In Reply: Dr. Hector clearly agrees that the plan was to reduce undesirable behavior. Punishment is the technical, behavioral term for consequences that suppress behavior.
People often misunderstand the terminology and methods of behavior therapy. The case report alerted clinicians to the adverse effects of this inadequate knowledge. Whether an intervention is intended as treatment or management, clinicians must assess the reinforcing and punishing properties of the consequences for each patient.
Let us clarify some points. Delayed time periods in no way invalidated the design. Mr. A was secluded for part of one period with no management plan and was in restraints during much of the periods with a management plan; both limited the opportunity for disruptive behaviors. We counted only the occasions on which he assaulted others or pressed the emergency button or attempted to do so, and only those on which both raters agreed (we discounted two disputed incidents). There was a statistically significant, positive association between the plan and disruptive behaviors. The reliability of Dr. Hector's counting is unknown. Nevertheless, his own figures (16 and five assaults in the periods with no management plan and 37 and 31 for the periods with the plan) also clearly show the plan was associated with increased disruptive behavior. The most parsimonious conclusion is that these increases in disruption (and perhaps the "psychotic episodes") were caused by the plan.
When we as clinicians can provide evidence that we use the most effective and least intrusive interventions, then we indeed have a service in which to take pride.