Function of Instructions in a Therapeutic context

by John Wesenberg, M.S, BCBA, LBA.

The Function of Instructions in the Therapeutic Context

Instructions, both explicit and implicit, are important to providing the best care to an individual in the therapeutic context. The difficulty is determining the interlocking contingencies needing to be shaped and strengthened in a package treatment. For this analysis, exposure and response prevention (ERP) for individual’s diagnosed with obsessive-compulsive disorder (OCD) will be the exemplar of how and when to use instructions in clinical care. Detailed, explicit instructions and feedback are important to a client in clinical care for the following reasons:

1. Therapeutic stimuli such as exposure assignments, practice and interoceptive forms, help with fluency and maintenance of expectations for a longer, and more consistent performance. These stimuli, when arranged and taught correctly, are easily accessible, readable, understandable, and sustained in the individual’s life in and out of treatment.
2. Instructions and feedback can be communicated in clear contingencies of reinforcement to promote behavior momentum and consistency in responding. If… then… or first… then… statements indicate when to engage in activities that maintain responding. These contingencies are strengthened by incorporating values and personal preferences. Establishing operations (abolishing and motivating effects of stimuli) are accounted for and manipulated by communicating in clear and specific rules.
3. Direct rules will create long-lasting maintenance of buy-in and momentum for responding correctly to stimuli that evoke fears. When the patient understands the contingencies that create the tools that allow them to respond differently to fear-evoking stimuli, there is a higher probability of effective maintenance and generalization.
4. Rules can be used as augmentals, in that rules may serve to alter the reinforcing value or punishing value of consequences. Augmentals act as an establishing operation for increases in intensity or magnitude of an exposure or new stimulus class. For example, a therapist may say to a client, “If you are able to look at another person and respond with a one word answer when that person initiates a question 80% of opportunities for a week, you are able to play the Nintendo Switch at the end of the week,” will probably result in the client seeking feedback on their responses to others, which was previously a neutral stimulus, and attempting to meet the criterion.

Now, let’s specifically look at how indirect, implicit instructions and metaphorical feedback are important to effective clinical care.

1. Metaphors and indirect instructions allow an individual to derive flexible instructions from mapping of contingencies onto previous experiences. This prevents client’s from over-following non-functional rules rather than responding appropriately to their context and contingencies as they occur. Therapists must always be aware that they are typically perceiving a client partially through their own verbal report and possibly biased rule-governed perceptions of themselves, others, and the world. Providing direct rules can dysfunction when therapists provide instruction based on how they believe behavior functions in contexts that they cannot directly observe and manipulate. Therapists must be mindful that providing metaphorical rules can assist a client in responding and learning effectively from contingencies as they occur; rather than responding by following what the therapist ‘says’ the client learns to track their environment better.
2. Metaphors increase the variability of how an individual responds to stimuli. Variability in responding increases the possibility for accessing new contingencies of reinforcement when responding to stimuli in the natural environment.
3. Metaphors are also most effective in reflecting complex instructions that require that the client begin to track the functions of their own behavior in context. For example, in explaining how exposures work to provide opportunities for learning, a therapist may let the client know that exposure therapy is ‘more like learning to ride a bike’ than attending ‘talk therapy’ – that the therapist’s role is much like ‘getting the client on the bike repeatedly and instructing on how best to improve performance.’ Further, the therapist may state that much like learning a bike – verbal instructions alone will not effectively produce the complex behavioral repertoire of sensing one’s weight shifting in motion and continuously correcting one’s behavior in reaction to felt positive and negative consequences.
4. Metaphorical feedback evoke a context for an endless opportunity of possibilities. This is exciting to an individual because of the behavioral cusps they are currently contacting and could be contacting in the future.

Reference

Houmanfar, R., Rodrigues, J., & Smith, G., S. (2009). Role of communication networks in behavioral

systems analysis. Journal of organizational behavior management, 29, 257-275, DOI:                          10.1080/016086093092102