Interview with the Founder and Director, Michael Partie

In June 2001 Richard Fiordaliso and Michael Partie met to discuss the origins and philosophy of the Therapeutic Options program. The following is a transcript of that interview.

Richard Fiordaliso:
What made you create Therapeutic Options? I mean, I personally know of close to a dozen such training programs, and doing a quick tour of the web, you can easily find a dozen more. Why create another one?

Michael Partie:
I was the chief Patient Abuse Investigator for a state Developmental Disabilities system. When I reviewed one year’s statistics I discovered that after factoring out incidents of financial exploitation, neglect, and sexual abuse, what remained was something like 75-80% of the total cases being the result of one person’s attempt to control another person’s behavior. In other words, most of these cases involved a staff person escalating his response to the behavior of a person receiving services until it crossed an ethical and legal boundary. Interestingly, these staff people were often surprised that what they did was considered abusive.

At the same time, I was seeing what I considered an unacceptable number of behavior incidents and restraints. The state actually had some solid and progressive policies governing the use of restrictive procedures. All state and contract agency staff were informed of what they cannot do in their work with people, but to my mind were left with inadequate training on what they should be doing. I thought a targeted training response was called for. When I shared these thoughts I was told that that wasn’t my job, that we had a training unit to do that. Because of my training as a Behavior Analyst and a long-standing personal interest in behavioral support and aggression, I began developing a program on my off time.

So you were prompted by specific research findings. How did you go about developing the curriculum?

When I started analyzing those abuse cases I asked myself, “These are not all evil people, so what is the fundamental error in judgment these people are making?” Many of these cases had a sort of uniform structure to them. I concluded that at some point the staff person involved in the incident lost track of what his relationship to the person receiving services was, and began acting out an inappropriate power dynamic. In most cases, staff begin their work without a clear understanding of what the helping relationship is and how it works. So that’s where I started—by specifying what the helping relationship is—and what it is not. That’s the foundation.

After we talk about the power of human relationships and explore how the helping relationship differs from a reciprocal social relationship, we begin examining some general principles of behavior and how people learn. In order to construct service environments that support growth and select against aggression, we must understand that all behavior, no matter how apparently bizarre or self-destructive, is functional for the individual who engages in it. Operating from that premise, we can provide opportunities for people to get their needs met in more socially constructive ways.

The curriculum stresses the helping relationship but incorporates behavioral theory. Do you consider yourself a behaviorist?

(laughs) Yes, but I’m a Zen Behaviorist.

Okay, I’ll bite. What’s a Zen Behaviorist?

Skinner said that behavior is lawful in the way physics is lawful and that these laws are always in effect. Reinforcement and gravity operate on us equally whether we want them to or not. Okay, however you feel about that statement, let’s just accept it for the purpose of discussion. Now, everyone would agree that the laws of physics certainly apply in a game of basketball, right? I mean you have gravity, mass, velocity, force, inertia, whatever, all operating as bodies move on the court. But no one learns to play basketball by starting with the physics. You don’t compute trajectories mathematically before shooting the ball, right? You don’t plot energy vectors in order to dribble down the floor. You learn to play through practice and over time you organically incorporate the physical laws that govern motion, without any attention to them or fuss. You learn how to hold the ball, how to arc for the shot or whatever without the actual mathematics. In fact, you cannot play basketball by starting with the underlying physics, even though those very physics govern what occurs during play.

I think the laws of behavior are very much like this. We don’t establish deprivation states and devise schedules of reinforcement when we spend time with friends and family. We don’t engineer behavior chains and use prompt hierarchies in our relationships. We don’t record frequency data and plot positive and negative celerations. The laws of operant learning are always in effect, but they are descriptive, not prescriptive laws. We don’t begin with them when we live out our social lives. Can you imagine trying to have a relationship with someone who operated that way? I doubt it could be done.

I believe the practice of providing strictly contingency management-based services is bankrupt. Use exclusively consequence-based interventions and you will almost always come face to face with the Crow in the Skinner Box Phenomenon.

What’s the Crow in the Skinner Box?

Do you know why they use rats and pigeons for operant learning experiments? One, because they’re cheap and have few advocates, but also because they learn things in an orderly and somewhat predictable way. They’re reliable. They go along with the program and produce nice results for the experimenter. So if you’re studying something like signaled avoidance or optimal foraging, they’re great subjects.

Do you know what happens if you try to run operant studies in a contained experimental space with crows? Crows will mess with you and wreck your experiment. Phil Hineline of Temple University told me that the crows in his study were able to steal food from the hopper when the lights were out and they would hoard food. He was using bits of dry cat food as reinforcers, and the birds sometimes soaked them in water and then tucked them into corners of the cage. Then, instead of pressing the manipulandum in the box for food, they would eat out of their hidden stash. In delayed match-to-sample, they would sometimes generate a dozen or so ‘correct’ responses in a row, and then go pot-luck for the next fifty because they had other access to food.

Now, almost by definition, the people we are supporting – the people who present challenging behaviors – are more crow than pigeon. In order to get the crow to behave the way you want in the experimental space strictly by managing consequences, you have to impose more and more rigorous controls and security. In human terms this means increasingly restrictive procedures and the risk of crossing the line into unethical applications of power and control. That’s when the peculiar coercive nature of reinforcement is manifest.

What do you mean by the coercive nature of reinforcement? How can reinforcement be coercive?

I’m talking specifically here about reinforcement that is mediated by the helper. For reinforcement to be effective the person must be in a state of deprivation relative to the reinforcer. When you make the bulk of activities, items, and attention contingent on behavior, you are manipulating or managing deprivation states in order to maximize the effectiveness of a reinforcer. If you don’t do this mindfully with careful attention to the both the clinical and ethical considerations, you are on dangerous ground.

Okay, I see where you’re going and it makes sense. But I’m a little confused. You teach behavioral principles but you don’t really believe in them?

I do teach behavior principles and I absolutely do believe in them. With very few exceptions, all behavior, no matter how odd or disturbing or self-destructive, is functional. It serves a purpose for the person doing it. It meets a need. In order to properly support a person to change his behavior we need to understand how it works, what it does for him. This is the core principle of Positive Behavioral Supports and a central principle of Therapeutic Options™.

We teach people how to conduct a basic functional assessment of behavior in order to determine its function. Once we understand the function of a particular behavior, our first obligation is to examine our service setting to determine whether the behavior is iatrogenic, that is, are we creating the problem by the way we deliver services? Are we being too restrictive? Have we been unresponsive to the person’s needs or preferences? Before we think about what changes the person needs to make, we have to determine what changes in the environment may be indicated. What supports does the person need in order to be successful in his world? It may be appropriate to help the person learn alternative behaviors to the behavior of concern. If that is indicated, we provide people a structure for doing this. But we stay on guard against the practice of blindly trying to fix people in broken environments.

My point is that if all you are doing is managing consequences, then the people on the receiving end of your programs – the people in touch with their inner crow -- will try to bootleg reinforcers, attempt to manipulate contingencies, try to defeat your programs, and run counter control procedures of their own. Life in these settings can become a kind of chess game with the helper and person receiving services on opposite teams. It is often subtle and sometimes not subtle at all. I’ve seen it a hundred times and I’m sure you have, too. Your intention is to film “The Miracle Worker” and instead you end up with “One Flew Over the Skinner Box.”

But if you start with the relationship and attend to the integrity of the relationship, much of the minutiae of contingencies will take care of themselves organically. Besides, and this is critical because the research is very clear, the relationship itself accounts for a huge percentage of the treatment outcome. As a matter of fact, 20 years of therapeutic outcome studies have consistently shown that the helping relationship itself combined with proper supports accounts for about 70% of treatment effects. That’s a powerful finding and should inform our services.

If you run into situations that you cannot address naturally through the relationship, and you understand the laws of behavior, you have a structure to analyze and understand what is operating, and you can fall back on “technique.” But technique should not be the focus of our practice. Jung said, “Learn your theories as well as you can but put them aside when you touch the miracle of a living soul.” He was speaking of psychoanalysis, but I think that statement applies just as profoundly to behavior analysis.

Let’s switch gears for a minute. Tell me a little about your thought process in developing the Therapeutic Options™ physical curriculum.

I taught crisis intervention for the state before someone decided it wasn’t a good use of my time. Periodically, out of nostalgia I guess, I would drop in on training sessions just to watch. Because I wasn’t actually doing the training I was able to see and process what was going on there at a whole other level. After a while I started focusing on the participants rather than on the instructors. It was a real eye opener.

What did you see?

That it was not uncommon for people to go through an entire day of training, learning these physical “techniques” and still have to be heavily coached and corrected during the skill assessment at the end of the day. In other words, after spending the whole day being “trained,” they hadn’t really learned anything. And this was true of the re-certification classes as well. The system required people to be re-trained each year. A substantial number of people would come to the class after having had the training at least once before, sometimes three or four times before, and look like it was the first time they had ever seen the material.

Why do you think that was?

There are two questions – Why do people have trouble learning the skills during training and why are the people who have learned the skills during training unable to remember them a year later?

People have trouble learning the skills – and here I’m defining learning as a relatively permanent change in behavior – because they do not practice them enough during the class. That’s the most obvious answer. Research suggests that in order to begin the neuro-muscular programming necessary to acquire and maintain a gross motor skill, a person must perform the skill at criterion at least twenty times. Now, when you watch these trainings you see that the participants typically rehearse the skill maybe ten times at most, and then only a few times at criterion because their initial attempts are uncertain or contain errors.

What about the people in the other group, the ones who learn enough to pass the skills test at the end of the class? Why can’t they remember the techniques when they return for the re-cert?

Again, there are probably a couple of processes at work here. The first and most obvious is that the environment in which these people work doesn’t demand use of the skill. There is insufficient rehearsal, either spontaneously in response to an emergency, or through planned supervised practice.

The other issue is the appropriateness of the skills being taught in the first place. If a person assaults you it happens very quickly. You rarely have time to analyze and plan while the attack is happening. Before, yes. But during, no. When the attack happens, you will fall back on either untrained habit or on training that has become habit. We teach people that in an emergency you will do what you trained yourself to do through practice. Unfortunately, the way most of these classes are taught, with abstract and unrealistic attack drills, do you know what behavior the participants practice the most? Standing there and allowing themselves to be grabbed. Each discrete physical “technique” for avoiding an attack is practiced maybe ten times, but standing still and letting someone close distance and get a hold of you is repeated more than a hundred times during the course of the training day. Which do you think the staff person is more likely to do in an emergency?

So, although a participant could perform the skill on the test at the end of the training day, he was really not prepared to recognize and respond efficiently to a real physical attack. What he should be learning is to manage the effects of adrenal stress and remain centered, to mind his distance, to maintain awareness and continually assess, and to begin his own movement at the moment the aggressor’s intention becomes manifest. That’s what we teach.

Do you believe that all staff should be taught physical contact skills?

I think staff need the tools to do their job, which is to support people. Each service system has to assess its own need. We can help with that. Training often serves both performance and risk management functions and each facility or agency has unique needs. But we don't insist that everyone in an agency be trained in the physical skills curriculum if there is no need for it. For instance, if you're working in a group home without a lot of transition in residents, and none of the people living there are ever aggressive, perhaps you don't need a lot of physical training. You certainly don't need the level of training someone working on an acute psychiatric inpatient unit needs. But again, each facility has to do its own assessment of staff training needs and administrative requirements.

Do you teach specific techniques for escaping grabs or chokes or whatever?

Yes. The emphasis is on perception speed and movement, but we do teach specific techniques for breaking holds and deflecting ballistic attacks. The difference is we believe our training provides staff a foundation for developing a set of tools that allow them to safely support people. We teach principles of movement and body mechanics, and a few foundation skills on which the rest of the physical curriculum is based so there are only a small number of discrete skills participants actually have to learn. We emphasize that each participant has the responsibility to develop those skills after the training. We will ensure that each person has a basic understanding of and ability to perform the physical skills but the reality is that ongoing practice and supervision are required for skill maintenance.