complex, is
orderly and not capricious. (pp. 8-9)
With the problems that face us, it seems reasonable to expect that behaviorists
and cognitivists will both rise to the occasion, recognize that they need one
another, end their turf battles, and join hands to work for the good of humanity
and for life on this planet. What seems to be a pace-setting event is the inclusion
of a seminar devoted to the integration of the views of both radical behaviorism
424 22 • AFTERWORD
and traditional clinical psychology at the annual convention of the Association

for Behavioral Analysis (ABA), held late May 1996, in San Francisco.
We need also to take notice of the promise that comes to us from outer
space-in the joining of United States and Russian spaceships to establish the
Atlantis-Mir space station. Medical research is being conducted to measure
and evaluate the effects of living in a zero-gravity environment. Russian cos-
monauts who have been living aboard Mir, their space station, for 3 liz months
are serving as subjects for a variety of tests. Results and further research will tell
us of the possibilities of our utilizing the therapeutic benefits of living in a zero-
gravity environment, the possibilities of setting up specialized clinics in space,
or of simulating zero-gravity conditions in specialized treatment centers on
Earth.
In conclusion, although this handbook covers a broad range of relevant
issues, space constraints have limited its coverage. Hopefully, its publication
will generate a second volume, and a third volume, and so on.
REFERENCES
ABA Newsletter (1996). Special convention edition, 19(1).
Catania, C. C. (1984). Learning (2nd ed.). Englewood Cliffs" NJ: Prentice-Hall.
Sidman, M. (19H9). Coercion and its fallout. Boston, MA: Authors Cooperative.
Sidman, M., & Ishaq, W. (1991). Beware of coercion. In W. Ishaq (Ed.), Human bebavior in today's
Skinner, B. F. (1991). Why we are not acting to save the world. In W. Ishaq (Ed.), Human bebavior
in today's world (pp. 19-J()). New York: Praeger.
About the Contributors
Jacob Azerrad is a clinical psychologist of private events in human behavior

who interned at the Children's Hospital change, the teaching of behavioral psy-
Medical Center in Boston. He was an as- chology in academic and applied settings,
sociate professor in the Department of and, most recently, the application of be-
Pediatrics at the University of Virginia havioral principles to HIV prevention.
School of Medicine. He has taught at Tufts Since 1991 she has served with the Cam-
University School of Medicine, The Mas- bridge, Massachusetts Center for Beha-
sachusetts School of Professional Psychol- vioral Studies as a fellow in the public po-
ogy, and Lesley College in Cambridge, licy program, with a focus on HIV preven-
Massachusetts. He is a member of the tion.
Massachusetts Psychological Association,
the Association for the Advancement of William M. Beneke, professor of psychol-
Behavior Therapy, and is currently in pri- ogy and research investigator at Lincoln
vate practice in Lexington, Massachusetts. University in Missouri, teaches learning,
behavior analysis, and physiological psy-
chology. He has conducted basic and ap-
Grace Baron received her MA ( 1%9) and plied research in the area of eating disor-
PhD (1975) in psychology from Boston ders since 1976. Much of this work has
College under the supervision of Joseph R. dealt with chaining and stimulus control
Cautela. She is currently professor of in the behavioral self-management of
psychology at Wheaton College, Norton, weight regulation. He is currently investi-
Massachusetts. She has served as director gating the interrelationships of obesity, ac-
of the Behavior Modification Unit, at Bos- tivity, diet, and energy balance in rats. He
ton State Hospital (1969-1972) and pro- received his BA in psychology from East-
gram director of the Groden Center, Provi- ern Washington University, and his MA
dence, Rhode Island (1976-19X I). Since and PhD degrees in experimental psychol-
19X I, she has served as consulting behav- ogy from the University of New Mexico.
ioral psychologist with the Groden Cen-
ter, a school and treatment center for per- Dawn M. Birk received her BA degree
sons with autism and other developmental from Colorado College in 1985 and her
disabilities. With G. Groden, she has co- PhD in psychology from Utah State Uni-
edited Autism: Strate/iies for Change versity in 1989. She also completed a
(1991, New York: Gardner Press). Her in- postdoctoral fellowship through Johns
terests in clinical behavior therapy and ap- Hopkins University School of Medicine
plied behavior analysis include the teach- and the Kennedy-Krieger Institute. Dr.
ing of self-control, understanding the role Birk obtained a certificate of gerontol-
425
426 ABOUT THE CONTRIBUTORS
ogy from Utah State University while bert J. Kearney, 1993, Pacific Grove, CA:
completing work on her doctorate. She Brooks/Cole).
has worked with the entire spectrum of Carl D. Cheney received his PhD in exper-
age groups, but has specifically gained ex- imental psychology from Arizona State
perience in working with the older popu- University in 1966. He was assistant pro-
lation. Dr. Birk has explored locus of fessor of psychology at Eastern Washing-
control, reaction time, maintaining and ton University from 1965 to 1968 and has
increasing skill performance, depression, been professor of psychology at Utah State
and activity in the elderly. She has served University since. He teaches and conducts
as a consultant and therapist for various research in the experimental analysis of
nursing homes, and currently works as behavior. His research is most often with
a psychologist for the Eastern Montana nonhuman subjects; however, he has con-
Community Mental Health Center in ducted research in perception, education,
Miles City, Montana. and basic learning with humans. Cur-
rently he is teaching behaviorology to ele-
Joseph R. Cautela is the originator of co- mentary school children and analyzing
vert conditioning and author of over 100 reinforcement schedule control with pi-
professional journal articles on the sub- geons. He is also involved in the investiga-
ject. He is currently director of the Behav- tion of neurotoxins and their impact on
ior Therapy Institute in Sudbury, Mas- sensory, motor, and learning processes in
sachusetts and also serves as consult- domestic livestock. The influence of phy-
ing psychologist to Harvard University totoxins and diet selection and learning
Health Services and clinical consultant to mechanisms in the fetal and early develop-
the Groden Center, Providence, Rhode Is- mental periods of animal life is of special
land. Dr. Cautela has served as director of interest since similar processes occur in
the Behavior Therapy Ward at Boston humans. Dr. Cheney is concerned with
State Hospital, has been director of the various programs of prevention and the
doctoral program in behavior modifica- social-environmental conditions that con-
tion at Boston College, and has been presi- tribute to the establishment and mainte-
dent of the Association for the Advance- nance of risky behavior. He has been a
ment of Behavior Therapy. Dr. Cautela is postdoctoral fellow in pharmacology at
also the author and coauthor of a number the University of Michigan and resident
of books, including Covert Condition- fellow at the Cambridge Center for Behav-
ing (with Dennis Upper, 1979, Elmsford, ioral Studies. He is a fellow of the Interna-
NY: Pergamon), The Covert Conditioning tional Behaviorology Association, editor
Handbook (with Albert Kearney, 1986, of Behaviorology, and director of the Utah
New York: Springer), Behavior Analysis State University Basic Behavior Labora-
Forms with Children (with Julie Cautela tory.
and Sharon Esonis, 1983, Cambridge,
MA: Cambridge Center for Behavioral Lacey O. Corbett received his BA from
Studies), Relaxation: A Comprehensive Providence College and his PhD from Bos-
Manual for Adults, Older Children, Young- ton College. He served as chairman of the
er Children, and Children with Special Department of Psychology at Providence
Needs (with June Groden, 1978, Cham- College and assistant professor of psychia-
paign, IL: Research Press), Behavior Analy- try (psychology) at Jefferson Medical Col-
sis Forms I and II (1981, Cambridge, MA: lege. He is the coauthor (with Nancy J.
Cambridge Center for Behavioral Studies), Corbett) of the film and manual entitled
and Organic Dysfunction Survey Sched- Relaxation Therapy: An Alternative to
ules (1981; Cambridge, MA: Cambridge Tension (1976, Plymouth, MA: Film Ther-
Center for Behavioral Studies), and The apy Associates). He is a clinical fellow in
Covert Conditioning Casebook (with Al- the Behavioral Therapy and Research Soci-
ABOUT THE CONTRIBUTORS 427
ety, the American Academy of Behavioral Dialogues Concerning the Foundations of

Medicine, and the Society of Behavioral Ethics (1989, Savage, MD: Rowman &
Medicine and he is a diplomate of the Inter- Littlefield), on the topic of wisdom and
national Academy of Behavioral Medicine moral philosophy and is currently work-
Counseling and Psychotherapy. He is in ing on two more, one discussing the rela-
private practice as director of Behavioral tionship between knowledge and wisdom
Therapy Associates, Plymouth, Massa- and another concerned with wisdom and
chusetts. the place of the humanities and the social
sciences in today's education. Prior to re-
Nancy J. Corbett is a clinical counselor
ceiving his PhD in philosophy from Bos-
specializing in the field of behavior thera-
ton University, Professor Garrett taught
py. For the past 21 years she has been em-
courses in philosophy in a program spon-
ployed in a multitude of psychological set-
sored by the University of Massachusetts
tings including Boston State Hospital, the
in Boston to inmates at Norfolk and Wal-
Veterans Administration Outpatient De-
pole state prisons. For the last decade, he
partment of Mental Health, The Rhode
has served as a consulting editor and advi-
Island Institute for Behavioral Modifica-
sory board member for an interdisciplin-
tion, and Behavior Therapy Associates.
ary journal, Behavior and Philosophy
She has participated in the training of doc-
(formerly, Behauiorism). Professor Gar-
toral candidates, conducted classes, semi-
rett's interdisciplinary interests date as far
nars and workshops, and lectured to vari-
back as his doctoral dissertation, Truth,
ous groups on the principles and practice
which defends a realistic version of truth
of behavior therapy. She has coauthored
based, in part, on B. F. Skinner's book,
with Lacey o. Corbett a manual entitled
Verbal Behavior. He is married, has two
Relaxation Therapy: An Alternative to
daughters, and lives in Newton, Massa-
Tension (1976, Plymouth, MA: Film Ther-
chusetts.
apy Associates). She has had extensive
experience in private practice doing be-
R. Douglas Greer is professor of educa-
havioral psychotherapy and behavioral
tion at the Graduate School of Arts and
medicine and has conducted many stress
Sciences and Teachers College of Colum-
reduction groups. Ms. Corbett received her
bia University. He received his PhD at the
MA in counseling psychology from Boston
University of Michigan in 1969. Cur-
College and is currently employed with Be-
rently, he is coordinator of the MA, EdD,
havior Therapy Associates in Plymouth,
and PhD degree programs in the Depart-
Massachusetts.
ment of Special Education that focus on
Richard Garrett has taught at Brandeis behavior analysis and behavioral disor-
University and Wellesley College and is ders. He is on the editorial boards of jour-
currently at Bentley College, where he has nal of Applied Behavior Analysis, Journal
been teaching courses in epistemology, of Behauioral Education, Behaviorology,
ethics, metaphysics, philosophy of science, and The Behauior Analyst and has pub-
logic, and philosophy of religion for the lished over 50 research and commentary
last 10 years. His publications and re- articles in the above journals, as well as in
search interests cover a wide range of the Journal of the Experimental Analysis
areas including ethics, philosophy of sci- of Behauior, Psychology of Music, journal
ence, metaphysics, epistemology, philoso- of Music Therapy, journal of Behauioral
phy of language, and the philosophy of Residences, Analysis and Intervention in
religion. Professor Garrett has a long- Deuelopmental Disabilities, and the jour-
standing interest in the topics of wisdom nal of Research in Music Education. He is
and moral philosophy, which in many the author or coauthor of five books de-
ways draw upon and synthesize the above voted to education and behavior analysis.
research areas. He has published a book, Over the last 25 years, he has sponsored
76 doctoral dissertations. He also origi- courses at the University of Oregon, Port-

nated the CABAS model of schooling and land State University, and Utah State Uni-
was one of the cofounders of the fred S. versity. He served, for brief periods, as a
Keller School. Dr. Greer is the father of psychologist at state mental hospitals in
three children (Angela, John, and Lissie). Oregon and California, headed a mental
health clinic in Dubai, United Arab Emi-
Michel Hersen is professor of psychology
rates, and, for more than 15 years, has
at Nova Southeastern University, Fort
conducted a private practice in psycho-
Lauderdale, FL. He is past president of
therapy and clinical hypnosis in Stamford,
the Association for Advancement of Be-
Connecticut, Eugene, Oregon, and Salt
havior Therapy; diplomate, American
Lake City, Utah. His current interests in-
Board of Professional Psychology; diplo-
clude (1) continuing research in cross-cul-
mate, American Board of Medical Psycho-
tural psychology; (2) a research project
therapists; and distinguished practitioner
that seeks to produce a synthesis of assess-
in psychology, National Academies of
ment procedures in clinical psychology
Practice. He is the author and coauthor of
and anthropology, particularly the use of
205 papers, 99 books, and 77 book chap-
participant observers in clinical work with
ters. His current research involves the
families and the use in anthropology of the
behavioral assessment and treatment of
method and rigor in assessment that have
older adults. He is coeditor of several jour-
been developed in psychological research;
nals, including Clinical Psychology Re-
(3) the putting together of a "psychology in
view, journal of Clinical Geropsychology.
real life" text, presenting-in simple, easy-
Behavior Modification, journal of Family
to-understand English-principles and
Violence, and journal of Anxiety Disor-
procedures in applied behavior analysis
ders. Dr. Hersen has been the recipient of
and cognitive psychology, a book designed
federal grants from the National Institute
for undergraduates, paraprofessionals,
of Mental Health, the US Department of
parents, and teachers who have not taken
Education, and the National Institute on
courses dealing with behavior manage-
Disabilities and Rehabilitation Research.
ment; and (4) a part-time practice in psy-
Waris Ishaq received his PhD from the chotherapy and clinical hypnosis.
University of Oregon, in human develop-
ment, in 1980, and his MA in history (US Albert J. Kearney, after graduating from
constitutional issues) from Portland State Stonehill College, went on to receive his
University in 1973. His focus of study, doctorate in counseling psychology from
training, and research during his doctoral Boston College in 1976. He has worked as
program and throughout his career has a school psychologist for the Maynard,
been on learning and overt and covert Massachusetts, public school system for
conditioning. Coeditor of this handbook, over 20 years. In addition, he has been a
with Senior Editor Joseph Cautela, Dr. Is- consultant to several schools and hospitals
hag edited Human Behavior in Today's while being involved in the private prac-
World (1991, Praeger), a collection of tice of behavior therapy. A past president
chapters by noted scholars, including B. F. of the New England Society of Behavior
Skinner. He currently serves as director of Analysis and Therapy, Dr. Kearney has
research and head of the paraprofessional coauthored two books and several articles
training division at the Pacific Behavior on covert conditioning and related topics
Sciences Center, Inc., a Eugene, Oregon- with Joseph Cautela. Besides working in
based nonprofit mental health research school and clinical psychology, his inter-
and service delivery agency. He also holds a ests include sport and exercise psychology.
courtesy appointment in the Department His experiences in a variety of sport and
of Anthropology faculty at the University exercise activities have helped shape this
of Oregon. He has taught psychology interest and the writing of his contribution
to this volume. A former captain of the Professor E. F. Malagodi. He moved to

Stonehill College hockey team, Dr. Kea- Boston, Massachusetts in 1984 to begin
rney's other athletic endeavors have in- conducting research in orientation and
cluded running over 25 marathons, com- mobility, and he designed and constructed
petitive Judo at the collegiate level, and the Bipedal Guidance System and the
several years' experience as a lifeguard and "walking lab." He received his PhD from
swimming instructor. Additionally, he is a the University of Florida in 1993. His pri-
licensed soccer coach who has coached for mary interest is in the integration of exper-
several youth soccer programs, including imental analysis and operant research
the Greater Boston Bolts. He is a senior methodology into applied settings and in
staff member for Rick Sewall Soccer Tech the rehabilitation of traumatic brain-in-
soccer camps and is currently vice presi- jured persons. Dr. Kupfer was a behav-
dent of his local soccer club. He has also ioral consultant to South Shore Mental
coached youth softball and icc hockey. Dr. Health, Quincy, Massachusetts. He is cur-
Kearney and his wife Anne, also a psy- rently program director at Mediplex of
chologist, maintain a private practice in Holyoke, Holyoke, Massachusetts. His
Medfield, Massachusetts, where they live long-time interest in music continues to
with their three daughters. manifest itself: Outside of his professional
hours, he can be found composing music
at his digital keyboard/ workstation, writ-
Christopher King is a postdoctoral fellow
ing poetry and lyrics, performing with his
in clinical neuropsychology at Bryn Mawr
band, or enjoying the company of his wife
Rehabilitation Hospital in Malvern, Penn-
and children.
sylvania. Dr. King received his BA from
Northwestern University, and his MS and
Glenn I. latham is a professor of educa-
PsyD from Nova Southeastern University
tion at Utah State University and director
in fort Lauderdale, Florida. He completed
of the Division of Technical Assistance of
an internship in clinical psychology at
the University's Center for Persons with
Norristown State Hospital in Norristown,
Disabilities. He is also director of the
Pennsylvania, with specialized training in
Mountain Plains Regional Resource Cen-
clinical neuropsychology and forensic psy-
ter, a federally funded project that pro-
chology. He is actively involved in neuro-
vides technical assistance to I () states and
psychological research through a collab-
the Bureau of Indian Affairs in strengthen-
orative effort between Norristown State
ing their capacity to serve difficult-to-
Hospital and the Medical College of
teach and difficult-to-manage children.
Pennsylvania/Eastern Pennsylvania Psy-
Dr. Latham has written and published ex-
chiatric Institute. Dr. King is also in pri-
tensively in the areas of parent and teacher
vate practice, specializing in clinical neu-
training. He is the author of two books,
ropsychology, geropsychology, and
The Power of Positiue Parenting: A Won-
nursing home consultation.
derful Way to Raise Children (1994, Salt
Lake City, UT: Northwest), and Keys to
Jeffrey Kupfer received his BS and MS in Classroom Management (1994, Park City,
psychology from the University of Florida. UT: Family Resources, Inc.), and two me-
During the course of his undergraduate diated training programs, Parenting Pre-
and graduate education in the experi- scriptions (1988, Salt Lake City, UT:
mental analysis of behavior program, he Reid) and Managing the Classroom blUi-
concentrated his studies on radical behav- ronment to Facilitate Effectiue Instruction
iorism and conducted research in condi- ( I 992, Mountain Plains Regional Re-
tioned reinforcement, schedule-induced source Center, Utah State University, Log-
(adjunctive) behavior, and experimental an, Utah). Prior to entering university
psychopathology, under the guidance of work, Dr. Latham was a classroom teach-
er for 6 years and a special education physical and psychological symptoms. He

school principal for 2 years. He has been a is the coauthor (with D. K. Whitla) of Pro-
member of the faculties of the University files in Cognitive Aging (1994, Cam-
of Utah and the University of Oregon, and bridge, MA: Harvard University Press),
a visiting professor at the University of Teenagers: When to Worry and What to
Hawaii and New Mexico State University. Do (1986, New York: Doubleday), and
He and his wife, Louise, are the parents of Understanding Human Adjustment (1983,
6 children and 12 grandchildren (and Boston: Little Brown). He is the senior au-
counting!). They reside in North Logan, thor of a computerized neuropsychologi-
Utah. cal test, Micro Cog: The Assessment of
Cognitive functions (1993, The Psycho-
Brady J. Phelps received his doctorate in
logical Corporation). Raised in Grand
the analysis of behavior at Utah State Uni-
Rapids, Michigan, Dr. Powell received his
versity in 1992, with his dissertation fo-
bachelor's degree from Lawrence Univer-
cused on the learning mechanisms un-
sity and his doctorate from Harvard Uni-
derlying behavioral tolerance to ethanol.
versity. He holds a diplomate in clinical
While in graduate school, Dr. Phelps taught
psychology. In his professional career he
a wide variety of courses in the depart-
has evaluated astronaut candidates for the
ment of psychology and he also served as a
Gemini and Apollo programs, studied the
graduate assistant in the department of bi-
impact of Big Brothers and Boys Clubs,
ology at Utah State. Dr. Phelps spent a
helped unemployed persons devise strate-
year as a lecturer for the University of
gies for finding jobs, developed a defi-
Maryland in the Republic of Korea and
nition of normalcy, and worked on inte-
joined South Dakota State University as
grating behavioral and psychodynamic
an assistant professor of psychology in the
techniques. In the spring of 1984, he was a
fall of 1992. Dr. Phelps is interested in
People-to-People delegate to the People's
animal models of behavioral ecology and
Republic of China. Dr. Powell married Vir-
has continued his interest in behavioral
ginia Stone in 1956. She administers the
tolerance and has applied behavior analy-
consulting practice. They have two chil-
sis to areas previously delegated to cogni-
dren and two grandchildren. Racquet
tive psychology, but to which cognitive
sports have been a chief outside interest,
theories have proved inadequate, as in the
along with gardening and occasionally
chapter in this volume. In addition, he has
raising puppies with his wife.
created a course at South Dakota that
looks at pseudoscience in psychology,
while also teaching introductory psychol- Daniel L. Segal is assistant professor of
ogy, physiological psychology, and other psychology at the University of Colorado
courses. Dr. Phelps is a member of the As- at Colorado Springs. Dr. Segal has spe-
sociation for Behavior Analysis, Division cialized clinical experience and training in
25 of the American Psychological Associa- the diagnosis, assessment, and treatment
tion, and Sigma Xi. of older adults. Over the past several
years, he has conducted programs of clini-
Douglas H. Powell is a psychologist, co-
cal research directed toward a wide range
ordinator of the Behavior Therapy Pro-
of psychological problems in the elderly
gram at the Harvard University Health
and has published numerous journal arti-
Services, and director of research in behav-
cles on diagnosis and intervention with
ioral science. Dr. Powell has held academic
this population. Dr. Segal is also experi-
appointments in the faculties of Arts and
enced in teaching and training practi-
Sciences, Education, and Extension. The
tioners to work with older adults.
author of more than two dozen papers on
behavior therapy, he directs the behavioral Jennifer L.. Twachtman received her BA in
treatment of individuals with a variety of psychology from the University of Rich-
mond and her MS in speech-language pa- of the International Behaviorology Asso-

thology from the University of North Car- ciation and associate editor of Behavior
olina at Chapel Hill. She is currently a and Social Issues. His recent publications
speech-language pathologist at the Brain- include "Experimental Analysis of Nega-
tree Hospital Pediatric Center in Brain- tive vs. Positive Rules in the 'Good Behav-
tree, Massachusetts. Prior to her arrival at ior Game'" (coauthored with Mary fran
the center, Ms. Twachtman worked at the Johnson and Doreen Vieitez) in Behav-
Groden Center in Providence, Rhode Is- iorology (fall 1993 ); "The Ulman-Skinner
land, a facility that serves individuals with Letters" in Behavior%gy (Spring 1993);
autism and related behavioral and devel- "Radical Behaviorism, Selectionism, and
opmental disabilities. While attending the Social Action," a chapter in Psychology
University of North Carolina at Chapel and Marxism, edited by Ian Parker and
Hill, she received specialized training at Russell Spears (in press); and "Marxist
Division TEACCH (Treatment and Educa- Theory and Behavior Therapy," a chapter
tion of Autistic and Related Communi- in Theories in Behauior Therapy (1995),
cation-Handicapped Children), North edited by William O'Donohue and
Carolina's pioneer statewide program for Leonard Krasner (1995, Washington, DC:
individuals with autism. In addition, she American Psychological Association).
was an assistant to Dr. Gary B. Mesibov,
Jerry C. Vander Tuig, associate professor
director of Division TEACCH, in a volun-
of nutrition and research investigator at
teer social skills group for adults with au-
Lincoln University of Missouri, teaches hu-
tism. Ms. Twachtman has presented her
man nutrition and conducts research in the
clinical work at several regional and na-
area of diet composition, metabolism, and
tional conferences.
obesity. He received his BS in biology from
Calvin College, Grand Rapids, Michigan,
Jerome D. Ulman is a professor in the De- and his PhD in zoology (physiology) from
partment of Special Education at Ball Iowa State University in 1976. Following
State University, where he directs the doc- graduate studies, he conducted postdoc-
toral program and teaches courses in the toral research in the Department of food
areas of behaviorological technology and Science and Human Nutrition at Michigan
behavior disorders. He received his bache- State University. He has published several
lors and ma,ters degrees in psychology research articles on diet composition and
from the University of South florida in energy metabolism in obese animal mod-
1965 and 1968, respectively, and his doc- els.
torate in educational psychology from
Southern Illinois University in 1972. Be- Vincent B. Van Hasselt is professor of psy-
fore joining the Ball State faculty, he had chology and director of the Interpersonal
been employed as a school psychologist in Violence Program at Nova Southeastern
Seminole County, Florida, as a research University in Fort Lauderdale, Florida. Dr.
scientist in the Behavior Research Lab at Van Hasselt received his MS and PhD
Anna State Hospital (now Choate Mental from the University of Pittsburgh and
Health and Development Center) in Illi- completed an internship in clinical psy-
nois, and as a behavioral consultant in In- chology at Western Psychiatric Institute
dianapolis public schools. His research in- and Clinic of the University of Pittsburgh
terests include experimental methodology, Medical Center. He was formerly pro-
the application of behaviorological tech- gram director of the Adolescent Drug
nology in special education, computer Abuse and Psychiatric Treatment program
technology, verbal behavior, and the so- at the University of Pittsburgh. Dr. Van
ciocultural implications of the natural sci- Hasselt is coeditor of the Journal of Child
ence of behavior. He is currently treasurer and Adolescent Substance AiJuse, Journal
of Family Violence, Handbook of Family
and Adolescents: A Clinical Approach, Julie S. Vargas is a professor of behav-

Handbook of Behavior Therapy and Phar- iorology in the Department of Education-
macotherapy for Children: A Compara- al Psychology and Foundations at West
tive Analysis, and Inpatient Behavior Virginia University. After college, where
Therapy for Children and Adolescents. He she majored in music, she taught third
has published over 130 journal articles, grade in New York City and graduated
books, and book chapters, including sev- from Columbia with a masters degree in
eral on the prevention, assessment, and music education. She married Ernest Var-
treatment of adolescent substance abus- gas and they moved to Pittsburgh, Penn-
ers. His Project for a Safe Family Environ- sylvania, where she taught fourth grade
ment, a multiple-component ecob- for a year, then worked for the American
ehavioral treatment program directed Institute for Research wntmg pro-
toward the problem of child maltreatment grammed instruction. She then went back
in inner-city families, has shown promise to school full-time, receiving her PhD in
in reducing levels of abuse and related educational research from the University
problems in this population. Dr. Van Has- of Pittsburgh. From 1966 to the present,
selt is the recipient of grants from the Na- Dr. Vargas has taught at West Virginia
tional Institute of Mental Health, the Na- University. Her areas of interest are in ap-
tional Institute of Handicapped Research, plications of behaviorology: instructional
Handicapped Children's Early Education design, verbal behavior, and research de-
Program, March of Dimes Birth Defects sign. She has published many articles and
Foundation, Buhl Foundation, and the three books-Writing Worthwhile Behav-
Pittsburgh Foundation. He has more than ioral Objectives (1973, New York: Har-
15 years of experience as a clinical practi- per & Row), Behavioral Psychology for
tioner, administrator, consultant, educa- Teachers (1977, New York: Harper &
tor, and researcher. Row), and Teaching Behavior to Infants
E. A. Vargas is professor of behaviorology and Toddlers (with B. Stewart, 1990,
in the Department of Educational Psy- Springfield, IL: Charles C Thomas). She is
chology and Foundations at West Virginia also author of a series of programmed in-
University. He received his doctorate in struction computer lessons on elementary
sociology from the University of Pitts- reading comprehension. She has published
burgh. His primary interests are behav- three articles about B. F. Skinner and is
iorology, instructional systems, organiza- continuing biographical work on his life.
tions, and verbal behavior. He has Dr. Vargas has been president of the Asso-
presented papers and published articles in ciation for Behavior Analysis and editor of
all of these areas of interest. He is a mem- The Behavior Analyst. She is currently
ber of the International Behaviorology chair of the publications board of the In-
Association and a director of the B. F. ternational Behaviorology Association,
Skinner Foundation. and president of the B. F. Skinner Founda-
tion.
Index
ABA. See Association for Behavior Analysis AIDS (acquired immunodeficiency syndrome)
(ABA) (cont.)
Acceptance, 406-407 Medline, 88-89
Accidental reinforcement, 246-247 prevention, 256-257
Acquired immunodeficiency syndrome I'sychlit, 88-89
(AIDS). See AIDS (acquired immu- scientific activity, 88-94
nodeficiency syndrome) behavioral publications, reporting in, 89-
AFDC. See Aid to Families with Dependent 94
Children (AFDC) See also HIV (human immunodeficiency vi-
Agca, Mahmet Ali, 190 rus)
Aged. See Aging; Elderly Aid to Families with Dependent Children
Aging, JS3-.199 (AFDC)
.ldjustment disorders and, 392 cash assistance, 2SS
aging m place, JIlS limitations on, threats of, 284
chemotherapy, .192-39.) requirements, 28 I
diet and, 395 residualist view of welfare programs, as,
functioning, mamtaming, and improving, 283
390-.192 See also Welfare programs
hOllsing,3RR-3X9 Aircrib, 267
intelligence, decreases in, 391 Alcohol abuse by elderly
lifestyle changes, 386-388 aftercare programs, 83
loclls of control, 385-386, .,89 aversion therapy, 78
losses, 390 behavior therapy, 77, 77-79, 82
memory, decreases in, J 91 cognitive-behavioral techniques in treat-
psychotherapeutic interventions, 392-394 ment, 74-7S, 82-83
psychotropic medication, 393 cognitive impairment, 76
response-contingent reinforcement, 386, depression and, 75
389,393 detoxification followed by socialization,
retirement, 386-387 77
mandatory, 388 diagnosis of, 70-71,82
self-concept, 386 family members, confrontation by, 71-72
sexual behavior, 391 "hidden" alcoholism, 70, 81
treatment issues and approaches, 392-395 isolated and impoverished older women,
Agriculture, Department of, 106, 112 treatment for, 77
AIDS (acquired immunodeficiency syndrome) late-onset alcoholics, 78
barriers to behavioral science, 95 motivation for treatment, 71-74
death, leading cause of, 88 multidimensional interventions, 78
433
434 INDEX
Alcohol abuse by elderly (cant.) Artificial intelligence, research on, 144

neuropsychological impairment, 76 Association for Behavior Analysis (ABA), 138,
physical impairment, 76 257
relapse prevention, 74-75 Athletic behaviors. See Sport psychology
response cost procedures, 77 Attention-seeking, 191-192, 363
self-medication, 75 Autism, 207-231
self-reporting, 83 behavioral instruction, 143, 212
social interventions, 77, 82 cognitive characteristics, 209-210
statistics, 69-70 communication system, 212-213
stigmatization and, 73 behavioral context, 218
treatment, seeking of, 72 communicative means, 218-221
veterans, 78 disturbances, 209
See also Substance abuse implementation of, 216-217
Alcoholics Anonymous, 82 picture exchange communication system,
Allen, Woody, 415-416 217
American National Red Cross, 318 respect, framework of, 213-216
America Now (Hams). 289 situational context, 217-218
Amnesia. See Brain-injured individuals, mem- symbol decisions, 219
ory rehabilitation techniques decision··making paradigm, 221-223
And the Band Played On (Shilts), 100 higher-level information processing, defi-
Anna O. case (Freud), 194 cits in, 209
Antecedent events, 242-243 intentionality, attribution of, 213-214
Anxiety joint attention, 212
relaxation training, 302 language, characteristics of
systematic desensitization, 252-253 aphasia, similarity to, 211
Anxiety meter, 252-253 echolalia, 210
Aphasia, 2 11 language-matched (MLU) typical chil-
Applied behavior analysis dren, 211
accidental reinforcement, 246-247 mentally retarded, similarities to, 211
antecedent events, 242-243 pragmatics, 211-212
appropriate behavior vs. good behavior, semantics, 211
236,254 syntax, 210-211
aversive stimulus, 248 nondesirable verbal behavior, 224-225
classical conditioning, 242 perceptual characteristics, 209-210
continuous reinforcement, 244 respect, framework of, 213-216
cultural determinants of behavior, 237, attribution, 213-214
253-254 ease, 215-216
imitative behaviors, 245-246 initiation, 214
inappropriate behavior vs. bad behavior, perspective, 215
236,254 social interaction, 212
laboratories, early work in, 241-245 speech, encouragement of, 224
language and, 250-252 transitioning between systems, 223-224
negative reinforcement, 247-249 understanding of, 208-212
non contingent reinforcement, 244 Autistic children. See Autism
operant conditioning, 242 Aversive controls, abandonment of, 272
paraprofessionals, need for, 237-238 Aversive srimulus
positive reinforcement, 243-244, 246 alcohol abuse by elderly, aversion therapy, n
radical behaviorism and, 249-250 applied behavior analysis, 247-248
reinforcement schedule, 244-245 Avoidance'
reprogramming social environment, 238- medical nonadherence, analysis of, 12
241 discriminated (signaled) avoidance, 12,
social learning, 245-246 17,21
systematic desensitization, 252-253 free-operant avoidance, 12-13
Appropriate behavior vs. good behavior, 236, one-factor theory, 13
254 two-factor theory, 13-14
INDEX 435
Baby-tender (B. F. Skinner invention), 264- Brain-injured individuals, memory rehabilita-

267,276 tion techniques (cont.)
reactions to, 266-267 visual imagery, 126-127
Balance, walking and, 46 written daily schedules, 128
Banff (Canada) Conference, 138 Branch Davidians, 422
Behavior. See specific topics Breast cancer, chemotherapy, 35
Behavioral medicine Breuer, Josef, 194
hrain-injured individuals, memory rehabili- Buber, Martin, 412
tation techniques, 123-133 Bush, George
covert conditioning, 23-43 Education 2001, 139
eating habits, improvement of, 105-121 environmental president, as, 256
medical nonadherence, analysis of, 9-21 Byrd, Senator, 248
psycho-oncology, 23-43
walking, nature of, 45-68 CABAS model of schooling
Behavioral selection, 144 description, 149-150
Behavior analysis, applied. See Applied behav- development of, 147
ior analysis learning disabled students, 150
The Behavior of Organisms (Skinner), 264 learn units, 149
Behaviorology, 144 parents' curriculum, 149
Behavior therapy. See specific topic students' curriculum, 149-150
Behavior therapy-generated insight (BGI), supervisors' curriculum, 149-150
.~01-314 teachers' curriculum, 149-150, 15]
behavior therapy added to psychotherapy, Cambridge Center for the Behavioral Studies,
307-308 101, 138
deterioration effects, 310 Cancer
negative effects, .~ 1 0 behavioral medicine in treatment of. See
spontaneous awareness enhanced by discus- Psycho-oncology
sion with tberapist, 304-306, 309 hopelessness and, 27
spontaneous recognition, 303-304 nature of, 25-26
i3evolld Freedom alld Dignitv (Skinner), 275, stress an d, 3 1
403 CARN. See Community Agency Referral Net-
BGI. Set' Behavior therapy-generated insight work (CARN)
(8C;1) Catalytic sequence, 302
Bibliotherapy, 348 CRO. See Community-Based Outreach (CRO)
BiJou, S,dney, 363 cc. See Covert conditioning
B1l1ldness. See Visual loss, walking and CDC National AIDS Clearinghouse, 10 1
Brain-injured individuals, memory rehabilita- Centers for Disease Control, 8)l
tion techniques, 123-].).) Chemotherapy
cognitive retraining, 130-131 elderly, 392-393
computer assistance, 125, 129 psycho-oncolo~y, 32, 33
concept rehearsal, 126-]27 breast cancer, 35
defining problem, 130-132 holistic treatment, goal of, 37
external memory aids, ]28-129 Chicago Cubs, 317
generalization training, 131 Children
practice drills, 125 attention-seeking, 191-192, 363
preview, question, read, state, and test autistic. See Autism
(PQRST), 127 cancer patients, covert positive reinforce-
self-instruction, 128 ment,31
specific techniques, 124-129 initial learning experience, 189-204
stimulus equivalence, 127-128 imitated behaviors, 199
strategy training, 126-127 maladaptive behaviors, 198
therapeutic nihilism, 132 nurturing behavior and, 193-195
vanishing cues method, 129 parents, encouragement of behaviors by,
verbal information, repeating of, 126- 196-199
127 time-outs, 201-202
436 INDEX
Children (cont.) Colleges and universities, improving (COllt.)

poverty; See also Aid to Families with Dc- new university model (cont.)
pendent Children (AFDC); Welfare library function, 183
programs organizational structure and, 178-186
increased welfare dependence, 281-282 partial organization model, 183
statistics, 281 personalized system of instruction, 179
reading and writing, learning of, 252 research function, 184-185
See also Parenti ng shaping model of instruction, 167-llR
Churchill, Winston, 419 organizational structure and, 16), 178-186
Classical conditioning requirement soilltions to problems of teach-
applied hehavior analysis. 242, 252 ing, lhO
psycho-oncology, 35-36 shaping model of instruction, I h 7-178
systematic desensinz,ltion model. 252 content and process ohjectives, illtcrac-
Clinical applicatIons tlon between, 174-175
heh'lVIor therapy-generated insight (BGl), creativity, 173
lOl-.l14 cumulative selection, 170
empathy, trailllng ot client, .137-35.'\ cumulative shaping cyhernetic (CSC),
human conditIOn, Improvemenr of, 4-5 170-173,175-178, ISO-lSI. 18S
sport psychology, 3IS-3.1) knowledg(' domain, 172
Clinton, Hilary, 238 performance objectiYes, 17.1-174
Clinton, Bill, 248 problem-solving domain, 173
Cognitive-hehavioral techniques in treatment students, 16 I
alcohol "huse, elderly, 74-75, 82-83 batch-processing of, I h.l
HIV (human immunodeficiencv virus), 96 failures of, 162-lh3
Cognitive impairment teaching, solutions to problems of, I hO, I h I
alcohol ahuse hy elderly, 76 bifacultyorganization, 178-ISh
hrain-injure~l individuals, memory rehahili- cumulative selection,170
tation techniques. See Brain-injured cumulative shaping cybernetic (eSC),
individuals, memory rehabilitation 170-173,175-178, Iso-un, 185
techniques division-of-Iabor teaching unit, 181-
Cognitive learning 182
movcment as basis for, 51 feedback, Ih9, 176-177
visual loss, walking and, 51-52 instructional team, 178-18h
Cognitive psychology lectures, 162
brain-injured individuals, memory rehabili- personalized system of instruction,
tation techniques, 130-131 179
radical behaviorism and, 249-250 presentation model of instruction, I h2
Colleges zlIld universities, improving, 159-188 quality control, 164, l7h-l78
bifaculty organization, 1lR-186 shaping model of instruction, 167-178
contingency paradigm, 166-67 tool soilltions to problems of teaching,
curriculum, 1hI 160
curve grading, 163-164 transformation paradigm, 161-1 h5
division-of-lahor teaching unit, 181-182 Columhi'"l University Teachers College, 141,
grade inflation, I h3-164 147-148
instructional team, 1 lR-186 CABAS model of schooling. See CA])AS
learning situation, basic components of, 161 model of schooling
market solutions to problems of teaching, Community Agency Referral Network
160 (CARN),81
new university model, 16S-ISh Community-Based OutrclCh (CBO), 81
administrators, roles of, IS5-18h Computet assistance, and memory rehabilita-
bibculty organization, 178-18h tion techniques for hrain-injured in-
cognitive revolution, 165 dividuals, 125, 129
contingency paradigm, 1 h6-h 7 Concept rehearsal, and memory rehabilitation
division-of-Iahor teaching unit, 181-182 techniques for brain-injured indi-
instructional teams, 178-186 \"iduals, 126-127
INDEX 437
Conditioning. See Classical conditioning; Cov- Creativity, 1n

ert conditiol1lng; Operant condition- Crimes and Misdemeanors (film), 415-
ing 416
Conditioning and Learning (Hilgard), 269 Criminal justice system, 422
Consequence training, and HlV (human immu- CSC system. See Cumulative shaping cyber-
nodeficiency virus), prevention of, 99 netic (CSC)
Contingency contract procedures, and sport Cuba, revolutionary, egalitarian populist wel-
psychology, 321 fare programs, 283-284
Contingency paradigm, and colleges and uni- Culture
versities, improving, 166-167 determinants of behavior, 237, 253-254
Contingent consequences, medical nonadher- poverty, superstructure of culture and, 288-
ence, analysis of, 14-15 289
Continuous reinforcement, 244 Cumulative shaping cybernetic (CSC), 170-
Cormorbidity, substance abuse by elderly, 75-76 173,175-178,180-181,185
Covert behavior, sport psychology, 324-331
Covert conditioning Darwin, Charles, 166, 190-191,271
chemotherapy, breast cancer, 35 Death, causes of
covert modeling AIDS (acquired immunodeficiency syn-
psycho-oncology, 30 drome),88
sport psychology, 328-.329 eating habits, relation to, 105
defined, 25 medical nonadherence, 10
empathy, training of client Decision-making paradigm, autism, 221-
covert extinction, 345 223
covert modeling, 347-348 Decision process, running, .122
covert sCl1'itization, .345 Depression, alcohol abuse and, 75
negative reinforcement, .>45 Desensitization, 252-253, 302, 303
positive reinforcement, .>45, .>46-347 Developmental considerations
self-control trial, .>47 aging, 383-399
grief and, 32 human condition, improvement ot, .3
HlV (human immunodeficiency virus), 99 parenting, 357-382
operant-learning theory, 24 Developmental disabilities
psycho-oncology, 23-43 autism, 143, 207-23 I
antecedent behaviors, 33-.>4 retardation, devclopmental, 147-149
behavioral assessment, 28-29 Dewey, John, 406
chemotherapy, 32, .n Diagl10stic and Statistical Mallual of Melltal
classical conditionlllg, 35-.,6 Disorders, Third Edition-Revised
conceptual concept of cancer, 27-28 (DSM-III-R)
conceptual model ot, 25-26 aging, 392
consequences of, 3S substance or alcohol abuse 111 elderly,
defined, 25 71
extinction, 32-33 Diem, Carl, 317
future considerations, 37-38 Dietary Guidelines for Americans, 108
hopelessness and cancer, 27 Diets (weight reduction programs). See Eating
imagery, 23-24 habits, improvcment of
modeling, 30 Differential Aptitude Test, 317
Pavlovian theoretical model, 26, 37 Disabled students
positive reinforcement, 30-32 behavioral instruction, 143
psychoneuroimmunology, 35-36 learning disabled, CARAS model of school-
radiation therapy, 33-35 ing, 150
relaxation, 29 Dissociation, sport psychology, 325
sensitization, 33-35 DNA, segment coding for malignancy, 38
target behaviors, 32-33, 34-35 Drug abuse. See Substance abuse
thought stopping, 29 Dual diagnosis, substance abuse by elderly,
visual imagery, 23-24, 36 75-76
sport psychology, 326-.1.30 Dys-ease, illness as, 24
438 INDEX
Eating disorders, 316 Egalitarian populist view of welfare pro-

Eating habits, improvement of, 105-121 grams, 283-284
change in habits, 117-119 Einstein, Alben, Y,7
self-monitoring, 118-119 Elderly
social support, 118-119 alcohol abuse
stimulus control, 117-118, 119 aftercare programs, 83
dietary guidelines, 106 aversion therapy, 78
elderly, 395 behavior therapy, 77, 77-79, 82
food guide pyramid, 108 cognitive-behavioral techniques in treat-
goal-setting, 107-110 ment, 74-75, 82-iU
life expect:mcy and, 106 cognitive impairmenr, 76
nutrition depression and, 75
change in habits, 117-119 detoxification followed hy socialization,
goal-setting and, 107 77
preparation of food, 1 13-114 diagnosis of, 70-7 I, 82
recenr changes in American diet, 106-107 familv members. confrontation by. 71-72
obeSIty, statistics on, 106 "hidden" alcoholism, 70, 81
recommendations, 119-120 isolated and impoverished older women,
recommended dietary allowances, 108 treatment for, 77
weIght reduction programs late-onset alcoholics, n~
assessment of current eat1l1g habits, 1 10 motivation for treatmenr, 71-74
cooking odors. 113 multidimensional interventions, 7g
eating chains, 111-117,119 neuropsychological impairment, 76
effectiveness of, 106 physical impairment, 76
goal-setting, 107-110 relapse prevention, 74-75
lack of adherence to, 107 response cost procedures, 77
portion control, 116 self-mcdication, 75
postmeal cleanup, 116 self-reporting, 83
preparation of food, 113-114 social interventions, 77
proscribed foods and failure, 109, 119 statistics, 69-70
purchasing of food, 112 stigmatization and, n
self-monitoring, 118-119 treatment, seeking of, 72
servi ng of food, 116-117 veterans, 78
snacks, 116-117 behavioral therapy, 394-395
social support, 118 chemotherapy, 392-393
stimulus control, 117-118, 119 dementia, 394
stimulus/response chains, 1 10-111 electroconvulsive therapy (ECT), 393
storage of food, 112-113 hypnotherapy, 394
Eating Slim, 118 intelligence, decreases in, 391
Ecclesiastes, 404-405 memory loss, 391
Echolalia, 210 psychoanalysis, 393-394
Eclectic therapy movement, 30 I psychotherapy, 394
Education psychotropic medication. 393
colleges and universities, 159-188 substance abuse, 69-85
decline of standards as social issue, 236, cognitive-behavioral techniques in treat-
421 ment. 74-75, 82-83
elementary and secondary schools, actions diagnosis of, 71
to improve (1984-1994),137-158 dual diagnosis, 7S-76
human condition, improvemenr of, 3 enabling, 79
learning, initial learning experience, 189- family therapy intervcntion, 79-80
204 group interventions, 80
special education departments, L) 7 illicit drug use, 70
teachers, for, 237-L)8 mainstreaming vs. elder-specific treat-
Education, Departmenr of. 422 ment, 72-73
Education 2001, 139 psychiatric comorhidity, 75-76
INDEX 439
Elderly (COllt.) Elementary and secondary schools, actions to

substance abuse (cont.) improve (1984-1994) (con!.)
relapse prevention, 74-75 selectionist-driven science of schooling,
same·aged peers, group interventions, 147-150
80 developmental retardation, prevention
sociotherapeutic interventions, 73 of,147-149
treatment, 72-80 stimulus equivalence research, 145
suicide rate, 75 strategic scientists, teachers as, 151
treatment issues and approaches, 392- tactics used to improve student response,
395 142-143
See also Aging teacher observation procedure, measure-
Electroconvulsive therapy (ECT), 393 ment,141-142
Elementary and secondary schools, actions to three-term contingency trial, measurement,
improve (1984-1994), 137-158 141-142
active student responding, measurement, Ellis, Albert, 198-199
140 Empathy, training of client, 337-353
advocacy efforts, 150-152 assessment of empathy (Empathy Survey
CABAS model of schooling Schedule), 341-345
description, 149-150 bibliotherapy, 348
development of, 147 case study, 349-351
learning disabled students, 150 clinical observation and, 339
learn units, 149 covert conditioning
parents' curriculum, 149 covert extinction, 345-346
students' curriculum, 149-150 covert modeling, 347-348
supervisors' curriculum, 149-150 covert sensitization, 345
teachers' curriculum, 149-150, 151 negative reinforcement, 345
conceptual changes, 143-147 positive reinforcement, 345, 346-347
behavioral selection, 144 self-control triad, 347
behaviorology, 144 definitions, 340-34]
epistemology, changes, 144 methods of training, 345-351
matching law, 145-146 negative empathy, 341-342
motative variables, 146 post-traumatic stress disorder (PTSD), nega-
operations, establishing, 146-147 tive empathy and, 342
radical behavIorism, 144 problems in employing, 35 I
'pontaneous speech, 146 satiation, 341
verbal behaVIOr, 147 shaping, 348
developmental retardation, prevention of, Empathy Survey Schedule (ESS), 341-345
147-149 Enabling, substance abuse by elderly, 79
Education 2001, 139 English Poor Laws, 282
educational research in behavioral analysis, Environmental issues, 256
151-152 Environmental Test Chamber. See "Skinner
journals and publications, reporting in, Box"
138, 150-152 Escape paradigm, medical nonadherence,
learning disabled students, CABAS model analysis of, 13, 16-17
of schooling, 150 ESS. See Empathy Survey Schedule (ESS)
learn units ET. See Empathy, training of client
CABAS model of schooling, 149 Evolution, theory of, 190,271
self-injurious or assaultive students, Exercise enhancement. See Sport psychology
increases of learn units by, 146 Extinction
uses of, 141-142 empathy, training of client, 345
measurement procedures, 139-142 psycho-oncology, 32-33
rate of responding, measurement, 142
research Family therapy intervention, and substance
artificial intelligence, 144 abuse by elderly, 79-80
basic science, 145 Fear, medical nonadherence, analysis of, 13-14
440 INDEX
Feedback HIV (human immunodeficiency virus) (cont.)

colleges and universities, shaping model of prevention of, behavior analysis and (cant.)
instruction, 169, 176-177 covert conditioning, 99
medical nonadherence and lack of immedi- involvement, how to accelerate, 95-101
ate feedback, 12-13, 16, 18 knowledge, expansion of, 100-10 1
Folkviews, poverty and, 295 operant approach, 97, 99
Food guide pyramid, 108 research on prevention, 96-97
Free-operant avoidance, 12-13 risky behavior, 100
Freud, Sigmund scientific activity in AIDS and HIY, 88-94
Anna O. case, 194 target behavior, 98-99
elderly, on, 393 Psychlit, 88-89
empathy, on, 339 scientific activity, 88-94
love and work, 197 behavioral publications, reporting in, 88-
nurturing behavior, learning and, 193-195 94
"talking cure," 194 threat of, 1
Wolf Man case, 194 See also AIDS (acquired immunodeficiency
Frost, Robert, 263 syndrome)
Homelessness, 236,421
GAI~ See Gerontology Alcohol Project (GAP) Homo sapiens, initial learning experience,
General Aptitude Test Battery. 317 189-190
Gerontology Alcohol Project (GAP), 78 Hopelessness, cancer and, 27
Getting the Love You Waitt (Hendrix), 195 Housing, aging persons, 388-389
Gibson, William, 192 How to Lie with Statistics (Murray), 285
"Golden Girls" (television program), 384 Hull. Clark, 263
Good life, essentials of, 411 Human condition
morality and, 412-418 defined, 2
Gorbachev, Mikhail, 256 improvement of, characteristics, 3-5
Gray, John, 267 Human immunodeficiency virus (HIV). See
Grief, covert conditioning and, 32 HIV (human immunodeficiency
Griffith, Coleman, 317 virus)
Group interventions, substance abuse by eld- "Humanist of the Year" award, 2
erly, 80 Hypnotherapy, 302
elderly, 394
Happiness, 411-412, 415-417
Harvard University, 13 Illness
Hawkins, Rob, 238 dys-ease, as, 24
Health and Human Services, Department of, nonadherence, medical. See Medical nonad-
106,108,112 herence, analysis of
Health care, managed, 422 See also AIDS (acquired immunodeficiency
Higher education. See Colleges and universi- syndrome); Cancer; HIV (human im-
ties munodeficiency virus); Psycho-on-
High schools. See Elementary and secondary cology; Raynaud's disease
schools, actions to improve (1984- Imagaletics
1994) sport psychology, 327, 330
Hill, Anita, 245 See also Visual imagery
Hitler, Adolph, 419 Imagery. See Visual imagery
HIV (human immunodeficiency virus) Imitative behaviors
chances of contracting, 15 applied behavior analysis, 245-246
epidemic, as, 15-16 initial learning experience, 199
Medline, 88-89 Immediate feedback. See Feedback
prevention of, behavior analysis and, 87- Inappropriate behavior vs. bad behavior, 236,
103 254
barriers to behavioral science, 95 Initiation, autism, 214
comprehensive behavior analysis, 98 Insight. See Behavior therapy-generated in-
consequence training, 99 sight (BGI)
INDEX 441
Integrative therapy movement, .)01 Listening, parenting and, 361-362

Intentionality, attribution of, and autism, 213- Locus of control, aging, 385-386, 389
214 Los Horconcs, 42.)
/ntemationai Encyclopedia of EducatIOn (Bi- Losing Ground (Murray), 285
jOu), .163
Intrinsic reinforcement, running, 319-320 Mainstreaming, elderly, substance abuse, 72-
73
Jacobsonian progressive relaxation Maladaptive behavior
cancer patients, 29 behavioral instruction, 143
sport psychology, 326 initial learning experience, 198
James, William, 15 Malthusian behaviorist view of welfare pro-
Jefferson, Thomas, 190 grams, 282, 287
Jobless recovery, 291 Mann, Jonathan M., 87
John Paul II, 190 Marxism, 291
Johnson, President Lyndon Baines, and War Matching law, elementary and secondary
on Poverty, 285 schools, actions to improve (1984-
Journals and publications 1994),145-146
American elementary and secondary educa- Maternal deprivation, 191
tion, reporting in, 138, 150-152 Medical nonadherence, analysis of, 9-21
HIV (human immunodeficiency virus), re- avoidance issue, 12
porting in, 88-94 discriminated (signaled) avoidance, 12,
Jung, Carl Gustav, 302 17,21
Juniper gardens, 140, 147-148 free-operant avoidance, 12-1.)
contingent consequences, 14-15
Kant, Immanuel, 416-417 definition, 17-18
Keller, Helen, 192, 203 escape paradigm, 13, 16-17
Knowledge domain, shaping model of instruc- ever-present aversive condition, 17
tion, 172 fear as factor, 14
Kozol, Jonathan, 282 immediate feedback and, 12-13, 16, 18
Kuder Personal Preference Schedule, 317 negative reinforcement, 13
Kupfer, Jeffrey, 45-68 pharmacists, role of, 18
physicians, role of, 18-19
L1I1guagc prevention issue, 12
applied behavior analysis and, 250-252 reasons for nonadherence, 1 1-16
,1Utlsm and, 210-211 reminder devices, 19
Laughter, parenting and, 3S9-360 social implications, 18
Law-and-order nisi" 235, 421 solutions, 16-20
Learning Medicare, 284
mitiallearning experi~nce, 189-204 Medlinc, 88-89
Imitated behaVIOrs, 199 Memory
maladaptive behaviors, 198 brain-mjured individuals, memory rehabili-
nurturing behavior, learning and, 193- tation techniques. See Brain-injured
195 individuals, memory rehabilitation
parents, encouragement of behaviors by, techniques
1%-199 elderly, 391
sibling caring, encouragement of, 199- Minnesota Multiphasic Personality Inventory,
201 317
time-outs, 201-202 The Miracle Worker (Gibson), 192
reading and writing, 252 Mobility, experimental analysis of. See Walk-
Learning disabled students, CABAS model of ing, nature of
schooling, 150 Morality, leading good life and, 412-418
Learn units. See Elementary and secondary Motivation
schools, actions to improve (1984- change, for, 409
1994) motative variables, 146
Life expectancy, eating habits and, 106 sport psychology, 319-323
442 INDEX
Motor skills PAC. See Puhlic Awareness Campaign (PAC)

vision in relation to, 47 Pain
walking and. See Walking, nature of covert extinction, 33
Mountain Plains Regional Resource Center, happiness, ingredient for, 411
ns Panel on Visual Impairment and its Rehabilita-
Mowrer, O. H., 13-14 tion, 55
Murray, Charles Panic attacks, desensitization and, 2S2, 302
How to Lie with Statistics, 285 Pap smears, 27
Losing Ground, 285 Paraprofessionals, applied hehavior analysis
and,237--238
National Commission on AIDS, 87, 95, 101 Parenting, 357-382
National Council on Patient Information and appropriate behavior of children, reactions
Education, 10 to, 365-370
National Council on the Aging, 386 osual and hrief acknowledgement, 369
National Institute for the Clinical Application description of behavior being reinforced,
of Behavioral Medicine, 23, .)8 369-370
National Pharmaceutical Council. 10 intermittent acknowledgement, 368-369
Natural selection, 166 verhal acknowledgement, 365-368
Negative relllforcement basic principles of behavior, 358-365
applied behaVIOr analysis, 247-249 consequences, shaping of behavior by, 363
empathy, rrainlllg of client, 145 conversation, 36()-.)61
medical llonadhercnn:, analysis of, 13 environment, shaping of, l58-.l62
sport psychology, runnlllg, .,20 laughter, importance of, 359-360
NeuropsychologlCal Impairment, alcohol listening, 361-362
abuse and, 76 ITIlshehavior of children, responses to, 370-
New university model. See Colleges and uni- 381
versities, irnproving arguing, .,77-378
Nonadherence, medical. See Medical nonad- criticism, .)75-376
herence, analysis of despair, 379-381
Noncontingent reinforcement, 244 force, use of, 379
Nuclear family, breakdown of, 1 hopelessness, .3 79-3 81
Nuclear holocaust, threat of, 235, 421 ignoring of inconsequential hehavior,
Nurturing hehavior, learning and, 191-195 370-371
Nutrition. See Fating habits, improvement of logic, 377
pleading, 379-381
Obesity questioning, 378-.) 79
chronic health prohlems associated with, 109 redirection of hehavior, 373-.)7)
statistics on, 106 sarcasm, 376
Ohio State University, second conference, selective reinforcement of appropriate he-
138, 140,152 havior, .171-.F3
Oklahoma Citv bomhing, 422 sibling rivalry, 370
Older persons. See Aging; Elderly threats, 376-.,77
Operant behaVior traps to avoid, 375-381
HIV (human immunodeficiency virus), pre- negative consequences vs. positive conse-
vention of, 97, 99 quences, 363-.165
walking as, 52-60 physical contact, 359-360
reinforcement, 62-66 positive consequences vs. negative conse-
verhal instruction and, 61, 63-65 quences, 363-.165
Operant conditioning positive reinforcement, 365-370
applied behavior analysis, 242 proactive behavior, 359
Skinner, B. E, on, 268 whining hehavior of children, 367-368
Operant-learning theory, 24 Pavloyian theoretical model
Optimism, 406 applied behavior analysis, 241-242
Orientation, experimental analysis of. See psycho-oncology, 26, 37
Walking, nature of Perception, transformation paradigm, 161
INDEX 443
PessImism, 405--406 Pragmatics, autism and, 211-212

PharmacIsts, medical nonadherence, dealing Praise, parenting, 365-370
with problem of, 18 Premack Prll1Clpie
Philosophical issues parenting, responses ro misbehavior of chil-
human condition, Improvement of, S dren, 376
wIsdom, 403--420 sport psychology, 322
Phobias, systematic desensitization, 252 Present-day society, advantages of, 1-2
Physical contact, parenting and, 359-ViO Preventive health hehaviors
Physicians, medical nonadherence, dealing HIV (human immunodeficiency virus). See
with problem of, 18-19 HIV (human immunodeficiency
Picture exchange communication system, virus)
autistic children, 217 medical nonadherence, analysis of, 12
Pleasure as ingredient for happiness, 41 I Preview, question, read, state, and test
Pollution, 235, 421 (PQRST), 127
Positive reinforcement Proactive hehavior, parenting, ,)59
applied hehavior analysis, 24,)-244, 246 Profile of Mood States, 318
empathy, training of client, 345 Psychlit, 88-89
parenting, 365-370 Psychoanalysis, elderly patients, 393-.'194
psycho-oncology, 30-32 Psychoneuroimmunology, 35-,~6
Post-traumatic stress disorder (PTSD), 342 Psycho-oncology, 23--4,)
Potentiating pairing, 302 hehavioral assessment, 28-29
Poverty, 236, 279-297, 421 chemotherapy, 32, ,B
alcohol abuse hy elderly and impoverished hreast C3ncer, 35
women, 77 classical conditioning, 35-36
anthropological considerations, 288-289 conceptual concept of cancer, 27-2X
hehavioral considerations, 286-287 conceptual model of, 25-26
children covert extinction, 32-Yl
increased welfare dependence, 281-282 covert modeling, 30
statistics, 28 I covert positive reinforcement, 30-32
conceptual framework of, 292-295 covert sensitization, 33-35
disciplinary viewpoints, viewed from, 286- antecedent hehaviors, 33-34
291 consequences of, Yi
ethical communities, 293-294 target behaviors, 34-,)5
folkvicws and, 295 defined, 25
institutions, 290-291,294-295 future considerations, 37-3N
jobless recovery, 291 holistic treatment, goal of, 37
living conditions, 282 hopelessness and cam;er, 27
mJcrocontll1gencie" 292-29., imagery, 2.'1-24
mall1stream economIc considerations, 289- Pavlovian theoretical model, 26, 37
290 psychoneuroimmunology, 35-)('
Marxist considerations, 291 radiation therapy, .U-35
natural science conceptual framework, relaxation, 29
292 target hehaviors, 32-,'-1
official poverty level, 280 covert sensitization, 34-35
radical institutionalism and, 290 thought stopping, 29
rural poverty, 2S0-281 visual imagery, 23-24, .'16
sociological considerations, 287-288 Psychotropic medication, elderly and, 393
superstructure of culture and, 288 PTSD, See Post-traumatic stress disorder
trends in, 281-282 (I'TSD)
War on Poverty, 285 Puhlic Awareness Campaign (PAC), 8 I
See a/so Aid to Families with Dependent Punishment. See Negative reinforcement
Children (AFDC); Welfare pro- Puzzle hoxes, 13
grams
PQ RST. See Preview, question, read, state, Quality control, teaching, solutions to proh-
and test (PQRST) lems of, 164, 176-1 n
444 INDEX
Rachel and Her Children (Kozol), 282 Self-respect, 413-414

Radiation therapy, psycho-oncology and, 33-35 Semantics, autism and, 211
Radical behaviorism, 144 Senior citizens. See Aging; Elderly
cognitive psychology and, 249-250 Sensitization
Radical institutionalism, poverty and, 290 empathy, training of client, 345
Raynaud's disease, 303-304, 309 psycho-oncology, covert sensitization, 33-
Reform, educational. See Elementary and sec- 35
ondary schools, actions to improve Sexual behavior, aging and, 391
(1984-1994) "The Shame of American Education" (Skin-
Rehabilitation ner), 137
alcohol abuse by elderly and impoverished Shaping, empathy, training of client, 348
women, 77 Shilts, Randy, 100
brain-injured individuals, memory rehabili- Sibling caring, encouragement of, 199-201
tation techniques. See Brain-injured Sibling rivalry, 199-201,370
individuals, memory rehabilitation Sidman, M., free-operant avoidance (Sidman
techniques avoidance), 12-13
visual loss, walking and Skinner, B. F., 261-278
ground surfaces, effect of, 55-58 applied behavior analysis, 241,248-250
mobility instructors, training by, 48-49 baby-tender, 264-267, 276
Reinforcement reactions to, 266-267
accidental reinforcement, 246-247 The Behavior of Organisms, 264
avoidance, nature of reinforcement, 14 Beyond Freedom and Dignity, 275, 403
continuous reinforcement, 244 changes in human behavior, on, 406
intrinsic reinforcement, running, 319-320 cognitive psychology, on, 249-250
negative. See Negative reinforcement controlled responses, on, 1 17
noncontingent reinforcement, 244 early life of, 262-264
positive reinforcement. See PosItive rein- education, on, 137-138, 151
forcement "Humanist of the Year" award, 2
response-conti ngent rei n forcement, 386, learning, on, 190-191,327
389,393 operant conditioning, on, 268
social reinforcement, 321-322 poverty, on, 287, 292
walking, nature of, 62-66 private stimuli, verbal behavior in response
Reinforcement Survey Schedule, 330 to, 64
Relaxation training reinforcement, 411
anxiety control, 252-253, 302 "The Shame of American Education," 137
cancer patients, 29 "Skinner Box," 263, 348
neural messages and, 311 Verbal Behavior, 147,272,275
phobias and, 253 Walden Two, 267-276, 423
Residualist view of welfare programs, 282-283 reactions to, 270-276
Response-contingent reinforcement, 386, "real" Walden Two, starting of, 270
389,393 Skinner, Deborah, 265-267, 272
Retirement, 386-387 Skinner, Eve, 265, 272
mandatory, 388 "Skinner Box," 263, 348
Rogers, Carl, 338-339 Social insurance view of welfare programs,
Running, psychology of. See Sport psychology 283,284
Rural poverty, 280-281 Social interventions, alcohol abuse by elderly,
Russell, Bertrand, 263 77, 82
Social issues
Schools. See Elementary and secondary applied behavior analysis, 235-259
schools, actions to improve (1984- education, decline of standards as, 236, 421
1994) environmental issues, 235, 256, 421
Self-reporting homelessness, 236, 421
alcohol abuse by elderly, 83 human condition, improvement of, 4
HIV (human immunodeficiency virus), psy- law-and-order crisis, 235, 421
chological variables, 100 managed health care system, 422
INDEX 445
Social issues (Wilt.) Stress

nuclear holocaust, threat of, 235, 421 cancer and, 31
pollutIOn, 2.>.'i, 421 illness, association with, 24
poverty, 236, 279-297, 421 Strong Vocational Interest Blank, 317
psvchological intervention strategies, 2)5- Students. See Colleges and universities; Ele-
259 mentary and secondary schools, ac-
SkInner, B. E, inventions and writings, 261- tions to improve (19S4-1994)
27il Substance ahuse
violence, 422 elderly, by, 69-85
Social learning, 24.'1-246 cognitive-behavioral techniques in treat-
Social Problems (Eitzen and Zinn), 287 ment, 74-75, 82-83
Social reinforcement, sport psychology, .121- diagnosis of, 71
.122 dual diagnosis, 75-76
Social support, weight reduction programs, enabling, 79
118 family therapy intervention, 79-80
Society of Behavioral Medicine, 24 group interventions, 80
Special education departments, 237 illicit drug use, 70
Spontaneous speech, 146 mainstreaming vs. elder-specific treat-
Sport psychology, 315-335 ment, 72-73
athlete, understanding of, 330 psychiatric comorbidity, 75-76
background, 316-318 relapse prevention, 74-75
covert hehavior, 324-331 same-aged peers, group interventions, 80
covert conditioning, 326-330 sociotherapeutic interventions, 73
covert modeling, 328-329 treatment, 72-80
dissociation, 325 social issue, as, 2.15, 421
eating disorders and, 316 See also Alcohol ahuse by elderly
imagery, use of, 326-327, 329-.330 Suicide rate, elderly, 75
imagaletics, 327, .330 Suinn, Richard, 252
research on, 332 Sullivan, Annie, 192,203
running, 318-324 Surgeon General's Report on Nutrition and
consequences, 322 Health, 106
contingency contract procedures, 321 Syntax, autism, 210-211
decision process, 322 Systematic desensitization, 252-25.1
long, slow, distance training, 32)-.124
motivation, 319-323 Target behaviors
negative reinforcement, 320 HIV (human immullodeficiency virus), pre-
i'remack Principle, 322 vention of, 98-99
response cost, 322 psycho-oncology, 32-.35
social reinforcement, 321-322 Teachers
training to run races, 323-324 colleges and universities
selt-control triad, 329 hifacuLty organizatioll, 17S-186
visuomotor behavior rehean,al (VMBR), cumulative selection, 170
326-328 cumulative shaping cybernetic (CSC),
Stimulus control 170-173,175-178,180-181,185
eating habits, improvement of division-of-Iabor teaching unit, 181-182
nutritional habits, change in, 117-118, feedback, 169,176-177
119 instructional styles, differences in, 16H-
weight reduction programs, 110-111 169
visual loss, walking and, 54 instructional team, 178-186
Stimulus equivalence lectures, 162
hrain-injured individuals, memory rehahili- market solutions, 160
tation techniques, 127-128 personalized system of instruction, 179
elementary and secondary schools, actions presentation model of instruction, 162
to improve (1984-1994),145 quality control, 164, 176-178
Stream, hehavior as, 15 requirement solutions, 160
446 INDEX
Teachers (cant.) Visual loss, walking and (COllt.)

colleges and universities (((JIlt.) mohility instructors, training by, 48-49
shaping model of instruction, 167-17H reinforcement, 62-66
solutions to prohlems of, 160 safe walking, research on. 50, 58
tool solutions, 160 shorelinc as mobilitv aid, 49-50, 56-57
education programs for, 237-238 stimulu; control, 54
science of teaching, 140 verbal responses by indivicltuls, 64-65
strategic scientists, as, 151 Visuomotor behavior rehearsal (V.Y1BR). 326-
tactics used to improve student response. 32X
142-143
Tenth Annual International AIDS Conference Walden Two (Skinner), 267-276. 423
(1994).87 reactions to, 270-276
Thomas, Clarence, 245 "real" Walden two. starting of. 270
Thought stopping, psycho-oncology, 29 Walking. natme of, 45-68
Tienenmen Square demonstrations. 256 balance" illlportance of. 46
Time-outs, children. 201-202 consequences of walking, GO
Traumatic hrain injun'. See Brain-injured illlli- directional continuity. 49
viduals. memor) rehahilitation tech- ground surLlces, effect of. 55-58
l11ques Illethodological isslIes. 50-52
Illolar-Ievel analysis. 4)
Unabomber.422 Illotor skills 'lIld, 46-47
United "lations. 419-420 operant behavior. walking 'lS. 52-60
Unl\'crslties. Sec Colleges 'lI1d universities reinforcelllent, 62-66
Upjuhn Compalll. 10 verbal instruction 'lIld. 61. 6.1-65
Utah Sute Univcrslt\. 23 H spccd, rnC;1"itlfCtnenr of, .13, Sh--SH. 60
Utopias. See Walde/1 7i~'() straight-line walklllg, 56-58, 611
three-term contingellL'v. 65
Verballkhavior (Skinner). 27 2, 27) verbal instruction and. hi, 6.1-("
Verbal instruction vIsIon and. 46 ..-47
private stimuli. verbal behavior in response ellvironmcntal input, 47
to. 64 loss of vision. See Visual loss. walking
walking and, 61, 63-65 and
Verbal rules of behavior, 15 wide-h~lsed gait. 47
Veterans, 'llcohol abuse hy elderly, 7H Want-want prohlems, 407-414
Veterans Administration Medical Center (Mis- Warning signal, discrimiluted (signaled)
sissippi). 7H avoilbnce. See Avoidance
Violence, 422 Wechsler Adult Intelligencc Scale-Revised, 3') I
Vision Weight reduction programs. See Laing habits.
motor development. in relation to. 47 improvement of
walking and, 46-47; see also Visual loss, Welfare programs
walking and Aid to Families with Dependent Children
environmental input, 47 (AFDC). See Aid to Families with De-
visual fields, 54 pendent Children (AFDC)
Visual fields, 54 antipoverty versus public assistance, 291
Visual imagery behavioral considerations. 286
brain-injured individuals, 126-127 egalitarian populist view of. 28,-284
psycho-oncology and, 23-24. ,)6 increased dependence upon, 281
sport psychology and, 326-327. 329-,>,)0 Malthusian behaviorist view of, 282. 287
Visual loss, walking and, 48-50 opportunity-insurance SLHe. United States
blindfolded individuals, experiments with. as. 284
59 purposes of, 282-284
cognitive features. 51-52 residlJJiist view of,282-28.1
disrupted walking. 58-59 social insurance view. 283, 284
ground surfaces, effect of, 55-58 "War on Welfare." 284
impeded walking, 58 West Virginia Univcrsirv, 23 S
INDEX 447
Wi"jom,4().l-420 Wolpe, Joseph

hetter world, as kev to, 40,-420 covert conditioning, l27
how to huild better world, 414-420 systematic desensitization model, 252
h;lPpiness ;lI1d, 41 1-412, 415-417 WomaJl '5 Day, 2.l ~
nwr3.iin, lcadJllg good lite and, 412-41 X Wooden, John, .ll2
optimIsm ;lI1d, 40(, World He3.lth Org3.nization, S7
I1l'SSlmISIll and, 4()5-406 World-want con tliets, 406-414
sclf-respeCl and, 413-414
"HlIld \·allle prtortties, 41 () Youth clliture, 25';-257
\\;lIlt-wanr problems, 407-414 Youth j'()/ic)" 152
world-wanr contlicts, 406-414
Wolf Man case (Frclld), 194 Zllllnick, Steven, 257-25~

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Current volumes in this Series

A BEHAVIOR ANALYTIC VIEW OF CHILD DEVELOPMENT

CASEBOOK OF THE BRIEF PSYCHOTHERAPIES

CLINICAL PSYCHOLOGY SINCE 1917

CONJOINT BEHAVIORAL CONSULTATION

CONTEMPORARY ISSUES IN BEHAVIOR THERAPY

FUNDAMENTALS OF BEHAVIOR ANALYTIC RESEARCH

GUIDEBOOK FOR CLINICAL PSYCHOLOGY INTERNS

KEY CONCEPTS IN PSYCHOTHERAPY INTEGRATION

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Springer Science+Business Media, LLC

Contemporary issues in behavior therapy : improving the human

ISBN 978-1-4757-9828-9 ISBN 978-1-4757-9826-5 (eBook)

© 1996 Springer Science+Business Media New York

In loving and fond memory of my deceased wives Shahenshah,

Jacob Azerrad • 19 Muzzey Street, Lexington, Massachusetts 02173

Grace Baron • Department of Psychology, Wheaton College, Norton, Mas-

William M. Beneke • Department of Social and Behavioral Sciences, Lin-

Dawn M. Birk • Eastern Montana Community Mental Health Center, 2507

Joseph R. Cautela • Behavior Therapy Institute, 10 Phillips Road, Sudbury,

Carl D. Cheney • Department of Psychology, Utah State University, Logan,

Lacey O. Corbett • Behavior Therapy Associates, 208 Sandwich Street,

Nancy J. Corbett • Behavior Therapy Associates, 208 Sandwich Street,

Richard Garrett • Graduate Center, Bentley College, Waltham, Massa-

Michel Hersen • Center for Psychological Studies, Nova Southeastern Uni-

Waris Ishaq • Department of Anthropology, University of Oregon, Eugene,

Albert J. Kearney • Action Therapies, 7 Carmen Circle, Medfield, Massa-

Christopher King • Department of Clinical Neuropsychology, Bryn Mawr

Jeffrey Kupfer • Mediplex of Holyoke, 260 Easthampton Road, Holyoke,

Glenn I. Latham • Department of Special Education, Center for Persons

Brady J. Phelps • Department of Psychology, South Dakota State University,

Douglas H. Powell • Harvard University Health Services, Cambridge, Mas-

Daniel L. Segal • Department of Psychology, University of Colorado at Col-

Jennifer L. Twachtman • Braintree Hospital Pediatric Center, 751 Granite

Jerome D. Ulman • Department of Special Education, Ball State University,

Jerry G. Vander Tuig • Cooperative Research, Lincoln University, Jefferson

Vincent B. Van Hasselt • Center for Psychological Studies, Nova South-

E. A. Vargas • Department of Educational Psychology and Foundations,

Julie S. Vargas • Department of Educational Psychology and Foundations,

Many undergraduates choose to become psychology majors because of their

Unfortunately, many current psychosocial and environmental problems hinder

2. Medical Nonadherence: A Behavior Analysis ............. 9

9. Acting to Save Our Schools (1984-1994) ................ 137

10. A University for the Twenty-First Century ................ 159

1l. The Primacy of the Initial Learning Experience: The

III. DEVElOPMENTAL DISABILITIES

12. Improving the Human Condition through Communication

IV. SOCIAL ISSUES

13. The Social Relevance of Applied Behavior Analysis and

16. Behavior Therapy-Generated Insight ..................... 301

Vi. DEVElOPMENTAL CONSIDERATIONS

19. The Making of a Stable Family ......................... 357

VII. PHILOSOPHICAL ISSUES

21. Wisdom as the Key to a Better World 403

Unfortunately, there are many undesirable circumstances that degrade or de-

Joseph R. Cautela • Behavior Therapy Institute, 10 Phillips Road, Sudbury, Massachusetts

dangers. Medical advances in the treatment and prevention of many diseases

CHARACTERISTICS OF IMPROVING THE HUMAN CONDITION

Interaction of Physical and Psychological Effects

Education and Improving the Human Condition

Developmental Considerations in Improving the Human Condition

levels of Improvement of the Human Condition