INTENSIVE TREATMENT OF PSYCHOTIC BEHAVIOUR BY

STIMULUS SATIATION AND FOOD REINFOR~~~E~*

T. AYLLON
Anna State Hospital, Illinois, U.S.A.

Suuun~-This investigation demonstrates that extensive and elective behavioural modification

is feasible without costfy and lengthy psy~hothera~utic treatment. In addition, the often heard notion
that another undesirable type of behaviour will replace the original problem behaviour is not supported
by the findings to date.

INTRODUCTION
UNTIL recently, the effective control of behaviour was Limited to the animal laboratory.
The extension of this control to human behaviour was made when Lindsley successfully
adapted the methodology of operant conditioning to the study of psychotic behaviour
(Lindsiey, 1956). Following LindsIey’s point of departure other investigators have shown
that, in its essentials, the behaviour of mental defective individuals (Orlando and Bijou,
1960), stutterers (Flanagan, Goldiamond and Azrin, 1958), mental patients (Hutchinson
and Azrin, 1961), autistic (Ferster and DeMyer, 1961), and normal children (Bijou, 1961;
Azrin and Lindsley, 1956) is subject to the same controls.
Despite the obvious implications of this research for applied settings there has been
a conspicuous lag between the research findings and their application. The greatest limita-
tion to the direct application of laboratory principles has been the absegce of control over
the subjects’ environment. Recently, however, a series of applications in a regulated
psychiatric setting has clearly demonstrated the possibilities of behavioural modification
(Ayllon and Michael, 1959; Ayllon and Haughton, 1962). Some of the behaviour studied
has included repetitive and highly stereotyped responses such as complaining, pacing,
refusal to eat, hoarding and many others.
What follows is a demonstration of behaviour techniques for the intensive individual
treatment of psychotic behaviour. Specific pathological behaviour patterns of a single
patient were treated by manipulating the patient’s environment.

The experimental ward and control aver the reinforcement

This investigation was conducted in a mental hospital ward, the characteristics of which
have been described elsewhere (Ayllon and Haughton, 1962). Briefly, this was a female
ward to which only authorized personnel were allowed access. The ward staff was made up
of psychiatric nurses and untrained aides who carried out the environmental manipulations
under the direction of the experimenter. Using a time-sample technique, patients were
observed daily every 30 minutes from 7.00 a.m. to 1I .OOp.m.

* This report is based, in part, on a two-year research project (1959-19611, conducted by the author
at the Saskatchewan Hospital, Weyburn, Saskatchewan, Canada, and supported by a grant from the
Commonwealth Fund. Grateful acknowledgment is due to H. OSMJND and I. CUNCEY of the Saskatchewan
Hospital. The author also thanks E. HAUGHTON who assisted in the conduct of this investigation, and
N. AZUIN and W. HOLTZ for their critical reading of the manuscript.

53
51 T. AYLLON

The dining room was the only place where food was available and entrance to the
dining room could be regulated. Water was treely available at a drinking fountain on the
ward. None of the patients had ground passes or jobs outside the ward.

Subject
The patient was a 47-year-old female patient diagnosed as a chronic schizophrenic.
The patient had been hospitalized for 9 years. Upon studying the patient’s behasiour on
the ward, it became apparent that the nursing staff* spent considerable time caring for her,
In particular, there were three aspects of her behaviour which seemed to defy solution.
The first was stealing food. The second was the hoarding of the ward’s towels in her room.
The third undesirable aspect of her behaviour consisted in her wearing excessive clothing,
e.g. a half-dozen dresses, several pairs of stockings, sweaters, and so on.
In order to modify the patient’s behaviour systematically, each of these three types of
behaviour (stealing food, hoarding, and excessive dressing) was treated separately.

EXPERIMENT I

Control of stealing food by food withdrawal

The patient had weighed over 250 pounds for many years. She ate the usual tray of
food served to all patients, but, in addition, she stole food from the food counter and from
other patients. Because the medical staff regarded her excessive weight as detrimental to
her heahh, a special diet had been prescribed for her. However, the patient refused to diet
and continued stealing food. In an effort to discourage the patient from stealing, the ward
nurses had spent considerable time trying to persuade her to stop stealing food. As a last
resort, the nurses would force her to return the stolen food.
To determine the extent of food stealing, nurses were instructed to record all behaviour
associated with eating in the dining room. This record, taken for nearly a month, showed
that the patient stole food during two thirds of all meals.

Procedure
The traditional methods previously used to stop the patient from stealing food were
discontinued, No longer were persuasion, coaxing, or coercion used.
The patient was assigned to a table in the dining room, and no other patients were
allowed to sit with her. Nurses removed the patient from the dining room when she
approached a table other than her own, or when she picked up unauthorized food from
the dining room counter. In effect, this procedure resulted in the patient missing a meal
whenever she attempted to steal food.

Results
Figure 1 shows that when withdrawal of positive reinforcement (i.e. meal) was made
dependent upon the patient’s ‘stealing’, this response was eliminated in two weeks. Because
the patient no longer stole food, she ate only the diet prescribed for her. The effective
control of the stealing response is also indicated by the gradual reduction in the patient’s
body weight. At no time during the patient’s 9 years of hospitalization had she weighed
less than 230 pounds. Figure 2 shows that at the conclusion of this treatment her weight
stabilized at 180 pounds or 17 per cent loss from her original weight. At this time, the
patient’s physicaf condition was regarded as excellent.
* As used in this paper, ‘nurse’ is a generic term including all those who actually work on the ward
(attendants, aides, psychiatric and registered nurses).
 INTENSIVE TREATMENT OF PSYCHOTlC BEHAVIOUR 55

FIG. 1. A response, food stealing, is eliminated when it results in the withdrawal of food
reinforcement. The dotted arrows indicate the rare occasions when food stealing occurred.
For purposes of presentation a segment comprising 20 weeks during which no stealing
occurred is not included.

1 I 1
0 7 14
Month

FIG. 2. The effective control of food stealing results in a notable reduction in body weight.
As the patient’s food intake is limited to the prescribed diet her weight decreases gradually.

Discussion
A principle used in the laboratory shows that the strength of a response may be
weakened by the removal of positive reinforcement fallowing the response (Ferster, 1958).
In this case, the response was food-stealing and the reinforcer was access to meals. When
he patient stole food she was removed from the dining room and missed her meal.
56 T. AYLLON

After one year of this treatment, two occasions of food stealing occurred. The first
occasion, occurring after one year of not stealing food, took the nurses by surprise and,
therefore the patient ‘got away’ with it. The second occasion occurred shortly thereafter.
This time, however, the controlling consequences were in force. The patient missed that
meal and did not steal again to the conclusion of this investigation.
Because the patient was not informed or warned of the consequences that followed
stealing, the nurses regarded the procedure as unlikely to have much effect on the patient’s
behaviour. The implicit belief that verbal instructions are indispensable for learning is
part of present day psychiatric lore. In keeping with this notion, prior to this behaviour
treatment, the nurses had tried to persuade the patient to co-operate in dieting. Because
there were strong medical reasons for her losing weight, the patient’s refusal to follow a
prescribed diet was regarded as further evidence of her mental illness.

EXPERIMENT II

Control of one form of hoarding behaviour through stimulus satiation

During the 9 years of hospitalization, the patient collected large numbers of towels
and stored them in her room. Although many efforts had been made to discourage hoarding,
this behaviour continued unaltered. The only recourse for the nursing staff was to take
away the patient’s towels about twice a week.
To determine the degree of hoarding behaviour, the towels in her room were counted
three times a week, when the patient was not in her room. This count showed that the
number of towels kept in her room ranged from 19 to 29 despite the fact that during this
time the nurses continued recovering their towel supply from the patient’s room.

Procedure
The routine removal of the towels from the patient’s room was discontinued. Instead,
a programme of stimulus satiation was carried out by the nurses. Intermittently, throughout
the day, the nurses took a towel to the patient when she was in her room and simply handed
it to her without any comment. The first week she was given an average of 7 towels daily,
and by the third week this number was increased to 60.

Results
The technique of satiation eliminated
number of towels per count found in the
in her room reached the 625 mark, she
more towels were given to her. During
found in her room was 1.5 per week.
procedure (Figs. 4 and 5).
the towel hoarding. Figure 3 shows the mean
patient’s room. When the number of towels kept
started taking a few of them out. Thereafter, no
the next 12 months the mean number of towels
Two photographs are included to illustrate this

Discussion
The procedure used to reduce the amount of towel hoarding bears resemblance to
satiation of a reinforcer. A. reinforcer loses its effect when an excessive amount of that
reinforcer is made available. Accordingly, the response maintained by that reinforcer is
weakened. In this application, the towels constituted the reinforcing stimuli. When the
number of towels in her room reached 625, continuing to give her towels seemed to make
their collection aversive. The patient then proceeded to rid herself of the towels until she
had virtually none.
 INTENSIVE TREriThlENT OF PSYCHOTIC BEHAVIOIJR 57

i
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E
3”
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s
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1
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I3 26
Wdh

FIG. 3. A response, towel hoarding, is eliminated when the patient is given towels in excess.
When the number of towels reaches 625 the patient starts to discard them. She continues to
do so until the number found in her room averages 1.5 compared to the previous 20 towels
per week.

During the first few weeks of satiation, the patient was observed patting her cheeks
with a few towels, apparently enjoying them. Later, the patient was observed spending
much of her time folding and stacking the approximately 600 towels in her room. A variety
of remarks were made by the patient regarding receipt of towels. All verbal statements
made by the patient were recorded by the nurse. The following represent typical remarks
made during this experiment. First week : As the nurse entered the patient’s room carrying
a towel, the patient would smile and say, “Oh, you found it for me, thank you”. Second
week: When the number of towels given to patient increased rapidly, she told the nurses,
“Don’t give me no more towels. I’ve got enough”. Third week: “Take them towels away.
. . . I can’t sit here all night and fold towels”. Fourth and fifth weeks: “Get these dirty
towels out of here”. Sixth week: After she had started taking the towels out ot her room,
she remarked to the nurse, “I can’t drag any more of these towels, I just can’t do it”.
The quality of these remarks suggests that the initial effect of giving towels to the patient
was reinforcing. However as the towels increased they ceased to be reinforcing, and
presumably became aversive.
The ward nurses, who had undergone a three year training in psychiatric nursing, found
it difficult to reconcile the procedure in this experiment with their psychiatric orientation.
Most nurses subscribed to the popular psychiatric view which regards hoarding behaviour
as a reflection of a deep ‘need’ for love and security. Presumably, no ‘real’ behavioural
change was possible without meeting the patient’s ‘needs’ first. Even after the patient
58 T.AYLLON

discontinued hoarding towels in her room, some nurses predicted that the change would
not last and that worse behaviour would replace it. Using a time-sampling technique the
patient was under continuous observation for over a year after the termination of the
satiation programme. Not once during this period did the patient return to hoarding
towels. Furthermore, no other behaviour problem replaced hoarding.

EXPERIMENT III

Control of an additional form of hoarding through food reinforcement

Shortly after the patient had been admitted to the hospital she wore an excessive
amount of clothing which included several sweaters, shawls, dresses, undergarments and
stockings. The clothing also included sheets and towels wrapped around her body, and a
turban-like head-dress made up of several towels. In addition, the patient carried two to
three cups on one hand while holdin g a bundle of miscellaneous clothing, and a large
purse on the other.
To determine the amount of clothing worn by the patient, she was weighed before each
meal over a period of two weeks, By subtracting her actual body weight from that recorded
when she was dressed, the weight of her clothing was obtained.

Procedure
The response required for reinforcement was stepping on a scale and meeting a pre-
determined weight. The requirement for reinforcement consisted of meeting a single
weight (i.e. her body weight plus a specified number of pounds of clothing). Initially she
was given an allowance of 23 pounds over her current body weight. This allowance
represented a 2 pound reduction from her usual clothing weight. When the patient exceeded
the weight requirement, the nurse stated in a matter-of-fact manner, “Sorry, you weigh
too much, you’ll have to ‘weigh less”. Failure to meet the required weight resulted in the
patient missing the meal at which she was being weighed. Sometimes, in an effort to meet
the requirement, the patient discarded more clothing than she was required. When this
occurred the requirement was adjusted at the next weighing-time to correspond to the limit
set by the patient on the preceding occasion.

Results
When food reinforcement is made dependent upon the removal of superfluous clothing
the response increases in frequency. Figure 6 shows that the patient gradually shed her
clothing to meet the more demanding weight requirement until she dressed normally. At the
conclusion of this experiment her clothes weighed 3 pounds compared to the 25 pounds
she wore before this treatment.
Some verbal shaping was done in order to encourage the patient to leave the cups and
bundles she carried with her. Nurses stopped her at the dining room and said, “Sorry, no
things are allowed in the dining room”. No mention of clothing or specific items was made
to avoid focusing undue attention upon them. Within a week, the patient typically stepped
on the scale without her bundle and assorted objects. When her weight was over the limit,
the patient was informed that she weighed “too much”. She then proceeded to take off
a few clothes, stepped on the scale again, and upon meeting the weight requirement, gained
access to the dining room. A few pictures are shown to illustrate this behavioural modifica-
tion (Figs. 7, 8, 9 and 10).
FIG. 4. The early stages of satiation. As the patient received the towels she folded them
properly and stacked them around her bed, Notice that the towels on her bed are also kept neatly.

FIG. 5. The pa Itient’s room just before she started to rid herself of the tc ,wels. Notice that
there : are still aI few stacks of folded towels, but now the chain, bed and floor are litc:l-aIly
covered with them.
FIG. 7. The patient as she appeared before the start of Experiment III. T!le thickness of her
legs is enhanced by approximately 2 dozen pairs of stockings that she wore. Notice the
bandages she wears on her wrists as well as the cups beside her.

FIG. 8. The patient eating in the dining room in the initial stages of Experiment III.
FICX 9. The patient after she started to discard a few items of clothing.

FIG. 10. The patient during the final stages of the experiment.
59 INTENSIVE TREATMENT OF PSYCHOTIC BEHAVIOUR

Week
FIG. 6. A response, excessive dressing, is eliminated when food reinforcement is made
dependent upon removal of superfluous clothing. Once the weight of the clothing worn by
the patient drops to 3 pounds it remains stable.
Discussion
According to the principle of reinforcement a class of responses is strengthened when
it is followed by reinforcement. A reinforcer is such when it results in a response increase.
In this application the removal of excessive clothing constituted the response and the
reinforcer was food (i.e. access to meals). When the patient met the weight requirement
she was reinforced by being given access to meals.
At the start of this experiment, the patient missed a few meals because she failed to
meet the weight requirement, but soon thereafter she gradually discarded her superfluous
clothing. First, she left behind odd items she had carried in her arms, such as bundles, cups
and handbags. Next she took off the elaborate headgear and assorted “capes” or shawls
she had worn over her shoulders. Although she had worn 18 pairs of stockings at one time,
she eventually shed these also.
During the initial part of this experiment, the patient showed some emotional behaviour,
e.g. crying, shouting and throwing chairs around. Because nurses were instructed to
“ignore” this emotional behaviour, the patient obtained no sympathy or attention from
them. The witholding of social reinforcement for emotional behaviour quickly led to its
elimination.
At the conclusion of this behaviour treatment, the patient typically stepped on the
scale wearing a dress, undergarments, a pair of stockings and a pair of light shoes. One of
the behavioural changes concomitant with the current environmental manipulation was
that as the patient began dressing normally she started to participate in small social events
in the hospital. This was particularly new to the patient as she had previously remained
seclusive spending most of the time in her room.
About this time the patient’s parents came to visit her and insisted on taking her home
for a visit. This was the first time during the patient’s 9 years of hospitalization that her
parents had asked to take her out. They remarked that previously they had not been in-
terested in taking her out because the patient’s excessive dressing in addition to her weight
made her look like a “circus freak”.
 T. AYLLON a
CONCLUSIONS

The research presented here was conducted under nearly ideal conditions. The variables
manipulated (i.e. towels and food) were under full experimental control. Using a time-
sample technique the patient was observed daily every 30 minutes from 7.00 a.m. to 11.OO
p.m. Nurses and aides carried out these observations which were later analysed in terms of
gross behaviour categories. These observations were in force for over a y.ear during which
time these three experiments were conducted. The results of these observations indicate
that none of the three pathological behaviour patterns (i.e. food stealing, hoarding and
excessive dressing) exhibited by the patient were replaced by any undesirable behaviour.
The patient displayed some emotional behaviour in each experiment, but each time it
subsided when social reinforcement (i.e. attention) was not forthcoming. The patient did
not become violent or seclusive as a consequence of these experiments. Instead, she became
socially more accessible to patients and staff. She did not achieve a great deal of social
success but she did begin to participate actively in social functions.
A frequent problem encountered in mental hospitals is overeating. In general this
problem is solved by prescribing a reduction diet. Many patients, however, refuse to take
a reduction diet and continue overeating. When confronted with this behaviour, psychiatric
workers generally resort to two types of explanations.
One explanation of overeating points out that only with the active and sincere co-
operation of the patient can weight reduction be accomplished. When the patient refuses
to co-operate he is regarded as showing more signs of mental illness and all hopes of
eliminating overeating come to an end.
Another type of explanation holds that overeating is not the behaviour to be concerned
with. Instead, attention is focused on the psychological ‘needs’ of the patient. These
‘needs’ are said to be the cause of the observable behaviour, overeating. Therefore the
emphasis is on the removal of the cause and not on the symptom or behaviour itself.
Whatever theoretical merit these explanations may have, it is unfortunate that they fail
to suggest practical ways of treating the behaviour itself. As a consequence, the patient
continues to overeat often to the detriment of his health.
The current psychiatric emphasis on the resolution of the mental conflict that is
presumably at the basis of the symptoms, is perhaps misplaced. What seems to have been
forgotten is that behaviour problems such as those reported here, prevent the patient from
being considered for discharge not only by the hospital personnel but also by the patient’s
relatives. Indeed, as far as the patient’s relatives are concerned, the index of improvement
or deterioration is the readily observable behaviour and not a detailed account of the
mechanics of the mental apparatus.
Many individuals are admitted to mental hospitals because of one or more specific
behaviour difflculiies and not always because of a generalized ‘mental’ disturbance. For
example, an individual may go into a mental hospital because he has refused to eat for
several days, or because he talks to himself incessantly. If the goal of therapy were
behavioural rehabilitation, these problems would be treated and normal eating and normal
talking reinstated. However, the current emphasis in psychotherapy is on ‘mental-conflict
resolution’ and little or no attention is given to dealing directly with the behavioural
problems which prevent the patient from returning to the community.
61 INTENSIVE TREATMENT OF PSYCHOTIC BEHAVIOUR

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