Behavior Modification for the Mentally Retarded—CHANGES
A film by Travis Thompson
Resident's voice: C-H-A-N-G-uh oh, E-S.
(Organ music played by a resident, some screaming and laughing in background)
Announcer: This is the Faribault State School and Hospital, Faribault, MN. Some 1800 mildly to profoundly retarded people live here. For many of them, it is the only home they will ever know.
(Organ music played by a resident)
Dakota Building, since its construction in 1913, has been the residence for the most profoundly retarded men—those most disturbed—and with the least ability to care for themselves.
(Organ music played by a resident)
(Screaming from Residents)
Residents are placed in Dakota Building only after failing to adjust in other buildings, usually because of destructive, assaultive behavior or because they cannot feed, dress and toilet themselves. One day is like another here. The "patients" do not improve.
(Screaming and voices for 30 seconds)
Robert Wente, Social Worker: Before you'd walk out into the ward, 40-50% of the patients were in various stages of undress.
Grace Crosby, RN: Many years ago, Dakota was considered a "punishment building." Men from other areas that would run away, abuse another patient, abuse a technician, were put in Dakota as a punishment. And many of them were returned back to their other buildings, some were left there. That's how Dakota really started. This is the type of patient we ended up with. Most of the men in Dakota have been in the institution 19 years. The IQ is 20—or many of them are untestable. We don't know the true IQ.
(Screaming for 53 seconds)
Announcer: The residents have been taken out of the locked ward and placed in a new program which uses a direct and effective technique called "Behavior Modification." In Behavior Modification, residents and a teacher work together in a small room. The goal is to train the resident to feed, dress and take care of himself to the limit of his ability.
Woman behavioral technician: He got to the point where I could sit him up at the table, if nothing else, for 15 seconds, and I would reward them with an M&M or a piece of candy... so this way—eventually it took 3-4 weeks. They learned that if they sat at the table they'd get the reinforcer.
Robert Wente, Social Worker: At first, the slightest effort toward the goal is rewarded. But then, by successive approximations, the patient must accomplish more and more of the task himself before receiving a treat.
Woman Behavioral Technician: That's a boy, good for you.
Announcer: For Ronald, tying his own shoes will be the end of a long and laborious training process in which each step is rewarded.
Woman Behavioral Technician: Ronald can go through all of these beads. He's the one that we had the trouble with at first. It took two months before he'd pick up a toy. But, being a quadriplegia, uh, it took longer. I started him out by just picking up something. The first thing he took was a teddy bear. From that we gradually worked to other toys. Then, we gradually worked—I got him to string the beads. I kept reinforcing him as he would pick up each one, before. Now we can go through the whole thing before I have to reinforce him. And then he gets a Hershey Bar. He is on the shoe now, starting with that. So far, it isn't going bad, I don't think, for what we started with—nothing.
Robert Wente, Social Worker: Yes, I think. Yes. If for some reason we had to drop the program, I think we'd see much of this negative behavior returning. (Pause 4 seconds) It really does pay to have programming. It does, in the long run, cut down the amount of time they have to spend treating patients for wounds or cleaning up after their messes.
Announcer: Early in the program, the tasks are designed to give the patients skill in manipulating objects—the first step towards learning to lace and tie shoes, button buttons, or zip zippers.
Richard Ranslow, Behavioral Technician: Push it down. Now, just hold it there. Can you push two of them at the same time? Good. Good.
Robert Wente, Social Worker: There were a number of destructive things going on. Residents used to shove chairs back and forth, against other residents and, uh, pretty soon somebody would get injured.
Woman Behavioral Technician: What's that song? (Singing—resident humming) Come on, sing it!
Robert Wente, Social Worker: That's one of the pluses with this. We've been told for a long time that we have a very severe morale problem here. And I think it's really improved. I think the technicians will say that, too. And it's because things do get better.
Tom, a Behavioral Technician: Mr. Seldon, What's this?
Mr. Seldon: B-Ball.
Tom, a Behavioral Technician: A ball.
Mr. Seldon: Shoe!
Tom, a Behavioral Technician: That's a shoe.
Mr. Seldon: Truck.
Tom, a Behavioral Technician: Truck.
Mr. Seldon: Caaaarr.
Tom, a Behavioral Technician: Car.
Mr. Seldon: Tractor.
Tom, a Behavioral Technician: Tractor, that's right.
Stephen Arhelger, Film-Maker: You've come a long way with this guy.
Tom a Behavioral Technician: Yeah, I'm very proud of this man. He used to never say a word.
Stephen Arhelger, Film-Maker: Really?
Tom, a Behavioral Technician: He used to just sit on the ward and you could walk right in front of him. He'd never look up at you. But now, he talks, he tries to get around and get the other kids in conversation, it's wonderful. I hope to get him saying sentences, but this is going to take several months.
Stephen Arhelger, Film-Maker: How long have you been at this?
Tom, a Behavioral Technician: About a month and a half with him.
Stephen Arhelger, Film-Maker: 20 years before that he didn't speak?
Tom, a Behavioral Technician: Never said a word. This boy never said a word. He'd never say a word, he'd get up in the morning and dress, sit on the couch and this is all he did.
Grace Crosby, RN: If this type of programming had been done with these men when they were young boys, there never would have been a Dakota Building.
Tom, a Behavioral Technician: But by working with them on the ward, you would have never dreamed that these kids had the ability, hidden, that they have down in the classroom. I just was amazed.
Child: (Singing repeatedly) Wanna run away.
Eric Errickson, Program Director: We've got a lot of folks here who don't need to be here. And institutions themselves have taught them some very bad habits about living in groups. Suppose one of the things we're doing now is aiding the resident in unlearning some of these bad kinds of things that we've taught him before. I think that's one of the choices the State of Minnesota makes if it's gonna create large institutions and make them warehouses for people, then you get folks who learn that kind of behavior.
Announcer: Behavior Modification works. Profoundly retarded patients can be taught self-care. And they can rejoin the human family.
(Mark Naftalin piano music and resident singing.)
In early Spring of 1968, Roger Johnson, MD and Eric Errickson, Faribault State Hospital medical director and program director, respectively, asked me if I would help them with some of their residents who they said "had behavior problems." I had experience applying behavioral intervention procedures with a small group of children and adolescents with intellectual disabilities in a day program in St.Paul, but had never worked with adults, especially adults with severe behavioral challenges.
On my first visit to Faribault State Hospital I talked with Dr. Johnson and Eric Errickson about the type of help they wanted and asked for more specific information regarding the behavior problems that concerned them. Their responses were vague and uninformative. I learned later they were concerned about scaring me off if they told me too much about the severe problems their residents encountered in their daily lives. I asked them to allow me to visit the building with the greatest challenges first, Dakota Building.
I was met at the building entrance by a nurse, Grace Crosby, who was in charge. She unlocked the outside door that led to a foyer. When I stepped into the foyer I encountered an odor that was familiar from my childhood. It was a mixture of the smell or urine, feces and antiseptic. It was similar to the smell in my grandfather's cattle barn north of Milaca, Minnesota. Then Grace locked the outside door behind us and I felt apprehension when I heard loud vocalizations and shouts coming from behind the second door leading into the building.
She unlocked the second door and when I stepped inside she locked it behind me, I felt a sense of alarm. As I looked around the long room with terrazzo tile floors, vaulted ceiling, rows of wooden lawn chairs along each wall and windows high off the floor covered by coarse mesh metal, I felt fear and shock. Men were milling aimlessly around the room, none wore shoes, many had no shirts and some were naked. The nurse told me the 67 men all had severe or profound mental retardation and were non-verbal. Some sat motionless in the lawn chairs, others rocked, flapped their hands, others screamed or shouted but their vocalizations contained no words, only loud uninterpretable sounds. I was struck by how many had what appeared to be cuts, scars, abrasions and what scrapes or wounds in various degrees of healing. One man was seated on the floor with no shoes or shirt leaning his back against the wall. He bent over from his waist until his head nearly touched his knees. Then he braced his bare feet against the floor and hurled his body backward, smashing the back of his head against the wall with a loud "smack" sound. I felt as though I would throw up. The nurse went on with her conversation with me seemingly oblivious to the man's actions. After the third or fourth time he smashed his head against wall, a male staff member approached him and dragged away form the wall and said, "Cut it out". The nurse told me the man banged his head all of the time and they had no idea how to make him stop. She seemed troubled by the man's behavior, but felt hopeless in finding a way to do something to help the man. She told me another resident was a problem because he bit off pieces of other residents' ears, noses and parts of fingers. After an hour or two observing the residents in Dakota Building I visited several other buildings that housed residents who had less severe disabilities, but all were badly in need of meaningful services.
When I returned to the administration building to meet with Eric Errickson and Roger Johnson at the conclusion of my tour I was still in shock. We discussed possible behavioral intervention approaches, but I told them I needed to think about whether I could help them. I told them I'd call in a few days to discuss whether I could be of any assistance. When I returned to Minneapolis that night I took a very long shower to get the smell out of my skin and hair. I couldn't get the images out of my mind of people existing in torment and for whom no one at the institution seemed to have any idea what to do to provide a better life for them. I remember thinking that I never wanted to go back to Faribault and witness the nightmare I had seen that day. Intermixed with that sense of revulsion was the realization that if I walked away, it was likely nothing would change for the men, women and children at Faribault. They would continue indefinitely existing in their urine and feces, and hurting themselves and others as they had for the previous 20 years or more.
After a day of agonizing emotional turmoil, I agreed to do what I could by developing behavioral intervention programs for the residents, beginning with Dakota Building. I reasoned that if we could make progress with the men in Dakota Building, it would be easier to secure buy-in from the staff in other buildings. I told Eric and Roger I had no idea how much I could accomplish but that I was willing to try. It was obvious the heart of the plan would be staff training and creating functional activities to occupy the residents' time. I visited Faribault every Friday starting at 8:30am and left around 3:30pm. After 2-3 weeks we were beginning to see progress with dressing, toileting, tooth brushing and some simple "make do" activities to keep the men occupied. But the task was overwhelming and it was obvious Faribault needed much more professional help than I could give them. They agreed to hire my graduate student John Grabowski who also spent one day a week there as well, which accelerated the gains. The administration agreed to hire additional graduate student consults. Linda McConahey, George Bigelow and Roland Griffiths, each of whom assumed responsibility working with staff and residents in one building. By early-summer it was becoming apparent to everyone that violent behavior had greatly decreased, the use of locked seclusion was plummeting, drug dosages had dropped, and the men spent most of their days engaging in constructive activities, even though many were not as functional as we would have liked.
It dawned on me that we needed to document what we were doing on film, and to use the film for training and to encourage policy makers to take action to uplift people like those at Faribault through more adequate services. I asked my friend Steve Arhelger, who was an amateur film-maker to spend a day with me at Faribault to get an idea how he might approach making a documentary film about the people there and the kinds of changes that were beginning to take place. Steve was a kind, compassionate guy who took immediately to the residents, trying to talk with them and engage them any way he could over the course of our visit. He told me later how his anguish about the injustice of the men's lives drove his decision to take on the project. He came up with an estimate of the cost of shooting the film, editing and having an initial print made. He calculated he could do it for $2500, assuming we donated our time. I met with my old friend Betty Hubbard and told her about the project. In her inimitable way, she replied, "You have to do it. We have to find a way to pay for it. We just have to." She talked with some people at the Minnesota ARC and spoke with Jane Mullery and Gerry Seldon who had access to resources who may be able to help. Once we secured promises for the $2500, we obtained permission from the administration at Faribault and Minnesota Department of Public Welfare to shoot the film, the project got under way.
We rented a commercial quality 16mm camera and Nagra tape recorder, similar to those used in television news at the time. We spent two full days filming at Faribault. We decided to use no artificial lighting because that would be too shocking to the residents. We had the raw film printed, and then began planning the editing sequence. We realized some things we wanted to include had been missed, so Steve Arhelger and sound-man Dave Rubenstein spent another day shooting missing sequences, including videoing interviews with staff that would serve as narration. As much as possible we wanted to avoid creating phony, sanctimonious script.
Steve Arhelger became obsessed with the project as we spent many, many hours together at film and sound rewinds viewing and editing the final version of the film. We ran out of money early, so instead of having professional titles made in a studio as planned, Steve captured frames from the film and printed them as stills upon which he superimposed stick on letters to create titles. They were pretty awful, but all we could afford. When we viewed the film the first time we were disappointed with the quality of some of grainy, dark images due to inadequate lighting, but realized in retrospect that they captured the reality of the lives of the people residing at Faribault. We felt we had told the truth about the lives of the men in Dakota Building and that they didn't have to be that way.
Al Austin, then a reporter for WCCO television, heard about the film and asked to see it. Al was notorious for his dead-pan countenance, but he was clearly moved when he saw the film. He and a WCCO film crew spent a day at Faribault shooting new professional footage he could use on air, and he did a lengthy report about Faribault State Hospital into which he spliced footage from our film. People at the CBS network evening news in New York apparently received a feed of the film and used a segment of our film for the lead in on Walter Cronkite's evening news several days later.
In the months and years after the film had been created we continued to make strides at Faribault, fed in part by the strange collection of staff from Faribault, my grad students and post-docs who met at my home in south Minneapolis every Wednesday evening to read relevant journal articles and discuss how they applied to our work at Faribault. We called it a Seminarty, because it was half seminar and half drinking beer and eating potato chips while we enthusiastically explored our next steps at Faribault. I have never known such a dedicated and enthusiastic group of people with great mutual respect for one another and a shared vision of science-based reform. It was a great loss when Steve Arhelger, the young man who shot and edited most of the film experienced an untimely death.
Roger Johnson and Eric Errickson left Faribault to receive training. They had initiated the changes at Faribault while other people with less character would have sat on their hands or gone fishing. The new administration at Faribault was unsympathetic with our efforts and after several months terminated our contracts and sent us packing. But the film "Changes" still exists that documents our earliest efforts to improve the lives of people who had been largely forgotten and who had no future. The film along with our two books based on our work at Faribault, Behavior Modification for the Mentally Retarded, (originally published by Oxford University Press in 1972 and was revised and expanded in 1977) provide lasting evidence that good things can happen to improve the lives of people with developmental disabilities, even under daunting and dispiriting circumstances.
November 1, 2006