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Journal of Mental Health Research in

Intellectual Disabilities
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A Review of Behavioral Interventions for

Psychotic Verbal Behavior in People With
Intellectual Disabilities
a a
Robert Travis & Peter Sturmey
a
Queens College and The Graduate Center , City University of New
York
Published online: 18 Dec 2008.

To cite this article: Robert Travis & Peter Sturmey (2008) A Review of Behavioral Interventions for
Psychotic Verbal Behavior in People With Intellectual Disabilities, Journal of Mental Health Research
in Intellectual Disabilities, 1:1, 19-33, DOI: 10.1080/19315860701686963

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 Journal of Mental Health Research
in Intellectual Disabilities, 1:19–33, 2008
Copyright © Taylor & Francis Group, LLC
ISSN: 1931-5864 print / 1931-5872 online
DOI: 10.1080/19315860701686963

A Review of Behavioral Interventions for

Psychotic Verbal Behavior in People With
Intellectual Disabilities
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ROBERT TRAVIS AND PETER STURMEY

Queens College and The Graduate Center
City University of New York

Individuals with intellectual disabilities who exhibit psychotic

verbal behavior are at increased risk for hospitalization and
dependence on external support. Traditionally, medication is the
clinical treatment of choice for this behavior. This article selec-
tively reviews the existing literature within the field of behavior
analysis on reducing psychotic verbal behavior in adults with intel-
lectual disabilities. Both contingency-based and function-based
treatments were effective. There was evidence that differential
reinforcement, noncontingent reinforcement, and response-cost
procedures were effective. The implications for future treatment
and research on delusional verbal behavior are discussed.

KEYWORDS psychosis, verbal behavior, developmental disabil-

ities, behavior analysis, functional analysis

People with intellectual disabilities (ID) experience the full range of psychi-
atric disorders, including psychotic disorders (Hemmings, 2006). Psychotic
disorders are typically treated exclusively with psychotropic medication.
However, behavioral analysis has a long history of conceptualizing,
analyzing, and treating the unusual verbal behavior associated with psychotic
disorders (Ayllon & Michael, 1959; Wilder & Wong, 2007). There have been an
accumulating number of papers on behavior analytic approaches to treatment
of psychotic verbal behavior in people with intellectual disabilities.
Durand and Crimmins (1987) defined delusional verbalizations as words
or phrases that are intelligible but appear in an inappropriate context.

Address correspondence to Robert Travis, Queens College, Department of Psychology,

65-30 Kissena Boulevard, Flushing, NY 11367. E-mail: rtravis76@yahoo.com
19
 20 R. Travis and P. Sturmey

Other behavior analytic researchers have labeled such verbalizations as

inappropriate vocalizations, bizarre speech, delusional speech, or psychotic
speech. These verbalizations have considerable impact on the independent
functioning and lifestyle of people with intellectual disabilities. The presence
of these verbalizations reduces appropriate verbal and other behavior, is
stigmatizing, and increases the likelihood that an individual will be hospi-
talized, sometimes repeatedly throughout the person’s lifetime (Wilder &
Wong, 2007). For people with intellectual disabilities who already present
deficits in adaptive functioning, the presence of delusional verbal behavior
results in further, potentially preventable disability fostering additional depen-
dence on external support and supervision (Tsakanikos et al., 2006).
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Clinicians have long considered delusional statements to be of organic

origin. The biomedical model makes the assumption that psychotic
disorders are due to underlying abnormalities in patients’ neurochemistry
or neuroanatomy (Wilder & Wong, 2007). Thus, these delusions are often
treated with medication intended to correct underlying organic defects in
both people with psychiatric disorders and people with intellectual disabil-
ities. Spreat, Conroy, and Fullerton (2004) reported that approximately 20%
of people with intellectual disabilities who received services in community
and institutional settings received an anti-psychotic medication. Psychotropic
medication has proven most effective at reducing the positive symptoms
of certain psychiatric disorders such as schizophrenia. However, it is not
effective in alleviating the negative symptoms, establishing adaptive behavior
to compete with the negative symptoms (Wilder & Wong, 2007), or in
addressing psychosocial aspects of psychotic disorders such as loneliness,
poverty, unemployment, and social isolation.
Behavior analysis offers an environmentally based treatment approach
that can be used alone or in combination with psychotropic medication
that manipulates the antecedents and consequences of delusional verbal
behavior in an effort to alter its frequency, intensity, or duration. Although
organic factors may be important in its origin, delusional verbal behavior
might be sensitive to environmental influences. Thus, it is conceivable that
psychotic verbal behavior might have systematic relationships to environ-
mental variables that can be identified and manipulated in order to modify
it (Layng & Andronis, 1984; Wilder & Wong, 2007). However, its function
is often obscured by the negative consequences of the behavior, such
as hospitalization and social withdrawal. It is a strong indication of the
powerful effects of immediate reinforcement that these responses continue
to occur despite the long-term negative costs to the individual. Psychotic
verbal behavior can be analyzed using functional analysis, and consequence-
based treatment strategies, such as differential reinforcement of alternative
behavior (DRA), differential reinforcement of other behavior (DRO), noncon-
tingent reinforcement, and response-cost procedures have been successful
at reducing delusional verbal behavior (Wilder & Wong, 2007). However,
 Psychotic Verbal Behavior 21

no review of this literature has been published. Therefore, the purpose of

this article is to conduct a review of this literature. We searched Pubmed,
the National Library of Medicine and Institutes of Health, a database of
publications, using the keywords psychotic speech, delusional speech, and
bizarre speech. Any study treating this behavior in intellectually disabled
adults and/or children was included in this review. Additionally, we reviewed
the reference sections of relevant studies and reviewed in this article any
study that met these criteria.
Before beginning a review of the literature, it would be beneficial
for readers unfamiliar with behavior analytic concepts to provide defini-
tions of the functional analysis process and of differential reinforcement and
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response-cost intervention procedures. A functional analysis consists of eluci-

dating reliable relationships between independent and dependent variables
and is a concept similar to the everyday meaning of causation (Skinner,
1953). One method of conducting a functional analysis consists of the appli-
cation of four conditions to assess the effects of different consequences on
the emission of a target behavior: escape, attention, alone, and control condi-
tions (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982). In escape conditions,
a participant is provided a brief break from some task demand contingent on
the emission of the target behavior. In attention conditions, the participant
receives social attention after the emission of a target behavior. In the alone
condition, no social consequences are programmed to occur contingent on a
target behavior. However, the behavior itself has consequences that are often
referred to as automatically reinforcing if the target behavior is systemati-
cally shown to increase under this condition. Finally, control conditions can
vary, but they often include providing some consequence for appropriate
responses and not providing consequences for target responses. Applying
these conditions systematically allows an experimenter and/or clinician to
identify the precise variables that control responding and to turn a behavior
on and off with the manipulation of the identified variables. In short, the
“cause” of the behavior is identified and can later be altered to produce
favorable outcomes. Researchers have applied this method and variations of
it to a wide range of clinical problems (Sturmey, 2007.)
This method of functional analysis is used to identify behavioral inter-
ventions such as differential reinforcement, noncontingent reinforcement,
response cost, and extinction procedures. Differential reinforcement consists
of providing reinforcement contingent upon preferred experimenter-defined
response topographies, such as appropriate verbalizations, and is often
combined with extinction to the target behavior. In extinction, the reinforcing
consequences maintaining the target behavior no longer occur contin-
gently on the emission of the target behavior. For example, in a combined
differential reinforcement and extinction procedure for inappropriate verbal
behavior, participants will receive reinforcement contingent on the emission
of utterances containing content pertaining to a news article they read, the
 22 R. Travis and P. Sturmey

weather that is forecasted for the day, or what type of work they would
like to do that day. However, if those participants stated that they were the
King of the planet and/or that they could eliminate a staff member with their
thoughts, they would not receive any reinforcing consequences after that
verbal behavior. The goal of these procedures is to provide reinforcers for
appropriate speech so that its frequency increases and to remove reinforcers
for inappropriate speech so that its frequency decreases.
Intervention may also include noncontingent reinforcement (NCR).
In noncontingent reinforcement, a reinforcer is delivered without being
contingent on any response. This procedure has two effects. First, it breaks
the contingency between the reinforcer maintaining the response. Second,
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by providing the reinforcer independent of the target behavior, it may also

decrease periods of reinforcer deprivation and thereby reduce the power
of that stimulus as a reinforcer. Both of these mechanisms may lead to a
decreased frequency of that response.
In response-cost procedures, the emission of a target behavior results
in the removal of a positive reinforcer. For example, in a token economy
system, a participant who emits a psychotic verbal response may lose tokens
he or she has earned for that day. A Response-cost procedure is an example
of negative punishment. It is implemented to reduce the frequency of the
target behavior. However, it does not provide reinforcing consequences for
other favorable response topographies, as occurs in differential reinforcement
procedures. For this reason, it may be added to differential reinforcement
procedures to increase the effectiveness of the intervention.

STUDIES WITH PSYCHIATRIC POPULATIONS

A number of studies have demonstrated the effectiveness of consequence-

based intervention strategies at reducing or eliminating psychotic and
delusional behavior in inpatient settings (Ayllon & Michael, 1959). For
example, Ayllon and Azrin (1968) used a token economy to increase
functional behavior in a group of patients institutionalized for a variety of
psychiatric symptoms. This procedure had the added effect of decreasing the
psychotic behavior of these adults. Ayllon and Azrin concluded that the token
economy decreased the occurrence of dysfunctional behavior by increasing
the occurrence of functional behavior. In short, the newly established
functional behavior appeared to replace the previous dysfunctional verbal
and other behavior. However, this hypothesis was not directly tested, and
consequence-based intervention was not directly applied to dysfunctional
verbal behavior. Other studies have demonstrated that contingency–based
interventions, sometimes in combination with other behavioral interventions
such as prompting, reduce psychotic speech and may increase appropriate
speech in people diagnosed with psychotic disorders (Bartlett, Ora, Brown, &
 Psychotic Verbal Behavior 23

Butler, 1971; Belcher, 1988; Liberman, Teigen, Patterson, & Baker, 1973;
Patterson & Teigen, 1973; Reichle, Brubakken, & Tetreault, 1976; Schraa,
Lautmann, Luzi, & Screven, 1978; Wincze, Leitenberg, & Agras, 1972). More
contemporary studies have demonstrated that psychotic verbal behavior can
be functionally analyzed and the results of these functional analyses can be
used to design effective treatments (Wilder, Masuda, O’Connor, & Baham,
2001; Wilder & Wong, 2007).

STUDIES WITH PEOPLE WITH INTELLECTUAL DISABILITIES

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There are two broad groups of studies using applied behavior analysis
(ABA) interventions for psychotic verbal behavior in people with intellectual
disabilities. The first group used simple contingency management interven-
tions, such as differential reinforcement of alternate (DRA) and other (DRO)
behavior and extinction, sometimes combined with antecedent interventions,
such as instructions. In DRA a specific alternate behavior is reinforced. In
DRO any behavior other than the target behavior is reinforced and hence
is sometimes called omission training. As in other areas of psychopathology
(Sturmey, 2007) other more recent papers have used pre-treatment functional
analyses to identify the functions of psychotic verbal behavior. The results of
these analyses were then used to design interventions aimed at decreasing
or eliminating this behavior.

STUDIES WITHOUT PRE-TREATMENT FUNCTIONAL ANALYSIS

Barton (1970) conducted one of the first studies addressing the effect
of consequence-based intervention on inappropriate verbal behavior in a
person with intellectual disabilities. When asked questions about items, the
participant would often make odd statements. For example, if the partic-
ipant was shown a magazine advertisement picturing a woman wearing
a certain outfit, the participant would state that she was “wearing a
hamburger.” If the participant requested a pencil and was asked by staff
how he intended to use it, the participant might state “to clean my shirt.”
Barton used differential reinforcement and response cost to decrease the
bizarre speech and increase the appropriate speech of Simon, an 11–year-
old boy diagnosed with severe intellectual disabilities of organic origin.
During sessions, the experimenter asked the participant questions about
magazine photos. In one baseline session, Barton measured the percentage
of inappropriate and appropriate responses to these questions using an ABAB
(A = baseline phase, B = treatment phase) single subject experimental
design. Barton found that reinforcement of appropriate verbal responses
resulted in large increases in correct responses and decreases in inappropriate
 24 R. Travis and P. Sturmey

responses. When the contingencies were reversed, such that inappropriate

responses were reinforced, inappropriate verbal responses increased and
appropriate responses decreased. This indicated that the participant’s speech
was sensitive to contingencies.
Dwinell and Connis (1979) also used consequence-based intervention to
address the inappropriate speech of adults with intellectual disabilities. The
researchers used social feedback to reduce the inappropriate verbalizations
of an adult diagnosed with mild intellectual disabilities. The treatment inter-
vention consisted of praise for not verbalizing inappropriately, reprimands for
verbalizing inappropriately, and instruction to verbalize appropriately after
the occurrence of an inappropriate verbalization. The intervention success-
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fully reduced the inappropriate speech and increased the context-appropriate

speech of the participants.
Stephens, Matson, Westmoreland, and Kulpa (1981) evaluated a similar
intervention package. They conducted two experimental studies to evaluate
the effects of instructions, modeling, rehearsal, and feedback on the psychotic
speech of 3 adults diagnosed with chronic schizophrenia and intellectual
disabilities. Fran, a 33-year-old woman diagnosed with chronic undifferen-
tiated schizophrenia and mild intellectual disabilities, participated in the first
study. Staff reported that she talked using nonsense phrases and repeated talk
about past problems for hours at a time in an intrusive way. She had good
self-help skills but periodically stopped bathing and caring for herself. She
took a stable dose of Chlorpromazine through the study. Target behaviors
included the number of times she changed the topic of conversation,
references to past problems, nonsense phrase inappropriate words, and
speech duration. Her speech was audiotaped and observed by independent
observers. The mean inter-observer agreement (IOA) was 96% (range 87%–
100%). The experimenters used an ABABAB experimental design to compare
her behavior during baseline and intervention. All sessions were structured
using prepared conversation scenarios selected at random from a large pool
of such scenarios. In baseline there were no programmatic consequences.
During intervention the therapist used instructions, information feedback,
modeling, and rehearsal to teach Fran appropriate verbal behavior. The
intervention was effective in greatly reducing and in some cases eliminating
psychotic speech during the therapy sessions.
The second study replicated these results and extended it by addressing
generalization and maintenance. There were 2 participants. Joan was a
61-year-old woman diagnosed with chronic undifferentiated schizophrenia
and moderate intellectual disabilities. She had a history of multiple hospital
admissions and periodic deterioration of self-care. Ann was a 29-year-old
woman diagnosed with chronic undifferentiated schizophrenia and severe
intellectual disabilities. Both received a maintenance dose of Chlorpromazine
throughout the study. The experimenters identified several target behaviors
related to psychotic speech, such as response relevance, speech volume,
 Psychotic Verbal Behavior 25

and response latency. Average IOA was 93% and 95% for Joan and Ann’s
data, respectively. The experimenters used a multiple-baseline-design across
participants, and treatment conditions were the same as in the first study.
The intervention resulted in reductions in psychotic speech and increases in
appropriate speech, such as appropriate voice volume and speech relevance,
in both participants. Further, these changes were maintained at follow-up
approximately 60 days after the main treatment had taken place. Additionally,
ratings of behavior by nurses on the ward also showed improvements in
speech and appearance.

STUDIES USING PRE-TREATMENT FUNCTIONAL ANALYSIS

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Durand and Crimmins (1987) conducted three experiments, the first two of
which analyzed the role of attention and task demands in the maintenance
of psychotic speech in a youth with autism. Psychotic speech was defined as
any statement that was intelligible but was in an inappropriate context. They
found that the frequency of psychotic speech increased with the introduction
of task demands, whereas varying levels of adult attention did not affect
psychotic speech. In the second experiment, the researchers made escape
from task demands contingent upon the emission of psychotic speech. The
frequency of psychotic speech increased with the implementation of this
contingency. In Experiment 3, the researchers reintroduced task demands and
taught the participant an appropriate functionally equivalent escape response
(“Help me”) to compete with psychotic speech. However, termination of task
demands was now contingent on the participant requesting help, whereas
the occurrence of psychotic speech did not terminate the demand condition.
Teaching the alternative, functionally equivalent verbal response resulted in
a reduction in psychotic speech.
Mace, Webb, Sharkey, Mattson, and Rosen (1988) conducted a functional
analysis and treatment of bizarre vocalization and work behavior. Jo
was a-29-year-old woman diagnosed with mild intellectual disabilities and
schizophrenia. She was taking 400mg of Mellaril during the study. She had
been admitted to a state hospital when she was 14 years old and had 15
years of psychopharmacology without significant impact on bizarre speech.
Bizarre speech consisted of speech referring to stimuli not present or not
being discussed, speech with inappropriate sexual content, and maladaptive
speech, such as saying “I cannot be helped.” They collected partial interval
sampling data on speech using audiotapes. They also collected data on
appropriate speech and the rate of completed work units. The experimenters
conducted an experimental analysis of bizarre speech. They compared the
rate of speech during individual and group conditions in which attention or
escape was provided contingent on bizarre speech. During escape condi-
tions she was given a break from work contingent on bizarre speech. The
experimenters used an ABAB design to assess the effects of these variables.
 26 R. Travis and P. Sturmey

Jo emitted an average of 6.5, 5.0, and 3.2 bizarre vocalizations per minute
during the group, escape, and individual experimental conditions. Therefore,
intervention consisted of guided compliance during work and ignoring and
contingent attention for appropriate vocalization during group situations.
Both treatments were highly effective in reducing psychotic speech and
increasing productivity and appropriate speech. Subsequent implementation
with four different staff and in a group home setting also demonstrated good
generalization into practical settings.
Mace and Lalli (1991) used both descriptive and experimental analyses
to assess the function of the bizarre speech of Mitch, an adult with moderate
intellectual disabilities. Mitch’s bizarre speech consisted of statements such
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as “I’ve got to put out that fire” when no fire was present and other state-
ments that were not related to the topic being discussed. Throughout the
course of this study, Mitch received 1,000 mg of tegretol and 750 mg of
mysoline daily to address grand mal seizures and 200 mg of Mellaril daily
to address “delusional and hallucinatory speech.” The researchers used both
descriptive and experimental analyses to identify the function of the bizarre
speech and to select an appropriate treatment. All observation/intervention
sessions took place in the group home where Mitch lived. The descriptive
analysis identified that bizarre vocalizations occurred most frequently under
the following antecedent conditions: when task demands were placed on
Mitch or when staff was not interacting with him. Additionally, bizarre
speech occurring during task demands was followed by the cessation of
task demands, and bizarre speech occurring during periods of noninteraction
was followed most frequently by staff attention. Thus, attention and escape
appeared to be two hypothetical consequences maintaining Mitch’s bizarre
speech.
Following the descriptive analysis, an experimental analysis was
conducted to test the two hypotheses. Bizarre speech occurred most frequently
when it was followed by attention. The experimenters then used this finding
to implement two interventions in a modified reversal design. The first inter-
vention consisted of NCR, with staff providing noncontingent attention on a
variable-time (VT) schedule (VT 30 s, 60 s, or 90 s), and providing attention
contingent on the emission of appropriate vocalizations. This alternated with
a reversal session where bizarre statements were followed by attention in
the form of social disapproval. Mitch’s bizarre vocalizations systematically
decreased across noncontingent reinforcement phases. In the second inter-
vention, the researchers taught Mitch functionally equivalent socially appro-
priate responses that would be substituted for bizarre vocalizations. Specif-
ically, they taught Mitch to initiate and expand on conversations. Training
functionally equivalent responses consisted of staff providing verbal prompts
to initiate in or to expand on conversations every 90 seconds. If Mitch failed
to respond appropriately to the verbal prompt, the staff would then verbally
model the appropriate response. Modeling correct responses continued until
 Psychotic Verbal Behavior 27

Mitch emitted the desired target response. Once initiations and expansions
were reliably emitted, prompting was faded and independent initiations were
then measured. Independent initiations were any statement that began a
conversation or changed its topic without a prompt. Independent expan-
sions were contextually appropriate statements or questions that added new
information to the conversation without a prompt. Mitch’s independent initi-
ations and expansions increased significantly with the introduction of this
intervention. Introducing conversation training increased independent initi-
ations and expansions from a minimum of 2 and 0, respectively, to a high
of 20 during training. These gains were maintained during generalization
sessions. Additionally, Mitch’s bizarre vocalizations decreased from a high of
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near 60 during baseline to a low of 0 during conversation training, initiation

maintenance and expansion training, and generalization phases. In conclusion,
the researchers were able to both reduce bizarre vocalizations and increase
Mitch’s conversation skills using the behavior analytic intervention methods
of extinction and noncontingent reinforcement and by training functionally
equivalent alternative responses to replace the bizarre vocalizations.
Dixon, Benedict, and Larson (2001) extended and replicated previous
research assessing the function of delusional speech in people with intel-
lectual disabilities. They used a differential reinforcement procedure to reduce
the inappropriate verbal behavior of an adult diagnosed with moderate-
ID and psychotic disorder not otherwise specified. The researchers defined
inappropriate verbal behavior as vocal utterances that were not relevant
to the context, sexually inappropriate remarks, or illogical placement of
words within a sentence. A functional analysis identified that the participant’s
inappropriate verbal behavior was maintained by attention. The researchers
used a reversal design alternating phases of DRA with baseline phases where
inappropriate verbal behavior was reinforced. This procedure produced an
increase in appropriate verbalizations during DRA phases, with a corre-
sponding decrease in inappropriate verbalizations. These results were repli-
cated across multiple contingency reversals, indicating that the content of
the participant’s verbal behavior was controlled by the contingencies imple-
mented during each phase.
DeLeon, Arnold, Rodriguez-Catter, and Uy (2003) took these findings
a step further and manipulated the content of the verbal attention that a
participant received as a reinforcer to assess the role it would have on the
bizarre and nonbizarre speech of an individual with intellectual disabilities.
They used a reversal design to assess the effects of the content of verbal
attention on bizarre and nonbizarre speech. The probability of the participant
exhibiting bizarre or nonbizarre speech varied as a function of the content
of experimenter attention. When the therapist provided contingent verbal
attention that included bizarre content, the participant was more likely to
engage in bizarre statements. When the therapist responded to bizarre or
 28 R. Travis and P. Sturmey

nonbizarre statements with attention that did not contain bizarre content,
nonbizarre statements increased.
Falcomata, Roane, Hovanetz, Kettering, and Keeney (2004) evaluated
the effectiveness of noncontingent reinforcement (NCR) in combination
with response cost at reducing inappropriate vocalizations maintained by
automatic reinforcement in an 18–year-old man with autism. The researchers
used a reversal design consisting of the following ordered phases: baseline,
NCR, NCR and response cost, baseline, NCR and response cost, NCR, and
NCR and response cost. During baseline the participant emitted inappro-
priate verbal behavior during 99.1% of intervals. This dropped to 55.6%
with the implementation of NCR. When a response cost was added to NCR,
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the percentage of sessions with inappropriate vocalizations decreased to a

mean of 1.2%. This change was systematic across repeated phase changes.
Thus, inappropriate vocalizations were under the control of the treatment
conditions.
Lancaster et al. (2004) used NCR to decrease the bizarre speech of
adults with dual diagnoses. Four participants engaged in the study: 2
were diagnosed with intellectual disabilities and schizophrenia, and 2 were
diagnosed with intellectual disabilities and bipolar disorder. Functional
analysis indicated that bizarre speech was maintained by social attention for 2
participants. The researchers then used an ABAB design with noncontingent
attention for appropriate speech during the treatment phase. Noncontingent
attention increased the percentage of intervals in which appropriate speech
occurred and decreased bizarre speech for one participant but had no effect
on appropriate speech in the other participant. However, bizarre speech did
decrease for the second participant. These changes were systematic across
treatment conditions, suggesting that the occurrence of bizarre speech was
influenced by NCR.
A study that as of today is unique comes from Arntzen, Tonnessen, and
Brouwer (2006), who used Skinner’s (1957) Verbal Behavior as a framework
for intervention with a 44-year-old woman with autism, mild intellectual
disabilities, and schizophrenia. She had a long history of institutionalization
and dangerous behaviors such as arson and violence and had recently moved
into a community setting. Arntzen et al. observed her verbal behavior and
classified it into Skinner’s verbal operants, such as tacts, echoics, and mands.
Tacts roughly correspond to statements describing events or things and are
maintained by interaction from other people. Echoics, correspond to imitating
other people’s speech, and are maintained by the match between the person’s
speech and the model’s behavior. Mands roughly correspond to requests
and are maintained by the thing or person specified in the mand itself.
Thus, verbal behavior’s function may vary, even though the verbal behavior
may have the same topography. For example, saying “coffee” may function
as a tact, echoic, or mand, depending on the variables that control the
response. One of the most important implications of Skinner’s analysis of
 Psychotic Verbal Behavior 29

verbal behavior is that one should analyze the function of the verbal behavior
and teach each function independently of each other.
Pre-intervention assessment indicated that the participant’s written verbal
behavior was a relative strength but that spoken verbal behavior, such as
tacts, were relatively weak. Therefore, Arntzen et al. (2006) implemented up
to eight 10-min daily teaching sessions to teach and strengthen the partic-
ipant’s spoken language using token reinforcement, attention, and extinction
of psychotic speech. Over many weeks the use of appropriate language
increased and psychotic speech decreased. This study was a case study and
did not use an experimental design.
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COMBINED BEHAVIORAL AND PHARMACOLOGICAL

INTERVENTIONS

Few studies have addressed the important question of the interaction of

psychotropic medication and behavioral interventions in the treatment of
psychotic speech. Fisher, Piazza, and Page (1989) investigated this possibility
when they assessed the independent and interactive effects of psychotropic
medication and behavioral interventions on aggression, disruption, and
psychotic speech in a child with dual diagnoses. During a functional analysis
psychotic speech occurred with greater frequency under social attention and
demand conditions. A multi-element/multiple baseline design was then imple-
mented to assess the independent effects of behavioral and pharmacological
treatment. Two therapists administered the interventions in different sessions.
The treatment with Therapist 1 was as follows: During a baseline phase
for both demand and social attention conditions, the participant received
1.5 mg of haloperidol. In the second phase, the dosage was increased
from 1.5 mg to 3.75 mg, and a token economy was concurrently adminis-
tered. During this token economy the participant earned tokens for appro-
priate speech and for 30-s intervals without disruption or aggression. In
Phase 3, the haloperidol dosage was increased to 4.2 mg. They discontinued
haloperidol at the end of this phase. A response cost was also added to the
token economy where psychotic speech, disruption, or aggression resulted
in the removal of tokens. In the fourth phase, no haloperidol was given,
and they added an overcorrection procedure consisting of cleaning an area
of the floor for 10 min to token economy and response cost. This was
implemented only when the participant had no tokens. Therapist 2 imple-
mented token economy, response cost, and overcorrection simultaneously
in demand and social attention conditions. In all treatment sessions prior
to this implementation, the participant received only haloperidol to address
psychotic speech, disruption, and aggression. Thus, the phases implemented
by Therapist 1 allowed for an assessment of the interactive effects of haloperidol
and contingency-based treatment, and the discontinuation of haloperidol
 30 R. Travis and P. Sturmey

also allowed for an assessment of contingency-based treatment alone.

Furthermore, comparison of participant performance between Therapists
1 and 2 allowed for an assessment of the independent effect of haloperidol.
The combined contingency-based treatments without haloperidol were
most effective in reducing psychotic speech and increasing appropriate
speech across both therapists. Haloperidol doses of 4.2 mg were correlated
with slight reductions in psychotic speech. Discontinuation of haloperidol
did not result in increases in psychotic speech. Thus, haloperidol did not
improve psychotic speech. In fact, haloperidol alone resulted in a marked
increase in the frequency of aggressive and disruptive behavior, which
was directly correlated with the dosage administered. Contingency-based
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treatments maintained disruptive-aggressive behavior at or near zero rates

once haloperidol was discontinued. Maintenance data at 4 and 8 months
post-treatment indicated that the gains in appropriate speech and decreases
in psychotic speech, disruption, and aggression were maintained with
continued contingency management without haloperidol. Thus, contingency-
based treatment had the dual benefit of reducing negative behavior and
increasing positive behavior.

DISCUSSION

These studies demonstrated the efficacy of behavior-analytic based treat-

ments at reducing the delusional verbal behavior of individuals with intel-
lectual disabilities. Specifically, the evidence above supports the use of DRA,
NCR, and response-cost procedures to reduce delusional verbal behavior.
Additionally, differential reinforcement procedures are effective at estab-
lishing socially acceptable alternative responses such as contextually appro-
priate speech, appropriate speech content, and appropriate voice volume,
which serve similar functions to the problematic delusional responses. Thus,
consequence-based interventions can both reduce problematic delusional
behavior and establish acceptable alternative behavior. Several studies
conducted functional analyses of psychotic verbal behavior in people with
intellectual disabilities. These studies demonstrated that, as in people without
intellectual disabilities (Wilder & Wong, 2007), psychotic verbal behavior can
be sensitive to environmental variables that can be manipulated to result in
effective treatment.
Participants in each study reviewed took psychotropic medication while
receiving behavioral interventions. Several had taken psychotropic medica-
tions for many years, which had been ineffective in treating their psychotic
verbal behavior. Hence, many of these participants were highly resistant
to conventional psychotropic treatment. Most studies explicitly mentioned
that psychotropic medication remained stable throughout each experiment,
hence changes in psychotropic medication were not confounded with behav-
ioral intervention. Therefore, the behavior changes demonstrated in each
 Psychotic Verbal Behavior 31

study can confidently be ascribed to behavioral intervention rather than

psychotropic medication. This suggests that behavior analytic interventions
can be successful for individuals unresponsive to psychotropic medication.
The only study to directly compare the effects of psychotropic
medication and behavioral intervention in people with intellectual disabil-
ities was that by Fisher et al (1989). Thus, we have little information on the
relative efficacy of combined behavioral and pharmacological treatment of
psychotic verbal behavior in people with intellectual disabilities. It is possible
that psychotropic medication may be quite effective and that these papers
addressed only people who failed to respond to psychotropic medication.
Furthermore, combining behavioral interventions with psychotropic medica-
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tions in participants whose psychotic verbal behavior continues despite

medication administration might increase the effectiveness of both treat-
ments. The studies reviewed also provide favorable evidence that behavioral
interventions alone may be successful if psychotic verbal behavior persists
once psychotropic medication has been administered. Future research should
compare the independent and interactive effects of psychotropic medication
and behavioral intervention with larger samples of participants to rule out
the possibility that the participants reviewed in these studies were refractory.
Additionally, behavior analytic interventions should be applied to other forms
of problematic verbal behavior. For example, Rehfeldt and Chambers (2003)
successfully reduced the perseverative speech of an adult diagnosed with
autism using a differential reinforcement procedure. Future studies should
expand the assessment of problematic verbal behavior to include other
response topographies such as perseveration or echolalia.
Behavioral interventions for psychotic verbal behavior are rarely imple-
mented in typical services. Notable in the papers reviewed here is the limited
number of studies that trained typical staff and family members to conduct a
functional analysis and implement behavioral treatment. A notable exception
is Mace et al. (1988), who trained residential staff to conduct behavioral inter-
ventions after researchers had conducted functional analyses and evaluated
the treatments implied by those functional analyses. Future research should
also address this unmet service need.

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