MENTAL HANDICAP VOL.

12 SEPTEMBER 1984
Self-control procedures:
a useful means of hel pi ng peopl e who ar e mental l y handi capped
to overcome problems of temper and aggression
Ian Fleming Mar t i n Tosh
Many people who are mentally handicapped are referred to
specialist staff on account of behaviour problems -especially
if they seemto be unable to control their impulsive behaviour
and resulting temper tantrums andor aggression. Referrals are
often made from community settings where people are required
to have a reasonably high degree of interpersonal and social
skills. People who are unable to get along with others or show
more acute problems of behaviour are often referred for
specialist advice and/or a change of placement.
When people have been referred to us for reasons of this kind
we have used a functional analysis (Kiernan, 1973) of the
behaviour to determine any relevant factors in their
environment. Although wehave occasionally discovered factors
which are directly related to problem behaviour , our experience
has usually been that the people referred have been responding
inappropriately to their environment. More specifically, they
have not developed self-control over aspects of their behaviour
and the absence of this has become a severe obstacle to their
independent functioning. This is important as we feel
insufficient emphasis is placed on helping people who who are
mentally handicapped to learn skills which will enable them to
manage, control, and determine aspects of their behaviour.
People who are mentally handicapped do not acquire basic
self-help skills (such as washing and dressing) without specific
teaching. If teaching is provided they can become sufficiently
skilled in the set tasks, but often remain unable to decide and
manage their behaviour in these areas independently. It is
logical to assume that self-management skills (including the
means to observe, monitor, and regulate their own behaviour)
also require to be taught if people who are mentally handicapped
are to develop these to complement other skills. At the moment
such training is rarely provided. Operant training techniques
commonly place controls upon the external environment in
order to provide specific experiences necessary for learning to
occur. However, this external manipulation by others
promotes reliance upon external factors in the environment
rather than the development of more internal forms of
control. As a result these techniques (for example contingency
management, token economy schemes) restrict the development
of behavioural options and encourage responses in the people
concerned that are in reaction to the controls in their
environment rather than in themselves.
This is particularly relevant to people who are unable to
control their impulsive behaviour for whom management
procedures have usually emphasised the controlling of
external factors (such as situations and contingencies) in the
environment. We consider that alternatives should be developed
to help people who are mentally handicapped to learn self-
control. In addition to overcoming problems of generalisation
and maintenance which are frequently associated with the more
usual management techniques (Connis and Dwinell, 1981) these
alternatives can set out to meet each individuals specific needs.
If people who are mentally handicapped are really to function
independently, rather than to simply perform skills
independently, achievement of self-management skills is
essential.
In the last decade much work (for example, Thoresen and
Mahoney, 1974) has been done on developing methods of self-
control. However, these have often been considered
inappropriate for people who are mentally handicapped because
of their perceived inability to observe, evaluate, and monitor
their own behaviour, and because many self-control procedures
have focused on abstract and verbally-based processes. We wish
to describe how a modified form of training in self-control was
used successfully to help two adults overcome problems of
temper and aggression.
Jane
J ane, aged 20 years, was referred by the staff of the adult
training centre she attended where she regularly blew up for
no apparent reason. The sequence of events involved making
unreasonable demands or failing to comply with appropriate
requests, sulking, anger, and aggressive behaviour (both verbal
and physical). J ane expressed remorse afterwards and appeared
to possess some insight into her behaviour, but claimed an
inability to stop herself from completing the chain of
behaviours. Functional analysis suggested the behaviour was
inappropriate and not related to inadequacies in her
environment. Staff thought that chronic problems present in
Janes family - from which she had been removed - had acted
as a model for some of her behaviour. Also, as she usually
received staff attention as a consequence of inappropriate
behaviour it was possible that this was maintaining the
behaviour .
A modified self-control procedure was used which
emphasised the use of self-monitoring techniques. (I n
themselves these are considered to have an important effect on
task performance and to act as a reinforcer for behaviour change
(Nelson, 1977)). J ane was encouraged to think of the physical
sensations she experienced as she proceeded along the
behavioural chain outlined above. With help and practice she
defined a hierarchy of five points which she could reliably
describe and recognise, for example, butterflies in my
tummy, hot face. J ane was pleased to have accomplished
this.
The next stage was to help J ane to recognise when these
sensations occurred and to stop at that point in the chain. A card
was developed upon which were recorded numbers given to each
of the five stages. J ane was to place a mark in the appropriate box
when she recognised and stopped at one of these stages and to
engage in a pre-arranged alternative behaviour, such as thinking
of a pleasant event. To further reinforce this it was arranged that
she should have immediate direct access to a named member of
staff, who would praise Janes behaviour and briefly discuss
with her any outstanding problems.
In the research literature, importance is attributed to peoples
ability to develop the means to reinforce their own behaviour
(Thoresen and Coates, 1976). For J ane reinforcement was
initially provided by the member of staff but this was faded out
~ ~ ~
IAN FLEMING is a Senior Clinical Psychologist, Services to Mentally Handicapped People, Salford
Health Authority and MARTIN TOSH is a Nursing Officer with responsibility for the Assessment and
Training Unit at Swinton Hospital.
110
@ 1984 British Institute of Mental Handicap
MENTAL HANDICAP VOL. 12 SEPTEMBER 1984
as the diary-card itself became a reinforcing stimulus for
appropriate behaviour.
Over a period of four weeks J anes behaviour rapidly
improved and she became able to impose self-control at an early
stage in the behavioural sequence. In the training centre the
blow-ups disappeared and the procedure was gradually faded
out. At a six-month follow up the improvement at the centre had
been maintained, although similar features were beginning to
occur in J anes residential setting. Although different factors are
relevant there it has been decided to implement a similar
procedure in that setting.
Polly
Polly, aged 34 years was referred in February 1982, by the
manager of the adult training centre she attended because of
aggressive and violent outbursts. Polly had been attending the
centre full time for close on 15 years. There had always been a
history of sporadic temper tantrums and attention-seeking
behaviours but these had increased in frequency and intensity
over the last six months. Pollys increased inappropriate
behaviour was not restricted to her work situation. Community
nurses had detected increased stress within the family due to
Pollys changed attitude at home, which was one of less
cooperation and greater argumentativeness. Such a change is not
uncommon in someone who has spent 15 years in the same job -
it is a fact of life that many people who are mentally handicapped
spend long periods in the same employment.
First programme
After a six week period of observation, which included a
reinforcement survey, Polly started on a programme aimed to reduce
her outbursts. Appropriate interactions with her fellow trainees and
staff were positively reinforced. If a temper tantrum or physical
outburst occurred Polly had to clean the area in which the incident
took place.
This programme was quite successful at first - Pollys
outbursts decreased from four to two per week - but two
factors became clear.
The first was that a more sophisticated method of treatment
would be necessary to remove Pollys residual inappropriate
behaviour, that is, the two outbursts per week. Secondly, Polly
was particularly prone to being taunted by J ohn, a fellow
trainee, who enjoyed seeing her in a state of excitement and
upset. This negative relationship, it was hoped, would provide
Polly with an opportunity to learn more about her ability to
control her behaviour.
A new programme, using modified self-control procedures,
was then begun:
Self-control programme
1. One 15-minute session will be held daily, Monday to Friday,
during Pollys attendance at the Assessment and Training Unit.
2. Polly will be asked to identify her emotional feelings prior to
losing her temper.
3. Polly will be asked to identify the physiological changes
occurring to her prior to her losing her temper.
4. Polly will be asked to identify a time, place, and peer group
where the majority of incidents occur.
5. The information gained from Polly will be categorised and
numbered, for example:
Emotions Physiological changes
1. Embarrassed 1. Felt Shaky
6. Number by number and category by category Polly will be
taught to recognise and act upon each stage separately, both
emotionally and physically.
7. Pollys ability to usethe typewriter will be used as an increased
opportunity to learn and as a positive reinforcer.
8. Pollys behaviour will beplotted on a graph before, during, and
after the self-control procedures. This will beexplained to Polly
who will be responsible for filling in the graph. (Polly
understands that the peaks in the graph mean bad behaviour
and that the ideal pattern to aimfor is a straight line across the
bottomof the page).
9. Polly will be asked to type at home two copies of key words and
phrases that she identifies in the sessions - one copy for herself
and one copy to be handed in. She will take her copy home, copy
it into her diary, and read it before she goes to bed. This will be
Pollys homework.
10. To ensure that Polly completes and studies her homework,
positive practice will be continued in the formof extra typing.
That is, if Polly does not produce the typescript of her homework
she will be asked to type out four copies in the office at the unit.
Results
Combined
outbursts outbursts per week
Physical Verbal total
First six weeks 4 4 8
Introduction of
First programme 3 3 6
Introduction of
After Self-control procedure 0 0.25 0.25
Self-control procedure 1 1 2
The formal self-control counselling sessions have ended and
Polly is now controlling her temper outbursts very successfully.
The occasional use of a key word or phrase that Polly
volunteered during the programme is all that is needed to
maintain the improvement. Polly attended an interview for a
domestic position in an elderly persons home soon after the
programme ended and was successful. After working at the
home for three months, it was identified that she did not possess
the interpersonal skills necessary for working with elderly
people, and it was decided that Polly should transfer to a local
authority laundry. She has continued to work there for over six
months with only two recorded outbursts of verbal aggression.
Conclusions
Many behavioural methods used to teach people who are
mentally handicapped rely on the use of external) controls. We
feel that it is important for people to develop skills that enable
them to control and manage their own behaviour without relying
on external factors. This is particularly important in people who
show temper tantrums and loss of control, behaviours which
feature in many of the behaviour problems for which
specialist advice is sought. I n people who are mentally
handicapped self-control skills, like others, will only develop if
they are specifically trained. We believe that it is possible to
modify and use aspects of the self-controllself-management
procedures that have been developed for use with other groups,
as long as extra attention is given to defining and implementing
the methods to be used.
I t was particularly noticeable how both J ane and Polly quickly
learned how to monitor their own behaviour once it was clearly
specified for them. We hope that the brief case histories
presented here will encourage others working with people who
are mentally handicapped to develop this field.
References
Connis, R. T., Dwinell, M. A. An evaluation of response maintenance with
self-monitoring procedures. Behav. Engineer., 1981; 7:2, 45-49.
Kanfer, F. M. Self-management methods. I n Kanfer, F. M., Goldstein, A.
P. (Eds.). Helping People Cliange. New York: Pergamon Press, 1980.
Kiernan, C. C. Functional analysis. In Mittler, P. (Ed.). Assessment for
Learning in the Mentally Handicapped. London: Churchill Livingstone,
1973.
Nelson, R. 0. Assessment and therapeutic functions of self-monitoring. In
Hersen, M., Eisler, R. M., Miller, P. M. (Eds.). Progress in Behavior
Modificarion. (Vol. 5). New York: Academic Press, 1977.
Thoresen, C. E., Mahoney, M. J . BehavivralSelf-Cvnrrol. New York: H
Rinehart, and Winston, 1974.
Thoresen, C. E., Coates, T. J . Behavioral self-control: some c
concerns . In Hersen, M., Eisler, R.M., Miller, P. M. (Eds.). Pr
Behavior Modificarion (Vol. 2). New York: Academic Press,
0 1984 British Insti tute of Ment al Handi cap