Nathan Azrin

At Anna State Hospital, one of his first initiatives was to try to reverse behaviors that patients had developed after years in psychiatric institutions, such as mutism or a lack of motivation to change from a hospital gown into regular clothes. In order to do this, Azrin together with Teodoro Ayllon developed a bartering system he called "token economics", which gave incentives to patients to make behavioral changes, such as putting on their clothes each day. The system was created based upon the work of Azrin's mentor BF Skinner's work in the behavior of lab rats.[4] The two behaviors Azrin sought to improve in patients were self-care activities (such as dressing or grooming) and job activities (such as washing dishes), specifically in adult female psychotic clients.[11] In practice, Azrin provided plastic tokens to patients as a reward for certain behaviors, tokens that could be used for "gifts" such as entering the television room or operating the television itself. An increase in the number of tokens provided was given for those that put the most care into their behavior. In 1968 Azrin and Teodoro Ayllon authored the book The Token Economy summarizing their work and findings.[4]

In the 1970s he worked with Mark Godley and George Hunt on the development of the Community Reinforcement Approach (CRA), applying behavioral therapy to the treatment of alcoholism. After the death of Hunt, Azrin performed the first outpatient treatment trial and first inpatient trial using the principles of CRA. His work also first introduced an abstinence-based goal to CRA, instead of the controlled drinking goal that was being used by other researchers.[12] The goal of CRA was to gradually change drinking-rewarded behaviors to non-drinking rewarded behaviors, including the changing of social networks and transitioning leisure environments. Later studies by Azrin also began to integrate medication-based help into the methodology.[13] Part of his research included the formation of "job clubs" as a method of alleviating unemployment problems, providing social support for them to enter the workforce in a way that the individual finds reward in the work they find, in addition to a daily structure of job-searching that replaces previous daily behavior.[14]

Azrin also developed Family Behavior Therapy (FBT) for dealing with juvenile misbehavior and narcotics use, after receiving a 1989 grant from the National Institute on Drug Abuse and National Institute of Mental Health.[15] The research considers how the behavior of family members can indirectly or purposely reinforce an adolescent's behavior. Any indirect reinforcement is controlled by ensuring all members of a client's family are present for therapy sessions, so that there is a group effort towards behavioral change. Therapy methods included contingency management, communication skills surrounding drug use, problem solving, and efforts to improve family relationships.[16] He co-authored the book Treating Adolescent Substance Abuse Using Family Behavior Therapy: A Step-by-Step Approach with Brad Donohue, aimed at providing a model for clinicians to employ with clients, based on his research. [17] Azrin has also done research on cigarette smoking addictions.[18]

In addition to academic works, in 1974 Azrin co-authored the parenting book Toilet Training in Less Than a Day with Richard M. Foxx, which sold more than three million copies and is available in several dozen languages. The technique in the book was shown to result in a 97% decrease in bathroom accidents during the week after training, following an average of 3.9 hours of "dry-pants training". Other tests showed the success rate was closer to 74%. Azrin is also credited for inventing the "time out" parenting technique as an alternative to corporal punishment.[3][4][19][20]

Azrin and Foxx's technique has drawn a considerable amount of controversy, with critics saying it is overly harsh,[21] and psychologist Dr Eda Leshan stating that “Although one is supposed to be kind and patient, it’s all done by forcing fluids (with things like salty potato chips and orange soda) and conditioned reflexes, leaving out such minor considerations as fears and fantasies, love-hate feelings, dependency and rebellion — the whole unconscious, which we have been struggling so hard to understand. It is an immoral book.” [21][22]

Azrin developed the concepts of "shaping" and "successive approximation" in his work with the mentally ill;[3] Psychology Today called Azrin one of the foundational "behavior shapers" and credited him with moving the work of Skinner from lab animals into the human realm.[23] These collectively used operant conditioning principles to introduce complex behavior to the developmentally challenged.[24] His research also included lab animal tests, such as incentivizing experiments with pigeons that produced the result that they are more likely to form a behavior if there is some reward involved rather than punishment.[25] Azrin was also involved in early research into autism during the early 1960s as a post-doctoral researcher, as well as later in his career.[26]

Azrin researched the concept of behavior reversal training, also known as habit reversal, in order to treat patients with uncontrollable physical tics, trichotillomania, and other repetitive behavior disorders[27][28][29] like stuttering or Tourette syndrome.[30] In 1977, he published Habit Control: Stuttering, Nail Biting, and Other Nervous Habits, which summarized his research, co-authored with Richard Nunn. In the 1970s, Azrin was involved in the government review of BF Skinner's Special Treatment and Rehabilitative Training research program at the Federal Medical Center for Prisoners in Missouri. He was named as one of three expert witnesses to review the program and findings, and defended the program as in line with the principles of behavioral psychology.[31] Further research of Azrin's include his development of the reciprocity counseling program for marriage counseling,[10] and the concept of "overcorrection", which uses positive punishment to correct undesired behaviors and foster desired behaviors.[32]

In 1975 Azrin published research[33] that led to his establishing a system for unemployed persons to assist each other in job finding. One insight from his research with his colleagues was that people on welfare or with disabilities do not possess the family and friends networks that others have to help them with finding jobs. Azrin created The Job Club Counselor's Manual (1981) which showed how to employ a system utilizing a small group of people who assisted each other in their job search by having the leader provide job search information and using positive behavioral leadership by recording member's positive actions such as number of employer contacts made, applications submitted, and interviews obtained. Participants take ownership of the quest as they share information and encourage each other. Azrin's successful job club concept soon spread throughout North America and continues to help people with obtaining employment.

Azrin served on the editorial boards of seventeen peer-reviewed journals, including the Journal of Applied Behavior Analysis, which he founded. He was also the Editor-in-Chief of the Journal of the Experimental Analysis of Behavior and a contributor to the Encyclopedia of Behavior Modification and Cognitive Behavior Therapy. As an author he published more than 100 behavioral studies in additional peer-reviewed publications,[3][6][34] and eleven books. Azrin's work made him one of the most cited behavioral scientists in the world.[3]

• The Token Economy: A Motivational System for Therapy and Rehabilitation (1968)
• Toilet Training the Retarded: A Rapid Program for Day and Nighttime Independent Toileting (1973)
• Toilet Training in Less Than A Day (1974)
• Habit Control in a Day: The Breakthrough Book that Describes Professionally Tested New Methods for Eliminating Stuttering, Nail Biting, Hair Pulling, Muscular Tics, and Other Nervous Habits (1977)
• Habit Control in a Day: Stuttering, Nail Biting, and Other Nervous Habits (1978)
• A Parent's Guide to Bedwetting Control (1979)
• Job Club Counselor's Manual: A Behavioral Approach to Vocational Counseling (1980)
• How to Use Overcorrection: For Misbehaviors and Errors (1980)
• How to Use Positive Practice (1981)
• A Parent's Guide to Bedwetting Control: A Step by Step Method (1980)
• Finding a Job (1982)
• How to Use Positive Practice, Self-correction, and Overcorrection (1999)
• Treating Adolescent Substance Abuse Using Family Behavior Therapy: A Step-by-Step Approach (2011)