Practical Psychotherapy

Behavioral Management in the

Rehabilitation of a Person with Severe
Mental Illness: The Path Less Travelled
Jyoti Mishra1 , Navneet Kaur1, Shikha Tyagi1 and Nitin Gupta1

ABSTRACT skills, and nonengagement are frequent Rehabilitation & Triage (DART) facility
In severe mental illness (SMI), such as behavioral problems in persons with for SMI patients. It includes a daycare
schizophrenia, rehabilitation begins immedi- SMI that impact their functionality. Cit- facility, halfway home facility, neuro-
ately. Aside from the token economy, there is ing functional impairment and resultant psychological rehabilitation, social skill
limited literature on behavioral modification disability, early intervention upon the training, vocational rehabilitation facil-
(BM), which is a crucial aspect of rehabilita- emergence of the initial symptoms of the ity, placement cell, crisis resolution, and
tion for person with severe mental illness disease is an important element in man- home-based treatment (CRHT) facility,
(SMI). We demonstrate the implementation
agement.4-6 In SMI, behavioral modifica- and disability certification cell. The
and effectiveness of BM for one year in
tion (BM) is integral to comprehensive institute provides both outpatient and
managing behavioral difficulties in a person
with SMI. The direct observation method rehabilitation. However, the literature inpatient rehabilitation services and has
and the ABC functional analysis model were on the use of BM in SMI focuses primari- 40 beds.
used for evaluation. Management, such as ly on the token economy, thereby restrict-
reinforcement and punishment, was imple- ing the broader scope BM encompasses. Clinical Presentation
mented. Pre- and postassessments revealed This article illustrates the application Accompanied by her elder brother, Ms.
a considerable decrease in problematic of BM other than token economy in reha- AK, a 32-year-old unmarried female
behaviors. This article also highlights the ob- bilitating persons with SMI. The goal is
stacles faced while managing the case and from a middle socioeconomic status,
to exemplify the difficulties encountered presented with the chief complaints of
caregiver burden in rehabilitation. In persons
throughout the process. It also high- irritability, aggression, odd behaviors,
with SMI, the application of BM enhances
the patient’s functionality and reduces the lights how giving sufficient attention to delusions, and hallucinations for the
caregiver burden. BM in SMI can facilitate the process of past 12 years. Her illness had an insid-
remission and recovery. ious onset with progressive worsening
Keywords: Contingency management, pos-
itive and negative reinforcement, punish- and had caused significant sociooccupa-
ment, Premack principle, rehabilitation
Study Setting tional dysfunction. She was diagnosed

S
The index person with SMI was managed with schizophrenia and had a history
evere mental illness (SMI) is a group
in a facility for inpatient rehabilitation of polycystic ovarian disease (PCOD)
of the most severe mental disorders
services at the Mental Health Institute and obesity. She had been hospitalized
with considerable functional im-
(MHI), Government Medical College five times in the past three years with
pairment.1-3 Having onset early in adult
& Hospital (GMCH), Chandigarh. The relapses consequent to noncompliance.
life adds to the morbidity and burdens
hospital has Disability Assessment Mental status examination revealed
the caregivers. Aggression, poor social

Dept. of Psychiatry, GMCH, Chandigarh, India.

1

HOW TO CITE THIS ARTICLE: Mishra J, Kaur N, Tyagi S and Gupta N. Behavioral Management in the Rehabilitation of a Person with
Severe Mental Illness: The Path Less Travelled. Indian J Psychol Med. 2024;XX:1–4.

Address for correspondence: Navneet Kaur, Dept. of Psychiatry, GMCH, Submitted: 30 Apr. 2024
Chandigarh 160032, India. Accepted: 30 Apr. 2024
E-mail: [email protected] Published Online: XXXX

Copyright © The Author(s) 2024

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Indian Journal of Psychological Medicine | Volume 46 | Issue 3 | May 2024 1

Mishra et al.
delusion of persecution, bizarre delu- Assessments and 3. Application of BM (Premack principle,
sion, auditory hallucinations (second positive and negative reinforcement,
person), visual hallucinations, odd Techniques negative punishment, contingency man-
behavior, and delusions of love and mis- The direct observation method and the agement, and contingency contracting).
identification, with the insight being ABC model were employed for eval- 4. Sessions with caregiver.
4/6. After attaining clinical stability, she uation. With the direct observation 5. Repeat assessment (Table 1).
was sent to the rehabilitation section for method, we can record interactions,
vocational training. During her voca- events, and behaviors as they happen in Behavioral Modification
tional trials, a plethora of behavioral real time.7 The ABC model is a functional Premack Principle9
problems were observed. She did not assessment form to formulate problem
participate in any ward activities, was behaviors.8 Information was collected This uses high-preference activities as
argumentative and intrusive, remained daily and weekly from the treating reinforcement for completing a low-
authoritative with others, was preoccu- team, rehabilitation staff, and caregivers preference activity. We identified the
pied with the thought of marriage and through interviews, observations, and reinforcements using this method.
job, and remained guilty of being a finan- review of clinical record. Contingency Management
cial burden to her brother. She would Frequency, duration, and intensity
repeatedly come to the treating team to ratings of the problem behavior were This strategy tied reinforcements to the
talk, and if not responded to, she would completed during ABC charting. On a desired behavior.
get very agitated and verbally abusive. 7-point Likert scale, the observers were Positive Reinforcement
At home, the caregivers, too, noted a instructed to give the excess behavior the
similar pattern of behavior. According This was applied to support fruitful
following intensity rating: 1 = never, 2 =
to them, after every hospital discharge, engagement—for instance, verbal praise
rarely (< 10% of the time), 3 = occasionally
she would disturb the whole family and for attending more therapy sessions.
(about 30% of the time), 4 = sometimes
talk only about marriage (“Since I am (about 50% of the time), 5 = frequently Negative Reinforcement
fine, why can’t I get married?”). Despite (about 70% of the time), 6 = mostly (about
being pacified, she would insist on mar- This was applied when the patient was
90% of the time), 7 = always (every time,
riage, become aggressive and verbally not performing the expected tasks.
i.e., about 100%). After discussion, the
abusive, stop participating in household treating team divided the severity of the Negative Punishment
chores, and often become noncompliant problem behavior into three categories:
We reduced her troublesome behavior
with medications. Because these behav- mild, moderate, and severe. The ratings
by subtracting the time spent in therapy
ioral issues were the major obstacles of 2 and 3 were classified as mild, 4 and
sessions.
to the treating team in planning voca- 5 as moderate, and 6 and 7 as severe. The
tional and psychosocial rehabilitation, following procedures were followed Contingency Contracting
she was referred for BM. The overall during the behavior intervention:
This entails creating a written behavioral
aim was to engage the patient and make
1. Identifying the excess behavior. contract between the patient and the thera-
her functional. Her problem behav-
2. Charting and quantifying excessive pist that outlines the patient’s performance
iors identified for further management
behavior (using functional assessment— of particular target behaviors in exchange for
were intrusiveness, excessive phone
the ABC model). predetermined consequences. This method
calls, and nonengagement.

TABLE 1.

ABC Charting of Patient’s Excess Behavior and Pre- and Postassessment of Frequency, Duration, and
Intensity.
Antecedent (A) Behavior (B) Consequence (C) Assessment Frequency Duration Intensity rating
1. F
 ree time due to low 1. Intrusiveness toward Temporary reduction Intrusiveness
engagement in activities treating team, staff, in distress
Preassessment 10–12 5–10 min Moderate
2. Availability of and fellow patients
(times a day) (50–70%)
supportive persons 2. Excessive phone calls
to family members Postassessment 1–2 0–1 min Mild
(times a day) (<30%)
Phone calls
Preassessment 15–20 5–20 min/ Severe
(times a day) per call (90–100%)
Postassessment 2–3 1–2 min/ Mild
(times a week) per call (<30%)

2 Indian Journal of Psychological Medicine | Volume 46 | Issue 3 | May 2024

 Practical Psychotherapy
was employed during her home parole to would stick to the session’s prescribed in her. He would, therefore, readily
manage her problem behaviors. timings and not disturb others. With comply with all her requests. The family
The patient’s written informed consent this approach, we were able to reduce her was psycho-educated about how their
was obtained. There were 45 sessions intrusiveness. over-engagement hinders her recovery.
with the patient and 25 with the caregiver. Further, an activity schedule was The brother could not spend mean-
Caregiver sessions covered expressed planned to increase her productivity, ingful time with his wife and children
emotion and coping skills. The sessions’ and positive reinforcement was used. To because he was too preoccupied with
duration and time were kept flexible and reinforce her productive engagement, worrying about the patient’s future.
individually tailored per the patient’s and an additional person from the treat- The stress on the caregivers was also
caregivers’ needs. After management, ing team was assigned to talk with her exacerbated, further altering family
postassessments were completed and for 40 minutes daily. Under the “per- dynamics. The brother was advised to
compared to assess the effectiveness of son-bound” technique, she was told to reappraise the situation, determine
the BM intervention. talk only to the assigned person and not priorities, and take corrective steps. He
everyone. She would typically express was psycho-educated on “me-time” and
Behavioral Intervention her worries to everyone, including the “family time.” The emphasis was on
The direct observation method and attendant, security officer, caregivers interpersonal relationships, the limit to
ABC charting were used as the base- of fellow patients, and visitors. It was yielding to the patient’s demands (espe-
line assessment. (Table 1). Rapport was reiterated that negative punishment cially during home paroles), and healthy
established. After charting her problem would be applied if she talked about communication patterns. Their myths
behavior, we noticed that as her psy- her concerns to anyone other than the and misconceptions about exorcism,
chopathology settled, she would begin one assigned. Her excessive use of the superstition, and marriage-related ideas
expressing worries about being unem- phone was another behavioral concern. were also addressed and clarified.
ployed, single, and a burden on her To lessen this, the caregivers were psy- The postassessment revealed large
family. She would constantly come to cho-educated on how to set boundaries improvements in the intensity, fre-
the treating team to discuss these prob- with her by establishing the frequency quency, and duration of the problem
lems. She would come at inappropriate and length of calls and adhering to them. behaviors (Table 1).
times and disturb the staff and fellow Moreover, if she did not comply with
patients. She would start shouting and the instructions, it would be followed Discussion
verbally abusing the treating team and by reducing the time allotted for phone Ms. AK was managed with BM for one
staff. Later, she would continually phone calls (negative punishment). At first, year, during which time her excessive
the caregivers at inconvenient hours and when the caregivers did not answer behavior improved. BM has been proven
cry aloud. Despite being pacified by the her calls other than the prefixed ones, useful in a variety of psychiatric pheno-
treating team, she would not listen or she would call them from the phones types, including schizophrenia,10–14 as
participate in any activities. After a dis- of fellow patients, their caregivers, and was also seen in our instance. In mental
cussion among the treating team, it was the staff. The treating team identified illnesses, reinforcement and behavioral
decided that she should use her excess these behaviors with the help of the change have an established functional
behavior of approaching others to talk caregivers, and the decided-upon nega- link.15 The current instance exemplifies
as reinforcement (Premack principle)9 to tive punishment was implemented. She the use of BM for problematic behavior
increase her productivity. To reduce her refused to participate in any household in a person with SMI in an institutional
“intrusion,” negative punishment and chores during her initial home paroles setting. Since high-preference activities
limit setting were done with the help and would only discuss her job and mar- frequently serve as excellent secondary
of “time-bound” and “person-bound” riage. A written contingency contract reinforcers,9 we implemented a similar
techniques. Under the “time-bound” was developed between the therapist principle. The reinforcement (talking to
technique, she was assigned a fixed time and the patient to target the behavior. someone) was made contingent upon
(40 minutes) to meet the treating team Per this contract, her desired behavior the desired behavior (productive engage-
each day. She was told she would get an was contingent on her home parole: if ment and nonintrusiveness) via limit
additional five minutes (reinforcement) she continued the problem behavior at setting (person-bound and time-bound).
with the treating team if she adhered to home, her subsequent parole would be As we introduced her to different voca-
the scheduled meeting times (i.e., 40 + reduced or canceled. With this approach, tional sections, we found keeping her
5 = 45 minutes). However, five minutes we could also improve her functionality focused on certain activities challenging.
would be taken away from her sessions at home. In the initial trials, her quality of work
(negative punishment) if she did not (i.e., could have been better; she needed to
40–5 = 35 minutes). Initially, it was diffi-
The Caregiver Session follow the instructions properly and was
cult for her to adhere to the prescribed Here, we focused on the following damaging the equipment. Finally, after
timings. As a result, she would succes- areas: highly expressed emotion and completing all relevant trials from the
sively lose the entire time assigned to effective coping. The patient’s brother vocational section, she was appointed
her. Subsequently, it was noticed that she was the caregiver emotionally invested office attendant. The objective was to

Indian Journal of Psychological Medicine | Volume 46 | Issue 3 | May 2024 3

Mishra et al.
teach her to follow the instructions prop- Conclusion 4. Miklowitz DJ. Adjunctive psychotherapy
erly and complete simple tasks. She was for bipolar disorder: State of the
expected to arrange the files, take them In a rehabilitation setup, it is necessary evidence. Am J Psychiatry 2008; 165:
to their respective areas, and bring them to structure the inpatient infrastructure 1408–1419.
to mirror the real-world scenario where 5. Mueser KT, Deavers F, Penn DL,
back after completing the task.
the patients can practice their behaviors et al. Psychosocial treatments for
In contrast to the earlier vocational schizophrenia. Annu Rev Clin Psychol 2013;
trials, she adjusted successfully, with in an environment that approximates
9: 465–497.
little difficulty, after a few days of the the community. BM is an evidence-based
6. Yildiz M. Psychosocial rehabilitation
trial. Nevertheless, the major challenge practice with notable clinical successes interventions in treating schizophrenia
was a job with no salary. Since she had in treating various behavioral issues in and bipolar disorder. Noro psikiyatri
nothing to gain financially, her irritation persons with SMI. This article highlights arsivi 2021; 58(1): S77–S82. https://doi.
and intrusiveness reappeared. There- that BM in persons with SMI should org/10.29399/npa.27430
fore, she was attached to an NGO that be individualized. Integrating BM in 7. CDC. Data collection method for program
persons with SMI can be effective in psy- evaluation: observation. US department
collaborated with the treating institute.
chosocial rehabilitation, as exemplified of health and human services. Centre
She began receiving remunerations from for disease control and prevention. 2018.
the NGO for her work. After that, the by the discussed instance.
Available at: https://www.cdc.
treating team was able to sustain her gov/healthyyouth/evaluation/pdf/brief16.
Declaration of Conflicting Interests
improvement. pdf
The authors declared no potential conflicts of 8. Zirpoli TJ. Behavior management: positive
Additionally, when asked to set her pri-
interest with respect to the research, authorship
orities, she listed her career first and her applications for teachers. 6th ed.
and/or publication of this article.
marriage second. Therefore, the focus of London Pearson Education Limited;
2014, p. 271.
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ing. She agreed to that and seemed less The authors received no financial support for the laws: I. Positive reinforcement. 1959;
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of her PCOD and weight as a marital article.
Management: Positive applications for teachers.
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and management of PCOD before pursu- at both point scales. One was taken at the time approach to abnormal behavior. 2nd ed.
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