Learning & Behavioral Approaches to Treatment
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patients treated with operant conditioning combined
with other treatment modalities (medication, group
therapy, occupational therapy, etc) [15]. Behavior
analysis was conducted during an initial four- to five-day
observation period, and reinforcers were individualized
for each patient. These included increased activity privi-
leges, access to textbooks, personal hygiene materials,
other patients for socialization, and reduction of medi-
cation dosage. Reinforcement was given daily, contin-
gent on a weight increase of 1/2 lb. All patients gained
weight, averaging 4.07 lbs. per week. This study is signif-
icant for more refined diagnostic criteria, including
greater than a 30% weight loss and amenorrhea greater
than six months in female patients. However, the
authors note the absence of exclusion criteria and the
possibility that two schizophrenics were part of the
sample. The study is also notable for a relatively long-
term follow-up in a fairly large sample, ranging from
four to five months after discharge. The results were ex-
tremely variable and included two deaths and several
other patients who "did poorly after discharge."
Pertschuk, continuing the work of Brady and Rieger,
reported a follow-up study of 29 patients, 27 of whom
were treated with operant conditioning for weight gain
in addition to medications [16]. Behavior therapy was
shown effective in 25 of the 27 patients. The study, rang-
ing from 3 to 45 months after discharge, was also signif-
icant for the finding that bulimia developed in ten
patients who did not report this as a problem on admis-
sion.
Agras et al reported a 1974 study using five single case
studies to investigate the relative importance of three
variables on weight gain using an A-B-A design [17].
They were reinforcement, size of meals, and infor-
mational feedback.
Reinforcement of daily weight gain was proved effec-
tive as in prior studies, but they also noted that weight
continued to increase during nonreinforcement
phases—although at a decreased rate. At this point, the
hypothesis of hospitalization as a negative reinforcer
was introduced. This was tested by having the patient re-
main for a 12-week period, regardless of weight change,
to remove the "discharge contingent on weight gain" ef-
fect. As predicted, the rate of weight increase declined,
and food intake greatly declined.
Informational feedback consisted of the patient re-
ceiving exact information regarding the number of calo-
ries consumed and mouthfuls of food taken after each
meal plus exact body weight every morning. Under con-
ditions of informational feedback plus reinforcement
versus reinforcement alone, weight clearly improved
under the former.
Size of meal presented versus weight gain was also
tested using a 3,000-calorie-per-day diet versus 6,000
calories, but only a weak treatment effect was noted.
While not demonstrated definitively, the authors felt
that informational feedback was more important than
positive reinforcement, but that combining all three
variables was the most efficacious.
Agras and Werne published a subsequent report in
1977 on the first 25 patients treated at Stanford Univer-
sity [18]. They used a similar protocol and noted that
only three of the 25 patients did not gain weight at dis-
charge.
Bhanji and Thompson [19] studied 11 anorectic
patients using operant conditioning often combined
with medications. Patients were allowed to specify their
own hierarchy of reinforcers, and these were made con-
tingent on progressively more stringent criteria—ini-
tially a complete meal but later modified to account for
actual weight gain. All but one patient gained significant
weight at discharge. Long-term (2 to 27 months) follow-
up was attempted using mailed questionnaires, but only
seven were returned, and only three contained a weight
update. The authors concluded that, based on limited
follow-up, operant techniques were useful for initial
weight gain, but were inadequate for long-term main-
tenance of normal eating and weight. However, it is un-
clear whether operant techniques were adequately
maintained after discharge.
Parker et al (1977) reported on ten anorectic females
treated with a combination of psychotherapy and oper-
ant conditioning, and in some cases medication [20]. Re-
inforcement consisted of giving the patient a variable
number of chips contingent on both cooperation with
staff (which was individualized) and weight gain. For ex-
ample, one chip was given for simply coming to weigh-
in, one for maintaining weight, and ten for each 1/2 lb
gained. These could be used to "purchase" passes, so-
cial activities, and other reinforcements that the patient
selected. Additionally, the patients received novelty gifts
at 1-lb weight-gain intervals. All patients are reported to
have gained weight during hospitalization. The authors
also emphasized the need to educate the staff that (1) a
behavioral approach to therapy did not imply a totalitar-
ian ideology, and (2) any comment on a patient's eating
behavior (as opposed to weight) was unproductive.
In 1977 Garfinkel et al studied 42 inpatients and out-
patients [21]. Of the 26 inpatients, 17 received operant
conditioning with other therapies and nine received only
other therapies. No outpatient received behavior ther-
apy. All patients were followed a minimum of one year
after discharge. Results showed that patients treated
with behavioral methods were statistically similar in final
weight to the remainder of the group. The authors also
attempted to design a scale, the "Global Clinical Score,"
to measure parameters other than weight. They con-
cluded that behavior therapy, while not superior to