Tuesday, 2 October 2012

Collaboration vs Behaviour Modification

One of the earliest decisions we made on the Adolescent Psychiatric Unit was a decision on what approach we would take towards the behaviour of young people on our ward.

As you may know psychiatry has gone through phases over its history. From the outset there have been two dominant schools of thought in terms of mental illness. A moral model which sees mental illness as a moral or spiritual problem and a medical model which sees mental illness as a disease of the brain. Both of these competing models still exist in various form today. (More on this in future posts.) The turn of the century saw the dawning of the psychoanalytic model which framed mental illness as "conflict" between conscious and unconscious processes, where unconscious drives overwhelmed the conscious mind leading to various symptoms of illness. As the century progressed a new paradigm took centre stage. Behaviourism arrived with the discipline of research based psychology. Behaviourism developed models of learning and behaviour that could be measured for research purposes, and dismissed motivational and emotional states that were more difficult to measure. Both of these models were fruitful in different ways but also led down sometimes unhelpful roads.  Unhelpful interpretations of the psychoanalytic model such as the common understanding of Dr. Spock's advice came on the scene. This interpretation was that all we had to do was love children unconditionally and they would thrive. This unfortunately missed the fact that it is natural for us to have expectations of children and give them responsibility, which they often resist. From the behaviorists came recommendations to reward and punish and shape children's behaviour much as we would train circus animals. This misses the point that rewards and punishments only work in the context of a healthy relationship which they themselves do not help establish.

Fortunately there have been new developments in the realms of developmental science upon which we may draw. In the 1950s John Bowlby and his student Mary Ainsworth introduced Attachment Theory to our theoretical repetoire. Borrowing from ethology, these clinicians used observational methods to establish that children develop patterns of behaviour in a relational context with their parents to establish a predictable pattern of establishing security which endure over time, generalize to relationships with significant others and romantic partners, and are often passed on from parent to child. New developments in behavioral neuroscience such as the establishment of the existence of mirror neurons and research on the process of parent child attunement have helped us gain an improved understanding of the developmental pathways for empathy and of theory of mind. These developments allow us to understand that learning occurs best in an attuned and secure relationship and at best involves more than simple conditioning.

On the Adolescent Psychiatric Unit we have followed a model of "Collaborative Problem Solving" (with start up consultation from Ross Greene). What we have moved away from is the model of Behaviour Modification which still dominates on many, perhaps most, hospital wards. In the Behaviour Modification model rewards are given for desirable behaviour and consequences meted out for undesirable behaviour. The problem with the behaviour modification model is that those who can cope with it are rewarded while those who can't are punished. What you get in the end is extremes of behaviour. Studies have shown that these kinds of interventions increase the rates of seclusion and restraint. Collaboration involves having and discussing expectations while taking the time to listen to the concerns and expectations of the young person. It involves understanding that young people may not always be able to meet our expectations, but that there are many different reasons why they may not. Using this model we can learn what some of the barriers to meeting the expectations of others might be in this particular child, increasing our understanding, while improving communication skills and trust. In a relationship where kids feel safe and understood they usually come to accept the expectations of others. So far this model has worked well for us, although it can be challenging and requires more thoughtfulness and effort than a simple behavioral model would require. Overall the results have been rewarding and our restraint and seclusion rates have been near non-existant.


  1. Let me have the honour of being the first to post. Excellent precis of the historical journey that psychiatry has taken. It is encouraging and reassuring that your unit has the same goal of reducing seclusion and restraints through a collaborative model. We have also relied heavily on Ross Green as well as the Engagement Model with a substantial nod to attachment as a way to engage, empower, collaborate and allow for the shared responsibility for improvements in health, sense of self and family life.

  2. Thank you Renter. Out of curiousity, in what context are you using your collaboration based approach?

  3. I think it's critical for HCPs working on the front lines to add their best thinking to the conversation in their line of work (ditto for any subject matter experts). It's arguably the most efficient and authentic way to innovate a therapeutic care by engaging different perspectives to solve problems together (much like the premise of this blog post).

    Separately, As a father of three (and a non-medical professional) your words resonate. Invariably, collaborating with my child on a solution is empowering for them and deeply satisfying for me, the parent. I feel that by doing this as consistently as possible, I'm giving them tools to be successful in life as they grow older and more independent. Trick is to have the perseverance to do this every time, which requires eternal patience. Interestingly, as a business professional, I try to take the same approach with my team mates. It would be egotistical of me to think I have all the answers to everyone's problems...Thanks again for adding value. Keep it up!

  4. I'd love to expand the discussion - taking Collaborative Model to child treatment units where the ALOS is longer than the traditional inpatient "stabilization" unit. At least in the US, inpatient units are typically 1 week stays, and treatment is at best, just getting the first steps in place in a longer process. In some areas longer term treatment is within a "state hospital," a residential treatment facility, or a "community-based" equivalent (the same supports, but without the bricks and morter building.)

    When I first became fascinated by child psychiatry, it was through narrative psychology, often rooted in the psychoanalytic tradition. My clinical training experience began on a unit with very behavioral roots, although strongly guided by developmental and attachment overtones. As an early career director of an inpatient unit, I balanced my ideas of what "seemed best," with the vision of the university hospital administration, the "real world," experiences of my seasoned staff, and the fiscal realities. Now, more seasoned (parenting 3 early elementary school boys does that) I am reassessing what are the best approaches for promoting real growth, change, resilience, and overall better behavior and functioning. My current professional position requires looking at these treatment models from a state wide, systems perspective. I'd love to hear thoughts from others who are questioning what are better approaches for this kind of work.

    Pedi-psych MD

    1. Welcome Anonymous! Good to hear from a fellow pedi-psych who is wrestling with the same issues. I am pleased to hear you are in a position to influence positive change! I wish you great success in doing so and I hope this blog may be of some inspiration to you.