 Hey, everyone, it's Dr. Howard. We're beginning our discussion now on behavior deceleration techniques, specifically positive punishment. Now, if you've gotten to this point and you have not yet watched the two earlier videos about misconceptions and behavior analysis, misunderstandings about what the terms positive and negative mean, and the video on form versus function, you should really check those out before starting these three videos on positive punishment. This first video is just going to focus on the history of mental health treatment and what I'm focusing on here are some of the historical and unfortunately kind of inhumane ways in which we have in the past tried to decelerate or stop behavior that our culture considers dangerous, disruptive, or disgusting. So those are the three D's that we really talk about when we consider what behavior is acceptable and unacceptable. If it's dangerous to the client or people around the client, if it's disruptive to the environment around the client, for instance, an agency where the client may live or the culture, the neighborhood in which they live their everyday life and disgusting, things that we would consider completely inappropriate in terms of hygienic standards or even interpersonal standards, those are the places that we tend to focus. And unfortunately in our history, we've used some procedures that would be considered probably inhumane by today's standards. I want to take you through briefly what those standards have been and this long-term view of where we are now when we talk about how we choose programs, how we intervene and change behavior. So let me switch here so I can give you some information on screen. So when we talk about the history of mental health treatment, it really helps to go all the way back to our earliest kind of pre-recorded history. And we know from looking at archaeological findings that some early tribes, some pre-historical groups, tended to view abnormal behavior behavior that's dangerous or unusual as caused by supernatural influences. These could range from everything like demonic possession to intervening by a deity or a God. And in favorable ways, this could be viewed as an actual intervention by your God. For instance, we have early shamans. But in some ways, if the behavior is disruptive, dangerous, disgusting, if it doesn't fit within what's accepted and it's not helpful to the group, then it would probably be seen as the intervention of an agent bent on destruction. And so in early, early, early treatment, the focus there would be on somehow exercising that spirit out through whatever methods possible. Maybe this is what we traditionally think of as exorcism. Maybe there's a right or some sort of religious proceeding that takes place where you try to remove that supernatural influence from the organism. Or sometimes there were more physical or direct interventions. In this case, one that we know of that was used commonly in these groups is called treponing. And this would be when a hole was either cut or drilled into the skull to allow spirits out of the body with the belief that that would release the spirit and the behavior would go away. Now, of course, you know, Stone Age brains, we aren't always the best at reasoning and decision-making. It would make sense that you put the hole in, people act a little bit better after the hole's gone into the organism. But was that due to a spirit being let out or is there another confounding variable, such as, well, now you have an organism whose experience, significant pain and trauma, is this the side effect of shock? And there's no evidence to suggest that treponing actually manages or treats behavior. So this is a very, very early example of one of the ways in which we tried to intervene to change or to ameliorate some of the symptoms associated with mental illness or that we really try to change a client's behavior. Now, moving forward a little bit, you see that in recorded history and in antiquity, some would argue that mental illness and personality come from these balancing of different chemicals or different what we're called humors in the body. Now, this is the foundation of most early medicine, this idea that the body, of course, tries to maintain homeostasis. We're familiar with this from general psychology, from biology, and this is widely accepted that the body should function a particular way. And when there's an imbalance in some way, then that can really mess up the system. So in ancient treatment, what we're talking about are methods that are meant to bring these four humors back into alignment. So the easiest explanation would be, for instance, if you have a sanguine temperament, you have a personality that's very gregarious, very outgoing, very fun-loving, and if it's too much, right? For instance, if you're experiencing symptoms that we might call mania where you're not thinking clearly, you're not rationalizing, you're a little bit out of control, then a person may recommend that you bring yourself back into homeostasis or back into alignment, you balance your humors by getting rid of some of that excess blood that you have. These would be things like bloodletting or using leeches. So this is ancient times, but you see that this form of homeostasis or balance in treatment actually continues well into 17, 1800s, and we see echoes of that when we talk about the ways in which psychoactive medications are used to balance neurotransmitters. We have the same philosophy there where one of the neurotransmitters may be out of alignment. So what we're going to do is supplement those neurotransmitters either by adding more or by adding an agonist that's gonna mimic the effects of the actual neurotransmitter or we're going to use an antagonist to block the neurotransmitter to make sure it doesn't come through. In modern treatment, that has some pretty good effectiveness. There's not as much support here again to suggest that balancing these bile, the blood, the phlegm, black bile, yellow bile, that that's going to be effective at changing behavior and managing any kind of mental illness. When we come forward a little bit into periods of time that we might call medieval times, that we might call the dark ages, it's kind of an uncharitable moniker that we give to those times. You see that between the 12 and 1500s, what we're doing to try to manage behavior is a lot of aggressive physical corporal control and body modification. So when we move into this period, you see that it doesn't matter what the behavior is. So long as you are not a disruption to the group, to the culture, to your neighborhood, to your society, that's what we're working on. We see things like beatings and burnings where you would try to, for instance, get the spirit out of you through actual branding. You see that there would be similar to how we might work in animal husbandry, some castration or removing parts of the body. For instance, if you gelled an individual, if you remove part of their reproductive organs, just like we do with dogs and cats or domestic animals, then that may calm the individual. There was also a belief in animism, this idea that different creatures had different properties. So for instance, if you wanna have a greater constitution, if you wanna be healthier, then it might help to get a transfusion of ox blood because ox are known as being very hardy animals and they can stand up to a lot of experiences in that way. So getting that transfusion is gonna give you the spirit or the essence of the animal and it's gonna help change the way that you behave. So if you wanna improve your health or if you wanna be calmer, maybe you need to get an injection of owl blood to increase your wisdom and your calmness. So these were widely used. And of course, one that we are much more familiar with, lobotomy was used intermittently and it became really, really very popular in the 1900s. So 19, I believe in the 50s, it became phenomenally popular as a form of treatment so much so that people were actually given correspondence courses on how to learn how to lobotomize people and then could just sort of drive from town to town offering this as a medical service. And we see that this started actually in the middle ages or what we might call medieval times prior to the Renaissance. Moving into the Renaissance, again, the focus really was on how do we make sure that folks who experience this kind of disruptive behavior, how do we make sure that we're protecting the populace from the client? How do we keep society safe but often at the expense of the person who's experiencing those symptoms and what you would find, especially in European countries like France, is that people who experienced madness, right? Or people who were considered lunatics. Again, this was back when we believed that it was tied to tied to the moon and the phases of the moon. People who experienced madness would be put into prison. The idea there being, we just need to protect society from the person who experiences the mental illness. So unfortunately, what that means is you have a person who may not be in their right mind. You have a person who may be needs, that support needs additional care. And now they're actually in a general population with hardened criminals. They're in with people who have their full faculties but who've engaged in violent behavior, violent crime. And so many people saw that during this period of time when folks were simply being incarcerated for their mental illness, that the people who would be victimized in this arrangement were actually the person experiencing the mental illness. So because of this, we see that there was a huge movement towards the use of of asylums. We have a modern perspective of what an asylum means, but at the time, consider that that these asylums were something very, very different, right? We had people coming in and taking people out of prison or taking people out of living in barns when their families couldn't manage them or couldn't have them in the house, taking people off the streets. And we now begin to recognize that a mental illness may be a medical issue. Now, this was around the time that we started noticing the relationship between syphilis, the sexually transmitted disease, and neuro syphilis, one of the long-term side effects or one of the long-term effects of having syphilis, okay? Neuro syphilis is where your brain matter actually starts to break down a little bit and a person who might otherwise be normal then develops these symptoms of madness because of the way that their brain reacts to their illness. So now that we see that this is affecting otherwise normal members of society, now we start to believe that, well, maybe something else is going on here. Maybe it's not that they're mad. The Philippe Pannell really helped advocate this idea that madness or mental illness is a medical condition. This requires treatment. It's not simply enough to throw people in jail or keep them in the attic where no one knows that cousin Steve is really messed up. We wanna take people. We wanna separate them out from a prison population, separate them out from any kind of victimization they might receive. And we wanna focus on finding what's actually causing the disorder. Now, even within the asylum system, we're still going back to forms of treatment that would focus on things like homeostasis. You might have ice baths to reduce the heat or the temperature of the mind if the brain is overheating due to the madness then we're gonna balance that through the use of ice baths or we might still use some forms of physical pain in order to manage that condition. But in this case, what's happening is folks are taking clients and moving them into these special facilities, these special hospitals. And these hospitals really were at the start, these very therapeutic environments. So what you see on the right are all of the staff who are working at this hospital, especially when you see them in France and England in Germany, these asylums are created and opened in these kinds of idyllic settings. These are much more like what we might think of as spas or a kind of country-based hospital setting than they are for what we in our modern society think of as asylums as these kind of scary places where people go. Contemporary writers at the time speak to the value of these asylums because we're really talking about a complete and dramatic change in your lifestyle where in your everyday life, you may be running around and stressed and you're in the city and everything's dirty and there's pollution everywhere. Asylum offers special protection. It's a very simple life. You can go there, you can get better, you're protected. If you really are just completely messed up, if you are mad, then you can be as mad as you prefer because now you're in this place, you're protected, you're cared for, it's structured and you can do that in a way that's not gonna harm society. Some believe even that by being in these settings, by just going through the process of being mad that some people would emerge from the depths of madness. They could work through it and through that process become saner, more stable functioning members of society. Now, of course, this is some but not all asylums and we discovered that Dorothea Dix is a famous researcher. She was a journalist who worked to get herself admitted to an asylum and ran one of the earliest exposés on these asylum-based treatment centers and discovered that what would happen in the treatment center was not always, I did like it was not always safe. In this case, Dorothea was physically abused, physically harmed by staff members working there and we discovered through this that while this was sort of the spirit of the asylum that in practice, many asylums were still places where people would experience significant abuse and there were calls, there were polls for reformation but at that time, really focused on how can we make sure that these are treatment facilities where people are being cared for but they're getting the care that they need and they deserve. We had made some changes through time and we were seeing that there was improvement and in America, we had a number of state schools where folks who experienced a variety of illnesses could go. You have places like state hospitals for the mentally ill, state schools for a condition at the time that would have been called mental retardation. We would refer to that now as an intellectual or developmental disability and again, these were being sold in very much the same way even though it's about 80 years later, these were being sold as very similar kinds of institutions. These are places where people can go and be safe and they get structured care and support and we didn't always do our due diligence as a society making sure that people were being cared for in the way that we thought that they were. So for instance, in the 70s, Geraldo got his big break by exposing this New York state hospital called Willowbrook and he broke this news of patient abuses at Willowbrook and by abuses, we're really talking about the type of behavior that's caused by just significant systemic neglect and a complete claim over population with respect to the number of staff that were available. But it was part of a larger culture at the time where doctors were recommending that families actually place their children, place their loved ones in these hospitals to make sure that they could get the best care possible but it wasn't always provided. Now that material is incredibly graphic but I would encourage you to follow the link in the description below, watch that video because I think it really helps highlight what can happen when we have these aspirational goals and the dangers of what happens when we don't have the resources to provide and make sure that the quality of care is as it should be. So as a result of exposing what's happening at Willowbrook, as a result of the things that Geraldo Rivera is reporting at the time, there was a national backlash and people were shocked. People were just completely amazed at the quality of treatment that children were receiving. These are children who are supposed to be in special schools where they can learn and become better people and they weren't getting it. So there was a national movement toward de-institutionalization and you can drive around the country even today and see that there are these huge empty buildings where people used to live and don't anymore because in some states, for instance, like Alaska, as a result of places like Willowbrook or places like institutions where foster children would be housed for large periods of time, some states have completely outlawed large state schools and large state treatment facilities but many others adopted or moved toward treatment models within their mental health departments that would idealize something that we call community-based treatment. So community-based treatment is where the person either stays within their own home or they stay in a home-like environment so that they can experience treatment in a naturalistic setting. This could be, for instance, a child who experiences an intellectual or developmental disability staying at home with mom and dad, but then a caregiver comes in to help coach and support mom and dad. This could be a person who experiences profound intellectual disability. Maybe they can't stay with mom and dad anymore so they live in a group home with other folks who experience intellectual disability and then as a group, they stay in the community, they learn skills and they learn those in the natural environment so they can be supported by the natural environment. That's really the key there. There's a higher visibility of people who are different and when you're in your own natural environment, you can harness not only the folks who are paid to be there with you at your staff, but you can take your client out into the community and they can make friends, they can meet people, they can meet people in their environment, they find what they love, they are people. So the services that are really meant, the spirit of services in community-based treatment are empowered services. Ways of keeping the individual who experiences the mental illness, the intellectual disability, what have you, a connected member, a connected part of their community. And you often see this very high overlap between community-based treatment and person-centered planning. The beauty of person-centered planning is that we're talking about a treatment modality where the client themselves are an active part of their own treatment. So it isn't necessarily that look at this behavior change program. It works for kids with autism, so I'm gonna give it to every child with autism, not, no. What it does is it recognizes that everyone is different, right? That what works for you may not work for me and vice versa. And in person-centered planning, what we're talking about is considering the whole person. Not just a problem behavior, but what is it about that person? What are their wants, their needs, their desires, their drives, their hopes, their dreams? What is it that we can do to help support them to recognize their desires and their interests, to capitalize on those, and help make sure that they're reaching their longer-term goals? So we really wanna be thinking about the future of the person. We wanna make sure that, for instance, Rebecca here, isn't just learning the skills necessary to make her calm and docile in her group home, but rather that her group home is supporting her so that she can learn the skills necessary to grow up, to get her own apartment, to live independently, to have a job, to meet someone she cares about, to have a family, to have whatever it is that Rebecca wants in life, right? That's the beauty of person-centered planning. And when we talk about behavior analysis, what I want you to realize is that at its spirit, at its core, behavior analysis is person-centered planning. So when you consider form versus function, we're not just interested in figuring out how do we reduce your problem behavior. We wanna figure out how do we teach you the skills necessary to live your whole life in the best way possible. All of the principles that we've described are universal. So reinforcement, shaping, punishment, these are universal principles, but that doesn't mean that the way that I use reinforcement is gonna be the same for you as it is for me, right? Your reinforcer is not my reinforcer. A punisher for you, if I even want to use one, which usually I don't, a punisher for you may not be a punisher for me and vice versa. So it's not enough that we're just adopting the same treatment modality for everyone. We really wanna carefully consider the person, the function of their behavior, and to develop a treatment program around that individual that's gonna help them support and live their best life. Now, remember, all of our clients are unique, so this is not a one-size-fits-all approach to treatment. What we're talking about is we're gonna find something that works for each individual and we're gonna carefully analyze is this working, is this not? We know that what works for one client won't work for another client, except that we may use those same universal principles. We may capitalize on the fact that organisms will do things that pay off again and again. We may use the principle of reinforcement but the actual procedure that we develop, that we refine is gonna be different for each of our clients. Because each client needs that unique plan to meet their own individual needs and their own individual goals. So, I hope that this better helps explain why when we talk about moving forward, why you wanna start in one place and not immediately jump right to punishment, that this makes sense. So if you have any questions about the content, please feel free to leave a comment in the description below. I know that this is a gross over simplification of the history of mental health treatment but I really want you to have that context for why we wanna focus on person-centered planning, why we wanna focus on reinforcement first as a behavior change procedure and do be sure to check out the next video where we actually talk about punishment as an intervention and talk about some of the strengths and limitations of that intervention. I'll see you guys next time.