In late December, John took a trip outside his residence to a local corner store, accompanied by two people: a staff member (1:1) and a member of the Beck team. The staff member was hesitant about the trip, given that upon exiting the residence John was yelling apparently random and irrational words and was difficult to engage with. As he walked, he was making erratic movements and crossing the street in between blocks.
On the way to the store both the staff member and the Beck team member attempted to engage with John in hopes of activating the adaptive mode and reducing John’s symptoms. These attempts were fruitless, and the staff member expressed concern that John would not be able to handle going into the store, given his display of positive symptoms.
However, upon entering the corner store, John actively looked for snacks and a soda and did not display any outwardly psychotic behavior. He went to the front counter and engaged in a logical and linear conversation with the store clerk. She asked, “Are you having a good holiday?” John replied, “Oh yeah! Hungry… but I’m better now,” indicating his snacks. He paid for his snacks and exited the store. On the walk home John remained in the adaptive mode and engaged in conversation about snacks he liked and what he planned to do for the rest of the day.
Incentive/Goal:The incentive has expectancy properties. That is, the individual expects to enjoy the snack and possibly the walk to and from the store.
Mode: Psychotic or Maladaptive Mode
Initially, on the way to the store, John was in the psychotic mode. His talk was unintelligible and irrational. He did not engage with staff despite attempts by the consultant and house staff.
Demand Characteristics of the New Situation:
Procuring the necessary snack and bottle of soda, making his way to the counter, waiting patiently in line, and providing the right amount of currency. There were also social demands that required him to engage in conversation with the store clerk and potentially other customers at the store.
John’s behavior when purchasing a snack can be analyzed within the framework of how his attentional resources were allocated. When John was walking to the store, his attentional resources were largely directed inward, so that there was not much available for effective communication with the staff. With the focus on the internal state and the activation of the regressive mode, his actual utterances appeared irrational. However, while at the store his attentional resources notably shifted and were reallocated to the external demands of the environment. John’s quick shift in modes seems to indicate a degree of flexibility.His behavior and skills matched the demands of the situation as they shifted.Page 3of 41-8-18We could hypothesize that this shift in flexibility might be reflected in a better score on the executive function test and the Penn battery, and a relatively benign score on the Beck Cognitive Insight Scale. In any event, we should try to correlate the scores on the BCIS with the scores on the executive function test.
Potential Dysfunctional Responses to Situational Demands:
The pleasant prospect of having a snack instills a receptive state in the individual. Thus, the situational demands involved in purchasing a snack are perceived as a means to an end. If the individual is not in a receptive state however, the situational demands are seen as burdensome and trigger an avoidance response. These situational demands may also evoke an apathetic response if the individual is not already geared to anticipating a pleasurable experience. For example, an individual was taken to a supermarket to purchase various items and she compulsively asked for the price of each item repeatedly as though the item was not worth the price. Thus, it is essential to prepare the individual for special experiences by inducing a pleasurable expectancy of the event.
John’s incentive was sufficient to propel him to the convenience store. He was in a mixed or psychotic mode, but at the same time erratically heading in the right direction with the supervision of the staff. When he entered the store there was a sudden switch to the adaptive mode. His behavior, motivation, and conversation were tuned in to the requirements of the situation. The combination of the incentive, the demand characteristics of the store, and the shopping activated the adaptive mode: he not only got what he wanted, he got the right change, and also joked with the cashier. John was able to activate his purchasing skills without having to go through coaching or skills training.The adaptive mode endured on the way home.It may be necessary to activate the adaptive mode in “creative ways” before a staff member can establish a good relationship.