The Case of Sam: Multidisciplinary Perspectives: Settings of Care: Long-Term Hospitalization

Sam would be far better served in a long-term hospitalization program that emphasizes a transition from supportive care to skill building than through continued maintenance in a community program that is unable to provide the necessary structure for this type of treatment transition.

An individualized psychosocial rehabilitation program for a patient like Sam begins with an in-depth functional analysis of behavior. The analysis is based on what is currently known about Sam's behavior and its antecedents and reinforcing contingencies. It also takes into account Sam's current desires, motivations, interests, and strengths. The functional analysis of behavior focuses treatment aimed at skill building by systematically removing or limiting the contingencies that reinforce Sam's current isolating and care-dependent behaviors and by using the contingencies to which Sam is responsive to successively reinforce approximations of the skills necessary for him to return to the community with enhanced autonomy. As his skills improve, the rehabilitation plan for Sam can increasingly incorporate community-based treatments, including day passes, periods of autonomous living, and perhaps some form of employment. A program based on such incremental improvements is most likely to lead to successful community integration; insight is not a necessary ingredient of the process.

How can such an approach be implemented that takes into account the specifics of Sam's behavioral presentation and skill deficits? At least three major reinforcers can be identified in the case description: alone time, an involvement with music, and the attention of multiple caretakers. It appears that caretaking is reinforcing a maintenance level of existence in which the skills needed for autonomous functioning are unnecessary. Presumably the acquisition of such skills would jeopardize this important reinforcer. Sam's involvement with music appears to be part of how he "self-reinforces" while alone. Isolation is, of course, part of his axis II disorder. However, a behavioral analysis of this component would not focus on isolation as a static symptom of a disease process but rather as behavior developing within the context of Sam's reinforcement history. At this point, his isolation leaves him susceptible to medication nonadherence, decompensation, and danger to self and serves as a signal summoning multiple caregivers, whose very presence reinforces the isolation they may be seeking to decrease.

A psychosocial rehabilitation program for Sam would lead to the development of an individualized skill-building plan, which would use the same reinforcers and concomitant strengths in the service of adaptive functioning and would provide additional supports when necessary to increase the likelihood of skill acquisition. Sam's interest in music could be thoroughly explored so that his treatment team would fully understand the nuances of his enjoyment of this artistic medium. For example, is it the words or the rhythms? Does he like to sing? Can he play an instrument, or would he be interested in learning to do so? Can he talk to peers about music or organize a social event focused on music? The more that is known about the topography and nuances of this strength, the wider its application in the reinforcement of new and adaptive functioning.

Sam could then be permitted specified and titrated periods of isolation, depending on his adherence to medication, his engagement in groups emphasizing the development of conversational skills, or his participation in a unit government meeting. Refinements would include allowing Sam to spend some of his time alone and engaged with his music and then asking him to report to a staff member something about his experience with the music during that time. Over time, Sam's "alone time" could be used as a reinforcer for learning how to play an instrument, playing it publicly, leading a group discussion on music, and so forth.

A similar approach to the reinforcing qualities of staff attention could be developed to run parallel with the reinforcing use of alone time. Special or extra time with staff, including individual sessions with a therapist, could be contingent on Sam's acquisition of increasingly autonomous behaviors. This reinforcement program could be constructed to function simultaneously with the use of alone time on alternating days to prevent habituation and boredom. Alternatively, if a slower approach to the shaping of desired behaviors is necessary because of Sam's regressed nature, the most desirable reinforcer (special staff time) may be saved for more significant changes in behavior.

The notion of removing a patient to a more restrictive level of care in order to achieve an eventually higher level of functioning and the use of an environment not isomorphic to the local community in order to achieve integration into that very community may seem both counterintuitive and costly. There is obviously no assurance that such a plan will be successful for Sam, because, unless care providers are vigilant, active inpatient treatment can quickly turn into institutionalized caretaking. However, the 20-year effort to provide appropriate services for Sam in a community setting has proven to be counterproductive, reinforcing the very behaviors that it seeks to change—an approach that is therefore not cost-effective.

In the outpatient context, the investment of the public mental health system's resources in long-term individual psychotherapy appears to be equally ineffective. In such a context, it is not clear what outcome the therapy is serving other than the maintenance of dependent behavior, because it is clear that increased insight is not a realistic goal for this intervention with this patient. In the inpatient psychosocial rehabilitation program proposed here, briefer individual sessions with a therapist may be a very cost-effective part of an overall skill-acquisition program. Ongoing individual coaching may also be helpful or necessary as part of maintaining Sam's increased autonomy when he returns to the community. However, future steps can be decided only when Sam's inpatient treatment plan is implemented and refined according to the outcomes it produces. This reinforcer—individual coaching—may also be phased out as Sam gains skills and as his autonomous functioning increases, which would relieve his need for the individual attention provided by coaching. Sam's increased ability to socialize with peers, begun over a shared interest in music, may lead to the development of peer-group friendships that will be ultimately more satisfying than therapy.