Title: Punishment and its alternatives
Author(s): J.L. Matson & T.M. DiLorenzo
Matson, J.L. & DiLorenzo, T.M., Punishment and its alternatives , New York: Springer, 1984.
This document summarizes those parts of the book that define punishment and discuss ethical issues.
This book discusses the use of behavioral therapies that involve punishment. Punishment is defined as the delivery of a stimulus immediately after a behavior so that the stimulus reduces the probability that the behavior will occur again. Since punishment only reduces or eliminates unwanted behavior, it should be used as a supplement to reinforcement procedures which reward desired behavior, not as a replacement for such procedures.
Two therapies which make use of punishment are aversive conditioning and covert sensitization. In aversive conditioning, the stimulus that normally elicits the maladaptive behavior is paired with an aversive stimulus. After repeated pairings, the once-pleasurable stimulus causes fear. Aversive stimuli that have been used include:
- Electric shock. This is very effective and causes no physical harm, however it is no longer used due to public and professional criticism.
- Noxious substances. These are substances that are not physically harmful but unpleasant to hear, smell, or ingest. Examples include pure lemon juice, aromatic ammonia, ice, loud noises, water squirts, and shaving cream.
- Drugs. These are difficult to control with sufficient precision.
In covert sensitization, punishing stimuli are presented not physically, but rather through imagery. The patient is told to imagine the maladaptive behavior, followed by imagining the aversive stimulus.
The effects and side-effects of therapeutic punishment are not fully known since research on humans has been minimal.
In the past, the misuse of therapeutic punishment has resulted from
- failure to try less aversive procedures when they may be effective
- failure to obtain patient approval for its use
- failure to ensure that the therapist is adequately trained
- frequent misuse of the methods
Stringent safeguards should be applied to decrease the chance of misuse of punishment.
In 1977, the Association for the Advancement of Behavior Therapy developed a statement to insure the proper use of behavior therapy. This document consists of a list of questions that each therapist should ask when developing a program of treatment. The Association writes that in answering these questions, the therapist should solicit the involvement of the client as much as possible, and give the fullest possible consideration to societal pressures on the client and the therapist. The questions are as follows:
- Have the goals of treatment been adequately considered? They should be written down, the client should understand them, and the therapist and client should agree on them.
- Has the choice of treatment methods been adequately considered? The published literature should show that the chosen method is the best procedure, and the client should be informed of alternative procedures with their risks and benefits.
- Is the client’s participation voluntary? The therapist must consider possible sources of coercion, and allow the client to withdraw from treatment. If treatment is legally mandated, the therapist should offer the available range of treatments.
- When another person or agency is empowered to arrange for therapy, have the interests of the subordinate client been sufficiently considered? The client should be informed of treatment objectives and allowed to participate in the choice of treatment. If the interests of the subordinate person and the superordinate person or agency conflict, this conflict should be reduced by dealing with both interests.
- Has the adequacy of the treatment been evaluated? The therapist should obtain quantitative measures of the problem and progress and make them available to the client.
- Has confidentiality of the treatment relationship been protected?
- Does the therapist refer the client to other therapists when necessary?
- Is the therapist qualified to provide treatment? The therapist should have training and experience in treating similar problems, and the client should be informed of any deficits. The following qualify to provide behavior therapy: a psychiatrist with three years of residency, a psychologist with a PhD, a masters-level social worker with two years of clinical experience, or a registered nurse with a graduate degree in psychiatric nursing and two years of clinical experience.
The authors elaborate on several of these items.
A. Goal of treatment. To determine the treatment goal, the following questions need to be addressed:
- Is the goal stated concretely and objectively?
- Is the goal directly related to the reason the client has been brought to the therapist’s attention?
- When the goal is achieved, can the therapist’s involvement with the client be terminated?
- Will the change in behavior benefit the individual more than the institution?
- Can the goal be achieved?
- Is the goal a positive behavior change rather than a negative behavior suppression?
- Does the goal involve changing a behavior that is actually constitutionally permissible?
B & C. Informed consent. According to the authors, the client’s informed voluntary consent is “the most important doctrine of all ethical standards.” Such consent involves three factors:
- Competence – the ability to make a well-reasoned decision, understand the nature of the choice, and give consent meaningfully.
- Knowledge – understanding of the treatment, alternatives, and potential risks and benefits. This is sometimes difficult to achieve since little is known about many treatments. Thus the client must understand that he need not consent, and can withdraw consent later.
- Volition – agreement to participate given without coercion or under duress
D. Empowerment of another person or agency. The authors write that concern for the well-being and quality of life for the client should be the paramount concern of each therapist. The therapist should consider who would benefit from a change in the client. Different people may view this change differently. The therapist may have to consider whether the therapy is designed to help the individual or to help the institution increase conformity or convenience. If the therapist cannot find a clear reason for the therapy to benefit the individual, he or she may have to refuse to provide treatment.